Unwarranted variation and the goal of net zero for the NHS in England: exploring the link between efficiency working, patient outcomes and carbon footprint.

In 2020 the NHS in England set a target of reaching net zero carbon emissions by 2040. Progress has already been made towards this goal, with substantial reductions in the use of environmentally harmful anaesthetic gases, such as desflurane, in recent years. Where an effective replacement already exists, changing practice to use low carbon alternatives is relatively easy to achieve, but much greater challenges lie ahead. The Getting It Right First Time (GIRFT) programme is a clinically-led, data-driven clinical improvement initiative with a focus on reducing unwarranted variation in clinical practice and patient outcomes. Reducing unwarranted variation can improve patient care and service efficiency, and can also support the drive to net zero. In this article we set out what the GIRFT programme is doing to support sustainable healthcare in England, why it is uniquely positioned to support this goal and what the future challenges, barriers, enablers and opportunities are likely to be in the drive to net zero.

The history and development of breast implants.

This review discusses the historical development of smooth and textured silicone gel filled implants, and examines the reasoning behind product development and aspects of surgical technique from a surgeon's perspective.

A numerical investigation and experimental verification of size effects in loaded bovine cortical bone.

In this paper, we present 2- and 3-dimensional finite element-based numerical models of loaded bovine cortical bone that explicitly incorporate the dominant microstructural feature: the vascular channel or Haversian canal system. The finite element models along with the representation of the microstructure within them are relatively simple: 2-dimensional models, consisting of a structured mesh of linear elastic planar elements punctuated by a periodic distribution of circular voids, are used to represent beam samples of cortical bone in which the channels are orientated perpendicular to the sample major axis, while 3-dimensional models, using a corresponding mesh of equivalent solid elements, represent those samples in which the canals are aligned with the axis. However, these models are exploited in an entirely novel approach involving the representation of material samples of different sizes and surface morphology. The numerical results obtained for the virtual material samples when loaded in bending indicate that they exhibit size effects not forecast by either classical (Cauchy) or more generalized elasticity theories. However, these effects are qualitatively consistent with those that we observed in a series of carefully conducted experiments involving the flexural testing of bone samples of different sizes. Encouraged by this qualitative agreement, we have identified appropriate model parameters, primarily void volume fraction but also void separation and matrix modulus by matching the computed size effects to those we observed experimentally. Interestingly, the parameter choices that provide the most suitable match of these effects broadly concur with those we actually observed in cortical bone.

Hematopoietic stem cell development: Using the zebrafish to identify extrinsic and intrinsic mechanisms regulating hematopoiesis.

Hematopoietic stem cells (HSCs) reside at the apex of the hematopoietic hierarchy, giving rise to each of the blood lineages found throughout the lifetime of the organism. Since the genetic programs regulating HSC development are highly conserved between vertebrate species, experimental studies in zebrafish have not only complemented observations reported in mammals but have also yielded important discoveries that continue to influence our understanding of HSC biology and homeostasis. Here, we summarize findings that have established zebrafish as an important conserved model for the study of hematopoiesis, and describe methods that can be utilized for future investigations of zebrafish HSC biology.

The acute effects of whole-body vibration on gait parameters in adults with cerebral palsy.

OBJECTIVES: As adults with cerebral palsy (CP) are surviving longer, interventions are needed to reduce spasticity and increase strength to improve mobility and life quality. Adults with CP are lacking a form of independent exercise that allows them to maintain or improve their ambulation skills. A new approach to increase muscle strength and flexibility called whole-body vibration (WBV) was assessed. METHODS: Using an individualized frequency (I-Freq) approach to WBV therapy the acute effects on gait in adults with CP was measured. In this study, eight adults with CP (age 20-51 years, two female) participated in two testing sessions: session one determined each individual's I-Freq; and session two included a 3D gait analysis before and after a WBV treatment. The WBV was administered in five, one minute bouts of vibration followed by one minute of rest. RESULTS: Following WBV exposure subjects experienced a significant increase in walking speed (P=0.047), stride length (P=0.017) and dynamic ankle range of motion (P=0.042). CONCLUSIONS: These data show that acute WBV treatments at I-Freq can improve measures of gait and mobility in adults with CP, however, future should assess potential long-term improvements.

Prolonged outbreak of meticillin-resistant Staphylococcus aureus in a cardiac surgery unit linked to a single colonized healthcare worker.

BACKGROUND: In low- as well as in high-prevalence settings, healthcare workers (HCWs) may be a substantial, under-recognized, reservoir of meticillin-resistant Staphylococcus aureus (MRSA) and an important potential source of transmission to patients. AIM: To report an outbreak of MRSA in a cardiac surgery unit in England over a 10-month period. METHODS: Cases were defined as patients and staff on the cardiac surgery unit from whom the outbreak strain was newly isolated between 20 May 2011 and 16 March 2012. Representative isolates from all cases were characterized by spa-typing, pulsed-field gel electrophoresis and multi-locus variable-number tandem-repeat analysis (MLVA). FINDINGS: Four patients appeared to acquire MRSA during their inpatient stay on the cardiac surgery unit. All four patients and one HCW were found to be carrying an identical epidemic (E)MRSA-15 strain (spa t032, pulsotype A, MLVA profile 16-6-3-1-1-17-1-4). No other members of staff were found to be colonized with MRSA. The colonized HCW was thought to be the source of the outbreak and was decolonized using a combination of nasal mupirocin, chlorhexidine body wash and oral rifampicin and doxycycline. CONCLUSIONS: This report highlights recent changes in the epidemiology of MRSA in England and suggests an important role for colonized HCWs in the transmission of MRSA to patients. Screening HCWs may provide an increasingly valuable strategy in managing linked hospital acquisitions and well-defined outbreaks where initial investigation does not reveal a source.

Educational support for the dental workforce: a review of the first five years of Retaining and Returning Advisers in England.

INTRODUCTION: Retaining and Returning Advisers (RRAs) were appointed to postgraduate dental deaneries in England in 2002 as part of the Government's strategy to retain the dental workforce and support return to practice following a career break. The study aimed to review RRAs' activities and consider the overall success of the RRA initiative five years from inception (2007). DESIGN AND METHODS: A case study design, conducted in three phases, drawing on qualitative data. In Phase 1, semi-structured interviews were held with all RRAs in England (n=12). Phase 2 involved an electronic survey of all 12 postgraduate dental deans in England (n=10). In Phase 3, analysis was undertaken and a final report prepared. RESULTS: RRAs have been flexible in responding to the changing policy context, and devolved funding for the role to the local, deanery level. They have adapted to support more diverse target groups including those seeking vocational training equivalence and underperforming dentists. Future priorities were envisaged to be associated with primary care trusts' commissioning and quality assurance responsibilities, and supporting all members of the dental team. CONCLUSION: RRAs have become well-established in deaneries and have made a successful contribution to addressing workforce and educational needs for a diverse group of practitioners.

Dural venous sinus thrombosis in anaplastic astrocytoma following concurrent temozolomide and focal brain radiotherapy plus bevacizumab.

Malignant gliomas have long been a therapeutic dilemma in neuro-oncology, with a poor overall prognosis. Standard treatment, consisting of primary resection, followed by radiation therapy and temozolomide, has improved prognosis. Recently, studies have looked at the addition of bevacizumab (Avastin), a humanized murine IgG1 monoclonal antibody against vascular endothelial growth factor-A, to conventional regiments. Bevacizumab gained US FDA approval for single agent use in recurrent glioblastoma in 2009. Known side effects of bevacizumab include increased risk of arterial and venous thromboembolism, as well as hemorrhage. With emerging data for the use of bevacizumab in malignant gliomas, the extent of risks such as bleeding and thrombosis in patients with primary brain tumors treated with bevacizumab remains unknown. Here, we present only the second reported case of dural venous sinus thrombosis during treatment with bevacizumab and the first reported case for a primary glioma treated with temozolomide, radiation, and bevacizumab.

Heritability of upper airway dimensions derived using acoustic pharyngometry.

Acoustic pharyngometry represents a simple, quick noninvasive method of measuring upper airway dimensions, which are predictive of sleep apnoea risk. The aim of the present study was to assess the genetic basis of upper airway size as determined using pharyngometry. Participants in the Cleveland Family Study aged >14 yrs underwent three acoustic pharyngometric measurements. Variance component models adjusted for age and sex were used to estimate the heritability of pharyngometry-derived airway measures. A total of 568 out of 655 (87%) subjects provided pharyngometric curves of sufficient quality. Although African-Americans tended to show narrower airways compared with white subjects, heritability patterns were similar in these two groups. The minimum cross-sectional area exhibited a heritability of 0.34 in white subjects and 0.39 in African-Americans, suggesting that 30-40% of the total variance in this measure is explained by shared familial factors. Estimates were unchanged after adjustment for body mass index or neck circumference. In contrast, oropharyngeal length did not show significant heritability in either ethnic group. The minimum cross-sectional area of the oropharynx is a highly heritable trait, suggesting the presence of an underlying genetic basis. These findings demonstrate the potential utility of acoustic pharyngometry in dissecting the genetic basis of sleep apnoea.

Supporting return to dentistry: a national evaluation of the Retaining and Returning Advisory Service.

INTRODUCTION: Workforce concerns in National Health Service (NHS) dentistry have led to Government initiatives to strengthen recruitment and retention. This study (commissioned by the Department of Health, England) explored the role, uptake and user reaction to the new Retaining and Returning Advisory Service in dentistry operating in all 12 postgraduate deaneries in 2002. METHOD: The primary focus of the evaluation study was the first year of the Retaining and Returning Advisory Service. All 12 Retaining and Returning Advisers (RRAs) were interviewed twice; all completed a record form for each one-to-one contact with users of the service (n = 217); and users' views were elicited through questionnaires (n = 82) and case study interviews (n = 10). RESULTS: RRAs' key activities in the first 12 months were to raise awareness of their role and provide one-to-one support for users (n = 217). Some also organised courses for dentists out of practice. Most one-to-one contacts were with female dentists on career breaks and registered on the Keeping in Touch Scheme (KITS). Support included: (i) planning continuing education; (ii) advice on job applications and requirements; and (iii) general careers guidance. Users' feedback was positive: confidence was increased and they valued targeted, hands-on courses. Postgraduate Dental Deans have integrated RRAs into their wider activities. CONCLUSION: The Retaining and Returning Advisory Service provided support to potentially vulnerable groups of dentists. The joint launch of the Retaining and Returning Advisory Service, the revised Keeping in Touch Scheme, and expanded availability of update courses created a comprehensive package of support.

Temporary registration in primary care for dentists moving to the UK from outside the EU: an evaluation of a national pilot scheme.

INTRODUCTION: An evaluation of a pilot scheme offering temporary registration with the General Dental Council (GDC) for up to six months in primary care for overseas-qualified (non-EU) dentists studying for the International Qualifying Examination (IQE) Part C. METHODS: In all five pilot sites dental attachments and supervisors were interviewed at the start (n = 10) in 2005. At six months, supervisors were interviewed again (n = 4), and dental attachments were surveyed (n = 5). Patient (n = 15) and staff (n = 27) views were elicited through questionnaires. RESULTS: Hands-on clinical practice was the prime motive for involvement. Patient safety was safeguarded through close supervision of attachments' dental treatment. The value of clinical experience, development of patient management skills, work in a dental team, and familiarity of NHS procedures was highlighted. Feedback from patients and staff was positive: attachments' enthusiasm, approach, willingness to take responsibility, and follow protocols were rated highly. The National Advice Centre for Postgraduate Dental Education (NACPDE), England coordinated the pilot (including selection and matching of candidates to supervisors). They established good links with pilot sites and maintained training standards. CONCLUSION: Temporary registration with the GDC provided valuable educational opportunities, specifically hands-on experience in primary care beneficial in preparing for IQE Part C. The evaluation demonstrated scope to consolidate the pilot and its expansion has been approved by the GDC.

Modifying integra as a regeneration template in deep tissue planes.

Contour defects resulting in deformity caused by lack of tissue can be improved by conventional surgery using autologous tissue, but there is always a donor site morbidity. Integra has been available since the early 1980's for use in acute burns and more recently in reconstruction. It has been shown histologically to act as a tissue regeneration template. The regenerated dermis is buried under an autologous thin split-skin graft. In this study, the principle of burying Integra (without the silicone layer) has been applied to deep tissue defects in 12 reconstructive cases. Such regenerated tissues survive at least 3 years after burying. Modification to the technique to avoid visible edges are being developed.

Key skills for newly qualified dentists: an evaluation of a West Midlands initiative.

INTRODUCTION: This paper reports an evaluation of the West Midlands Key Skills initiative that provides a framework for learning during vocational training (VT). METHOD: The 48 vocational dental practitioners (VDPs) who began their VT in August 2001 in the West Midlands were surveyed at the start and end of training (45 completed both surveys). They rated their confidence and experience in the 31 components of the Six Key Skills on visual analogue scales. Views were elicited in a survey of both VDPs (47 returns) and their general practice trainers (44 returns). Semi-structured interviews were also held with a stratified sample of 9 trainers and all four VT advisors. RESULTS: In terms of VDP progress, a statistically significant increase in confidence and experience was found in each of the 31 components. Six themes were identified in the views data. (i) Supporting the development of Key Skills; (ii) workload implications; (iii) the "right" six? (iv) links with the advanced diploma (MFGDP(UK)); (v) assessment of VT; and, (vi) consistency and quality assurance. CONCLUSION: VT successfully develops the confidence and experience of newly qualified dentists in the Six Key Skills and has been well received by the majority of VDPs, trainers and advisors in the West Midlands.

The impact of course attendance on the practice of dentists.

INTRODUCTION: This paper reports the impact of course attendance on the practice of dentists. METHOD: Phase One: A survey sent to all general dental practitioners (GDPs) in three deaneries in England. The survey included self-ratings of the impact of course attendance on practice. Phase Two: Interviews with 20 dentists before and two to three months after they had participated in a self-selected course. The response rate to the survey was 54% (n = 2082). Comparisons with national data showed no notable bias in the sample for gender, owners/partners and age/experience. An ordered logit model was used to explore the net effect of factors (including years' experience in general dental practice and gender) on dentists' ratings of course impact. RESULTS: Course attendance was judged to impact on practice. Impact rating was affected by participation rate and years' experience. Barriers to implementation included cost, time, NHS constraints and personal or staff issues. Impact was enhanced when selection of courses was based on learning needs although courses may also serve usefully to confirm current practice. CONCLUSION: There is much that dentists themselves can do to enhance the impact of courses, principally by reflecting on learning needs. They should be supported in the development of personal learning plans.

The concept of safer face-lifting.

Face-lifting is now a common aesthetic procedure, performed mainly by plastic surgeons but increasingly also by ENT surgeons, oral surgeons, general surgeons and dermatologists. The level of expertise is dependent on training and exposure to patients, in addition to basic surgical skills. With cosmetic surgery clients, a holistic approach to patients is becoming increasingly important and, with increasing demands from the Care Standards Committee, there should be less demand for part-time aesthetic surgeons. This paper describes the working practice and thought processes of a single surgeon, based on 14 years of a busy aesthetic surgery practice. There are numerous types of face-lift described in the literature but, in practical terms, the simplest technique often gives the best result, with little risk of morbidity. Undoubtedly, some clients need an aggressive approach but, in most cases, the vertical pull mini-face-lift gives consistently good results in cases that are carefully assessed preoperatively and managed by skilled aesthetic/plastic nurses in the postoperative period. This paper is unique in its holistic approach to assessment, technique and aftercare. It is designed for the sensible surgeon, looking for a low-risk technique that reaps professional satisfaction and a happy client base. The more complex face-lift should be referred to recognized specialists in the field.

Participation of UK dentists in continuing professional development.

INTRODUCTION: This paper reports participation of dentists in continuing professional development (CPD) and factors affecting participation. METHOD: All general dental practitioners (GDPs) in three deaneries in England were surveyed. The overall response rate was 54% (n = 2082); by deanery it was 68% West Midlands, 45% South West and 44% Anglia. Findings across deaneries were remarkably similar. Comparisons with national data show no notable bias in the sample for gender, owners/partners and age/experience. RESULTS: Most frequent forms of CPD were journal reading and courses in which almost all engaged. A score based on individual participation in CPD over the 12-month period was calculated. The mean score (hours) for participation in verifiable CPD was 31 (median 25) and for general, 29 (median 29). In terms of the GDC's Lifelong Learning Scheme, 57% were already undertaking 50 hours. Net of other effects, those less likely to be doing 50 hours are those with more years in practice and single-handed practitioners. Greater access to courses and media-based CPD is desired. CONCLUSION: Certain groups of dentists will need support to meet the requirements of the GDC's Lifelong Learning Scheme. Statutory peer review or clinical audit will significantly alter the CPD profile of most dentists. This has implications for facilitators.

Surface analysis of titanium maxillofacial plates and screws retrieved from patients.

This investigation is a controlled human plate-retrieval study. The surface appearances and elemental composition of 50 titanium maxillofacial plates and associated screws retrieved from 39 patients were compared with a control sample of unused plates and screws using stereomicroscopy, scanning electron microscopy and energy dispersive X-ray analysis. There were two surface finishes, either anodized or non-anodized. Surface contamination was detected on both retrieved and control plates consisting of aluminium and silica and was more commonly present on non-anodized specimens. Manufacturing defects comprising rough metal edges and protuberances were identified on the unused controls and surgical damage was evident on the retrieved specimens. There were no signs of corrosion or surface deterioration on the retrieved plates and screws which had been in the tissues for between 1 month and 13 years. There was no evidence from this study to support the routine removal of titanium maxillofacial miniplates plates due to corrosion up to a period of 13 years.

Recommendations for improving the assessment of postgraduate dental education.

This paper makes recommendations for the improvement of assessment in postgraduate dental education. The recommendations are based on a twelve-month study conducted in 1998/99 which evaluated the strengths and weaknesses of the existing assessment systems. Evidence was taken from examination syllabi, assessments and records. Semi-structured interviews were conducted with representatives from national bodies and with trainers and trainees in the West Midlands. Strengths in parts of the system include: commitment and professional experience; commissioned work; opportunity to share experience; a monitoring framework; procedures for maintaining standards and examples of broadbased assessments. Weaknesses include: lack of assessment of quality; existence of some forms of unregulated assessment; lack of transparency and lack of clarity between training and assessment. Development is recommended in three broad areas: a competence-based model of assessment; distinguishing assessment from the analysis of educational needs and quality assurance. The introduction of a competence-based model is the most significant and is addressed in some detail. Specific proposals for consideration by national regulatory bodies and education providers include: strengthening the management of assessment; national leadership in the development of a competence model of assessment; widening the assessment base; clearer criteria for inspection; revisions to how vocational training, HO/SHO training and general professional training are assessed and training for trainers.