Patient ratings in exercise therapy for the management of tendinopathy: a systematic review with meta-analysis.

OBJECTIVE: To synthesise exercise therapy intervention data investigating patient rating outcomes for the management of tendinopathy. DESIGN: A systematic review and meta-analysis of randomized controlled trials investigating exercise therapy interventions and reporting patient rating outcomes. SETTING: Any setting in any country listed as very high on the human development index. PARTICIPANTS: People with a diagnosis of any tendinopathy of any severity or duration. INTERVENTIONS: Exercise therapy for the management of tendinopathy comprising five different therapy classes: 1) resistance; 2) plyometric; 3) vibration; 4) flexibility, and 5) movement pattern retraining modalities, were considered for inclusion. MAIN OUTCOME MEASURES: Outcomes measuring patient rating of condition, including patient satisfaction and Global Rating of Change (GROC). RESULTS: From a total of 124 exercise therapy studies, 34 (Achilles: 41%, rotator cuff: 32%, patellar: 15%, elbow: 9% and gluteal: 3%) provided sufficient information to be meta-analysed. The data were obtained across 48 treatment arms and 1246 participants. The pooled estimate for proportion of satisfaction was 0.63 [95%CrI: 0.53-0.73], and the pooled estimate for percentage of maximum GROC was 53 [95%CrI: 38-69%]. The proportion of patients reporting positive satisfaction and perception of change increased with longer follow-up periods from treatment onset. CONCLUSION: Patient satisfaction and GROC appear similar and are ranked moderately high demonstrating that patients generally perceive exercise therapies positively. Further research including greater consistency in measurement tools is required to explore and where possible, identify patient- and exercise-related moderating factors that can be used to improve person-centred care. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO ID=CRD42020168187 CONTRIBUTION OF PAPER.

Local and national laparoscopic skill competitions: residents' opinions and impact on adoption of simulation-based training.

BACKGROUND: Dedicated practice using laparoscopic simulators improves operative performance. Yet, voluntary utilization is minimal. We hypothesized that skill competition between peers, at the local and national level, positively influences residents' use of laparoscopic simulators. METHODS: A web-based survey evaluated the relationship between Canadian General Surgery residents' use of laparoscopic simulation and participation in competition. Secondary outcomes assessed attitudes regarding simulation training, factors limiting use, and associations between competition level and usage. RESULTS: One hundred ninety (23%) of 826 potential participants responded. Eighty-three percent rated their laparoscopic abilities as novice or intermediate. More than 70% agreed that use of simulation practice improves intra-operative performance, and should be a mandatory component of training. However, 58% employed simulator practice less than once per month, and 18% never used a simulator. Sixty-five percent engaged in simulator training for 5 h or less over the preceding 6 months. Seventy-three percent had participated in laparoscopic skill competition. Of those, 51% agreed that competition was a motivation for simulation practice. No association was found between those with competition experience and simulator use. However, 83% of those who had competed nationally reported >5 h of simulator use in the previous 6 months compared to those with no competition experience (26%), local competition (40%), and local national-qualifying competition (23%) (p < 0.001). CONCLUSIONS: This study does not support the hypothesis that competition alone universally increases voluntary use of simulation-based training, with only the minority of individuals competing at the national level demonstrated significantly higher simulation use. However, simulation training was perceived as a valuable exercise. Lack of time and access to simulators, as opposed to lack of interest, were the most commonly reported to limited use.

Molecular logic of neocortical projection neuron specification, development and diversity.

The sophisticated circuitry of the neocortex is assembled from a diverse repertoire of neuronal subtypes generated during development under precise molecular regulation. In recent years, several key controls over the specification and differentiation of neocortical projection neurons have been identified. This work provides substantial insight into the 'molecular logic' underlying cortical development and increasingly supports a model in which individual progenitor-stage and postmitotic regulators are embedded within highly interconnected networks that gate sequential developmental decisions. Here, we provide an integrative account of the molecular controls that direct the progressive development and delineation of subtype and area identity of neocortical projection neurons.

Issues encountered with kilovoltage x-ray reference dosimetry when changing codes of practice from TRS 277 to TRS 398.

A difference of 12% has been observed in the output of an 80 kV, 2.2 mm A1 HVL x-ray beam when comparing measurements made according to the TRS 398 medium energy protocol with measurements made according to the TRS 277 low energy protocol. Absorbed dose to water chamber calibration factors used for the TRS 398 measurements were derived from standards of air kerma with the use of the TRS 277 medium energy protocol, and given this fact the discrepancy observed can be considered in terms of a difference between the TRS 277 low and medium energy protocols for this beam. Repeat measurements using the TRS 277 low and medium energy protocols have been made to confirm this. The most likely origins for the discrepancy observed are the chamber perturbation correction, p(u), obtained from TRS 277, and the value of the measured percentage depth dose at a depth of 2 g.cm(-2) for this beam. Given these findings, reference dosimetry for this beam will be performed according to the TRS 398 low energy protocol.

Linear accelerator output variability.

The Wellington Cancer Centre is equipped with two matched linear accelerators (Varian 2100CD) linear accelerators (identified as SN1027 and SN42). Each morning, before treatments commence, a radiation therapist carries out an output constancy check of the radiation output and every fortnight a physicist measures, in a phantom, the delivered radiation dose to check on the machine calibration. The daily output checks have been recorded into a database (Argus QA for Radiation Oncology) since August 1997 and in June 1998 the fortnightly calibration measurements were added. The information in the database, up to April 2003, has been analysed to consider the quality of the daily constancy checks as compared with the fortnightly calibration measurements and whether the data contains useful information on machine performance. After allowance for the effects of machine recalibration the fortnightly calibration measurements had an average standard deviation of 0.4% and the daily constancy checks 0.8%. The daily constancy checks had a greater number of large deviations than would be expected assuming a normal distribution and were not a good predictor of the need for a recalibration. The fortnightly calibration measurements with a much lower spread give a reliable indication of the need for a recalibration allowing the adoption of a +/- 1% tolerance. Over the period analysed one accelerator (SN42) was relatively stable with the output generally drifting between +/- 1% while the other (SN1027) had a consistent increase in the average output of about 2.5% per year.

Dosimetry of small electron fields shaped by lead.

Electron radiotherapy fields are commonly used to treat superficial cancers. Field shaping can be achieved by placing lead on the patient surface to minimise the dose to surrounding areas. However, significant dosimetry changes under high density material edges for electron fields have been reported in the literature. This project evaluated the dosimetry of small dimension electron fields shaped with lead placed on the surface. Comparisons were made between circular lead cutouts placed on the skin and low melting point alloy cutouts placed in an applicator. Depth doses, profiles and output factors were measured using a diode detector in a water phantom. Film was also used to determine surface dose delivered when the lead cutouts were placed on the surface. Minimal differences were observed between the different setups for the depth dose curves, although significant differences were seen in the penumbra and the surface doses. The penumbra is smaller for the lead cutouts placed on the surface, however, significant dose increases at the edge of the field were observed for larger fields and energies; this may result in undesirable clinical effects.

Anti-oxidants-- a protective role in cardiovascular disease?

Established risk factors for cardiovascular disease (CVD), such as hypertension, smoking and diabetes mellitus, explain only some of the observed variation in clinical events. This has maintained interest in other nutritional and biochemical factors that might contribute to the underlying pathophysiology of CVD. All of these risk factors are associated with increased oxidative stress in the vessel wall, which may contribute to CVD by several mechanisms. Studies in animal models of CVD have suggested that natural and synthetic anti-oxidants can prevent the development of clinical end points. These observations have generated the hypothesis that anti-oxidant therapy might also prevent CVD in human populations. This has been supported by epidemiological studies showing a negative correlation between circulating concentrations or dietary intake of natural anti-oxidant vitamins and CVD event rate. Many studies have also demonstrated a beneficial effect of anti-oxidants on surrogate markers of CVD such as endothelial function and lipoprotein oxidation. However, the results of large prospective randomised controlled intervention trials, mostly involving vitamin E in patients at increased risk of CVD, have been disappointing and have failed to demonstrate the anticipated benefits. This paper will critically examine the evidence and try to offer some explanation for the apparent failure of animal and epidemiological data to translate into meaningful clinical benefits.

Applications of automated amino acid analysis using 9-fluorenylmethyl chloroformate.

A rapid and sensitive fully automated method for the determination of primary and secondary amino acids in different matrices is described. Amino acids are derivatized with 9-fluorenylmethyl chloroformate using an automated precolumn derivatization technique. Data are presented to show that the technique is both reproducible and highly sensitive. Applications of the technique are presented, including the analysis of peptide and protein hydrolysates and the profiling of free amino acids in physiological fluids.

Early identification of future medical students using initial undergraduate grades.

This study assessed whether overall academic performance in undergraduate medical coursework can be predicted with reasonable accuracy by using grades from initial college-level courses rather than total premedical grade point averages (GPAs). Initial college grades from four areas, MCAT scores, and NBME I and II scores were recorded for students admitted to the University of Washington Medical School, for students admitted to other medical schools, and for students not admitted to any medical school. The results documented a high relationship between cumulative GPAs and initial grades, with differences found between those students admitted to medical school and those not admitted. The importance of this study is the documentation that little predictive utility is gained by waiting for overall college GPAs from medical school applicants. Initial GPAs are available 2 years earlier than overall GPAs and provide virtually the same information. Exploratory suggestions for medical school admission policies are made.

Performance of residents who had academic difficulties in medical school.

An assessment of how well graduates of one medical school performed in residency training was undertaken to assess the school's monitoring of students' performances. The minutes of the school's student progress committee for four years were reviewed to identify all students who had had academic difficulty. Seven students had been recommended for dismissal but ultimately graduated, 22 students were on academic probation for longer than one year, and 22 students were on academic probation for less than one year. The residency performance of 43 of these 51 students were compared with the performances of a randomly selected group of students who had had no academic difficulties and had graduated during the same period. Of 12 performance and knowledge items assessed by the residency directors for the studied graduates, the one dealing with quality of interaction with patients showed significant differences among the residents. The residents who had had academic difficulty had lower ratings on this item than the residents who had not had academic trouble. On all other items, those residents who had had academic difficulties received generally lower scores than the other residents, but the differences were not statistically significant. Of the seven students considered for dismissal, one had been dismissed and one had withdrawn from the residencies; the other five generally received positive ratings from their residency directors. The findings suggest that the medical school's overall monitoring of students' performance was working and confirmed the authors' opinion that each decision concerning a student with academic difficulties should be based on the student's individual situation.

Curricular influences on preventive-care attitudes.

Attitudes are one of the most important outcomes of medical education, but little is known about curricular influences on specific attitudes. This study examined changes in attitudes toward 20 preventive-care services in a cohort of 175 medical students. Specifically, a cohort of medical students was followed over a 30-month interval that spanned the period from medical school entry through the first 6 months of clinical clerkships. Perceived importance, as well as student confidence in the ability of primary-care physicians to provide 20 preventive-care services, was examined. Importance ratings for preventive-care services remained stable, while levels of confidence in the ability of physicians to provide the services increased. Implications of the results are discussed in relation to the possibilities for emphasizing disease prevention content in medical education.