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1.  The Cleveland Clinic: a distinctive model of American medicine 
The Cleveland Clinic is a large healthcare system based in Cleveland, Ohio (USA) with an extensive American (throughout Northeast Ohio; Weston, Florida; and Las Vegas, Nevada) and global presence (in Abu Dhabi, UAE; and with training alumni in >70 countries). Cleveland Clinic was founded in 1921 as a distinctive medical model with a tripartite mission of “better care of the sick, investigation of their problems, and more teaching of those who serve” which has been vibrantly maintained. Distinctive aspects of the Clinic include its being a closed staff, salaried, group practice which is physician-led and which features 1-year faculty appointments and a vigorous annual review process for all physicians and leaders. Regarding its tripartite mission, the Clinic has demonstrated longstanding clinical excellence, e.g., with consistent ranking as first in cardiovascular care in U.S. News and World Report and top-10 rankings in at least 12 other specialties. A longstanding tradition of research has contributed landmark discoveries, including performance of the first coronary revascularization procedure, the first intra-coronary angiogram, the world’s third face transplant, ongoing development of a breast cancer vaccine, etc. Regarding education, the Clinic serves many educational audiences excellently through its Education Institute. These audiences include medical students, graduate medical trainees, faculty physicians, nurses, and allied health providers (both within the Cleveland Clinic and from other institutions worldwide), and patients. The Education Institute also includes the Cleveland Clinic Academy, which offers training in leadership competencies to physicians, nurses, and healthcare administrators both within the Cleveland Clinic and to visitors from abroad (through the Executive Visitors Program and the Samson Global Leadership Academy for Healthcare Executives). The latter program is an intensive 2-week residential leadership development course for emerging healthcare leaders focusing on both personal leadership competencies and on healthcare system thinking (www.portals.clevelandclinic.org). Participants from 18 countries have attended to date.
doi:10.3978/j.issn.2305-5839.2013.12.02
PMCID: PMC4200609  PMID: 25333009
Cleveland Clinic; model of medicine; excellence; clinical care; research; education
2.  A Spoonful of Math Helps the Medicine Go Down: An Illustration of How Healthcare can Benefit from Mathematical Modeling and Analysis 
Objectives
A recent joint report from the Institute of Medicine and the National Academy of Engineering, highlights the benefits of--indeed, the need for--mathematical analysis of healthcare delivery. Tools for such analysis have been developed over decades by researchers in Operations Research (OR). An OR perspective typically frames a complex problem in terms of its essential mathematical structure. This article illustrates the use and value of the tools of operations research in healthcare. It reviews one OR tool, queueing theory, and provides an illustration involving a hypothetical drug treatment facility.
Method
Queueing Theory (QT) is the study of waiting lines. The theory is useful in that it provides solutions to problems of waiting and its relationship to key characteristics of healthcare systems. More generally, it illustrates the strengths of modeling in healthcare and service delivery.
Queueing theory offers insights that initially may be hidden. For example, a queueing model allows one to incorporate randomness, which is inherent in the actual system, into the mathematical analysis. As a result of this randomness, these systems often perform much worse than one might have guessed based on deterministic conditions. Poor performance is reflected in longer lines, longer waits, and lower levels of server utilization.
As an illustration, we specify a queueing model of a representative drug treatment facility. The analysis of this model provides mathematical expressions for some of the key performance measures, such as average waiting time for admission.
Results
We calculate average occupancy in the facility and its relationship to system characteristics. For example, when the facility has 28 beds, the average wait for admission is 4 days. We also explore the relationship between arrival rate at the facility, the capacity of the facility, and waiting times.
Conclusions
One key aspect of the healthcare system is its complexity, and policy makers want to design and reform the system in a way that affects competing goals. OR methodologies, particularly queueing theory, can be very useful in gaining deeper understanding of this complexity and exploring the potential effects of proposed changes on the system without making any actual changes.
doi:10.1186/1471-2288-10-60
PMCID: PMC2914732  PMID: 20573235
3.  Ensuring Quality Cancer Care: A Follow-Up Review of the Institute of Medicine’s Ten Recommendations for Improving the Quality of Cancer Care in America 
Cancer  2011;118(10):2571-2582.
Responding to growing concerns regarding the safety, quality, and efficacy of cancer care in the United States, the Institute of Medicine (IOM) of the National Academy of Sciences commissioned a comprehensive review of cancer care delivery in the US healthcare system in the late 1990s. The National Cancer Policy Board (NCPB), a twenty-member board with broad representation, performed this review. In its review, the NCPB focused on the state of cancer care delivery at that time, its shortcomings, and ways to measure and improve the quality of cancer care. The NCPB described an ideal cancer care system, where patients would have equitable access to coordinated, guideline-based care and novel therapies throughout the course of their disease. In 1999, the IOM published the results of this review in its influential report, Ensuring Quality Cancer Care. This report outlined ten recommendations, which, when implemented, would: 1) improve the quality of cancer care; 2) increase our understanding of quality cancer care; and, 3) reduce or eliminate access barriers to quality cancer care.
Despite the fervor generated by this report, there are lingering doubts regarding the safety and quality of cancer care in the United States today. Increased awareness of medical errors and barriers to quality care, coupled with escalating healthcare costs, has prompted national efforts to reform the healthcare system. These efforts by healthcare providers and policymakers should bridge the gap between the ideal state described in Ensuring Quality Cancer Care and the current state of cancer care in the United States.
doi:10.1002/cncr.26536
PMCID: PMC3272132  PMID: 22045610
Oncology Service; Hospital; Quality of Health Care; Benchmarking; Guideline Adherence; Medically Uninsured; Palliative Care; Comparative Effectiveness Research
4.  An Overture for eCAM: Science, Technology and Innovation Initiation for Prosperous, Healthy Nepal 
Nepal the “Shangri-La” in the lap of the Himalayas is gearing up for modern times as it starts rebuilding after a decade of senseless violence and destruction. The nation one of the poorest in the global development index is rich in natural resources and biodiversity. Reports of medicinal plants far exceeding those recorded and reported so far are encouraging and at the same time concerns for medicinal plants under threat as a result of overexploitation are emerging from Nepal. The harsh mountain terrains, lack of industrialization and harnessing potentiality of its areas of strength; water; natural resources and tourism make it poor in per capita income which averages ~ 300 US$, with half the population living under >1$ a day. Nepal is beginning to realize that the way ahead is only possible through the path of Science and Technology (ST). Nepal Academy of Science and Technology formerly known as Royal Academy of Science and Technology organized the fifth national conference held every 4 years that took place in the capital Kathmandu during November 10-12, 2008. The ST initiation event saw the participation of ~ 1400 people representing over 150 organizations from the country and experts from abroad. The theme for the fifth national meet was “Science, Technology and Innovation for Prosperous Nepal”. Complementary and Alternative Medicine (CAM) was an important theme in the event as the realization for the need of ST research focused in CAM for harnessing the chemo diversity potential was univocally approved.
doi:10.1093/ecam/nep156
PMCID: PMC3136358  PMID: 19875434
5.  Muscle Strength and Qualitative Jump-Landing Differences in Male and Female Military Cadets: The Jump-ACL Study 
Recent studies have focused on gender differences in movement patterns as risk factors for ACL injury. Understanding intrinsic and extrinsic factors which contribute to movement patterns is critical to ACL injury prevention efforts. Isometric lower- extremity muscular strength, anthropometrics, and jump-landing technique were analyzed for 2,753 cadets (1,046 female, 1,707 male) from the U.S. Air Force, Military and Naval Academies. Jump- landings were evaluated using the Landing Error Scoring System (LESS), a valid qualitative movement screening tool. We hypothesized that distinct anthropometric factors (Q-angle, navicular drop, bodyweight) and muscle strength would predict poor jump-landing technique in males versus females, and that female cadets would have higher scores (more errors) on a qualitative movement screen (LESS) than males. Mean LESS scores were significantly higher in female (5.34 ± 1.51) versus male (4.65 ± 1.69) cadets (p < 0.001). Qualitative movement scores were analyzed using factor analyses, yielding five factors, or “patterns”, contributing to poor landing technique. Females were significantly more likely to have poor technique due to landing with less hip and knee flexion at initial contact (p < 0.001), more knee valgus with wider landing stance (p < 0. 001), and less flexion displacement over the entire landing (p < 0.001). Males were more likely to have poor technique due to landing toe-out (p < 0.001), with heels first, and with an asymmetric foot landing (p < 0.001). Many of the identified factor patterns have been previously proposed to contribute to ACL injury risk. However, univariate and multivariate analyses of muscular strength and anthropometric factors did not strongly predict LESS scores for either gender, suggesting that changing an athlete’s alignment, BMI, or muscle strength may not directly improve his or her movement patterns.
Key pointsImportant differences in male and female landing technique can be captured using a qualitative movement screen: the Landing Error Scoring System (LESS).Female cadets were more likely to land with shallow sagittal flexion, wide stance width, and more pronounced knee flexion.Male cadets were more likely to exhibit a heel-strike or asymmetric foot-strike and to land with toe out.Lower extremity muscle strength, Q-angle, and navicular drop do not significantly predict landing movement pattern in male or female cadets.
PMCID: PMC2995501  PMID: 21132103
Jump-landing; ACL injury risk; motor patterns; qualitative movement screen
6.  MUSCLE STRENGTH AND QUALITATIVE JUMP-LANDING DIFFERENCES IN MALE AND FEMALE MILITARY CADETS: THE JUMP-ACL STUDY 
Recent studies have focused on gender differences in movement patterns as risk factors for ACL injury. Understanding intrinsic and extrinsic factors which contribute to movement patterns is critical to ACL injury prevention efforts. Isometric lower-extremity muscular strength, anthropometrics, and jump-landing technique were analyzed for 2,753 cadets (1,046 female, 1,707 male) from the U.S. Air Force, Military and Naval Academies. Jump-landings were evaluated using the Landing Error Scoring System (LESS), a valid qualitative movement screening tool. We hypothesized that distinct anthropometric factors (Q-angle, navicular drop, bodyweight) and muscle strength would predict poor jump-landing technique in males versus females, and that female cadets would have higher scores (more errors) on a qualitative movement screen (LESS) than males. Mean LESS scores were significantly higher in female (5.34 ± 1.51) versus male (4.65 ± 1.69) cadets (P<.001). Qualitative movement scores were analyzed using factor analyses, yielding five factors, or “patterns”, contributing to poor landing technique. Females were significantly more likely to have poor technique due to landing with less hip and knee flexion at initial contact (P<.001), more knee valgus with wider landing stance (P<.001), and less flexion displacement over the entire landing (P<.001). Males were more likely to have poor technique due to landing toe-out (P<.001), with heels first, and with an asymmetric foot landing (P<.001). Many of the identified factor patterns have been previously proposed to contribute to ACL injury risk. However, univariate and multivariate analyses of muscular strength and anthropometric factors did not strongly predict LESS scores for either gender, suggesting that changing an athlete’s alignment, BMI, or muscle strength may not directly improve his or her movement patterns.
PMCID: PMC2995501  PMID: 21132103
jump-landing; ACL injury risk; motor patterns; qualitative movement screen
7.  A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial 
BMJ Open  2011;1(2):e000137.
Introduction
Corticosteroid injections (CSI) are a recommended and often-used first-line intervention for shoulder impingement syndrome (SIS) in primary care and orthopaedic settings. Manual physical therapy (MPT) offers a non-invasive approach with negligible risk for managing SIS. There is limited evidence to suggest significant long-term improvements in pain, strength and disability with the use of MPT, and there are conflicting reports from systematic reviews that question the long-term efficacy of CSI. Specifically, the primary objective is to compare the effect of CSI and MPT on pain and disability in subjects with SIS at 12 months.
Design
This pragmatic randomised clinical trial will be a mixed-model 2×5 factorial design. The independent variables are treatment (MPT and CSI) and time with five levels from baseline to 1 year. The primary dependent variable is the Shoulder Pain and Disability Index, and the secondary outcome measures are the Global Rating of Change and the Numeric Pain Rating Scale. For each ANOVA, the hypothesis of interest will be the two-way group-by-time interaction.
Methods and analysis
The authors plan to recruit 104 participants meeting established impingement criteria. Following examination and enrolment, eligible participants will be randomly allocated to receive a pragmatic approach of either CSI or MPT. The MPT intervention will consist of six sessions, and the CSI intervention will consist of one to three sessions. All subjects will continue to receive usual care. Subjects will be followed for 12 months.
Dissemination and ethics
The protocol was approved by the Madigan Army Medical Center Institutional Review Board. The results may have an impact on clinical practice guidelines. This study was funded in part by the Orthopaedic Physical Therapy Products Grant through the American Academy of Orthopaedic Manual Physical Therapists.
Trial Registration
http://clinicaltrials.gov/ NCT01190891.
Article summary
Article focus
Shoulder pain is a common symptom in patients seeking healthcare for musculoskeletal complaints.
Corticosteroid injections (CSI) are a common first-line intervention for shoulder pain in primary care settings, but their long-term efficacy has not been established.
The long-term efficacy of manual physical therapy and CSI will be evaluated and compared from baseline out to 1 year after enrollment.
Key messages
Manual physical therapy has been shown to provide improvements in pain and function in patients with shoulder impingement but has not been directly compared with CSI.
Understanding which interventions have better long-term outcomes may be instrumental in helping improve clinical practice guidelines for the management of shoulder impingement syndrome.
Strengths and limitations of this study
This randomised controlled study will compare the effectiveness of a manual physical therapy approach to a corticosteroid injection in patients with shoulder impingement.
This is a pragmatic study evaluating two interventions that are standard practice and have been shown to be effective for shoulder impingement.
Even as a single blinded randomised clinical trial there is no true control group, and we cannot state whether true a cause-and-effect relationship exists.
Owing to the pragmatic nature of the study, the intervention will not be standardised, which could make it difficult for clinicians to replicate.
The lack of a gold standard with the diagnosis of shoulder impingement makes this population difficult to study.
doi:10.1136/bmjopen-2011-000137
PMCID: PMC3191586  PMID: 22021870
8.  Two Hundred Cases of Paralytic Foot Stabilization after the Method of Hoke 
Dr. Oscar Lee Miller was born on a farm in Franklin County, in northeast Georgia [6]. He obtained a teachers’ certificate and taught school several years after high school before he attended the University of Georgia and then graduated from the Atlanta College of Physicians and Surgeons (now Emory University School of Medicine) in 1912. He took postgraduate training in Atlanta, working with Dr. Michael Hoke (whose name is associated with hindfoot arthrodesis). He entered military service in 1917, then returned to private practice after the armistice. As with other first Presidents of the AAOS, foreign experience was important, and in 1921 he visited Sir Robert Jones and other British surgeons. Upon returning he moved to Gastonia, North Carolina and helped develop the North Carolina Orthopaedic Hospital, an institution focusing on crippled children. In 1923, he opened an office which eventually became the Miller Clinic in nearby Charlotte. (The Miller Clinic and Charlotte Orthopedic Specialists merged in 2005 to create OrthoCarolina.)
Dr. Miller was active in the AOA as well as the AAOS, and was a member of the Argentine Surgical Association. He became President of the AAOS in January, 1942, only days after the bombing of Pearl Harbor. In his Presidential address he emphasized the importance of the care of crippled children and urged a strong relationship with the Latin American orthopaedic community [1]. He served as Chair of a committee that created the Inter-American Orthopaedic Fellowship Program, for Latin American surgeons to visit training centers in the US. He also urged the AAOS to develop a library “as a repository for all pertinent records.” The Executive Committee outlined a program in June, 1941, to present a “motion picture exhibit,” a feature of the meeting which subsequently became the Instructional Course Lecture [2]. Under his leadership at that meeting, the AAOS passed a resolution regarding support of the country during the war years: “It is the desire of the American Academy of Orthopaedic Surgeons to offer its wholehearted support to our Country in this serious emergency.” A telegram with the resolution was sent to the President of the United States.
Miller had a lasting interest in foot surgery, undoubtedly influenced by Hoke. We reprint here Miller’s report of Hoke’s triple arthrodesis for paralytic feet [3]. Astonishingly, Miller states this was the only operation performed for paralytic feet in his clinic over a three-year period, yet he reported 200 cases in this short time; obviously the number of polio patients at the time was devastating. Among these 200 cases, 121 were of the “clubfoot type,” 62 had pes cavus (on which he wrote in 1927 [4]), and 17 pes calcaneus (on which he wrote in 1936 [5]). Miller reports eight cases of flail feet (although it is unclear whether these are additional cases, or fall within one of the three categories since the numbers of those categories add to 200). His focus is to describe the basic operations with indications for supplemental procedures including tendon transfers. As was often common practice in describing procedures at the time, he did not report the followup results and did not provide references [3]. Oscar Lee Miller, MD is shown. Photograph is reproduced with permission and ©American Academy of Orthopaedic Surgeons. Fifty Years of Progress, 1983.
References
Heck CV. Commemorative Volume 1933–1983 Fifty Years of Progress. Chicago, IL: American Academy of Orthopaedic Surgeons; 1983.Heck CV. Fifty Years of Progress: In Recognition of the 50th Anniversary of the American Academy of Orthopaedic Surgeons. Chicago, IL: American Academy of Orthopaedic Surgeons; 1983.Miller O. Two hundred cases of paralytic foot stabilization after the method of Hoke. J Bone Joint Surg Am. 1925;7:85–97.Miller O. A plastic foot operation. J Bone Joint Surg Am. 1927;9:84–91.Miller O. Surgical management of pes calcaneus. J Bone Joint Surg Am. 1936;18:169–172.Oscar Lee Miller 1887–1970. J Bone Joint Surg Am. 1971;53:400–401.
doi:10.1007/s11999-007-0029-y
PMCID: PMC2505288  PMID: 18196377
9.  Management of acute gastroenteritis in healthy children in Lebanon - A national survey 
Background:
Acute gastroenteritis remains a common condition among infants and children throughout the world. In 1996, The American Academy of Pediatrics (AAP) revised its recommendations for the treatment of infants and children with acute gastroenteritis.
Aim:
The purpose of this survey was to determine how closely current treatment among Lebanese pediatricians compares with the AAP recommendations and to determine the impact of such management on the healthcare system.
Patients and Methods:
The outline of the study was based on a telephone questionnaire that addressed the management of healthy infants and children below five years of age with acute gastroenteritis complicated by mild to moderate dehydration. In addition, the costs of medical treatment and requested laboratory studies were calculated.
Results:
A total of 238 pediatricians completed the questionnaire. Most pediatricians prescribed Oral Rehydration Solutions (ORS) for rehydration (92.4%), advised breastfeeding during acute gastroenteritis (81.5%), and avoided parenteral rehydration for mild to moderate dehydration (89.1%). In addition to ORS, oral fluids such as soda, juices, and rice water were allowed for rehydration by 43.7% of pediatricians. Thirty-one percent of pediatricians delayed re-feeding for more than 6 hours after initiation of rehydration. Only 32.8% of pediatricians kept their patients on regular full-strength formulas, and only 21.8% permitted full-calorie meals for their patients. 75.4% of pediatricians did not order any laboratory studies in cases of mild dehydration and 50.4% did not order any laboratory studies for moderate dehydration. Stool analysis and culture were ordered by almost half of the pediatricians surveyed. Seventy-seven percent prescribed anti-emetics, 61% prescribed probiotics, 26.3% prescribed antibiotics systematically and local antiseptic agents, 16.9% prescribed zinc supplements, and 11% percent prescribed antidiarrheal agents.
Conclusion:
Pediatricians in Lebanon are aware of the importance of ORS and the positive role of breastfeeding in acute gastroenteritis. However, they do not follow optimal recommendations from the AAP concerning nutrition, laboratory examinations and drug prescriptions. Consequently, this poses significant financial losses and economic burden.
doi:10.4297/najms.2010.2512
PMCID: PMC3338213  PMID: 22558558
Acute gastroenteritis; Lebanese pediatricians; laboratory studies in acute gastroenteritis in children; oral rehydration solutions
10.  Management of patient adherence to medications: protocol for an online survey of doctors, pharmacists and nurses in Europe 
BMJ Open  2011;1(1):e000355.
Introduction
It is widely recognised that many patients do not take prescribed medicines as advised. Research in this field has commonly focused on the role of the patient in non-adherence; however, healthcare professionals can also have a major influence on patient behaviour in taking medicines. This study examines the perceptions, beliefs and behaviours of healthcare professionals—doctors, pharmacists and nurses—about patient medication adherence.
Methods and analysis
This paper describes the study protocol and online questionnaire used in a cross-sectional survey of healthcare professionals in Europe. The participating countries include Austria, Belgium, France, Greece, The Netherlands, Germany, Poland, Portugal, Switzerland, Hungary, Italy and England. The study population comprises primary care and community-based doctors, pharmacists and nurses involved in the care of adult patients taking prescribed medicines for chronic and acute illnesses.
Discussion
Knowledge of the nature, extent and variability of the practices of healthcare professionals to support medication adherence could inform future service design, healthcare professional education, policy and research.
Article summary
Article focus
A protocol for a cross-sectional survey of healthcare professionals in Europe to examine the perceptions, beliefs and behaviours of healthcare professionals—doctors, pharmacists and nurses—about patient medication adherence.
The questionnaire used in the survey of healthcare professionals is described in detail.
Key messages
There is an acute need for evidence regarding healthcare professionals' beliefs, perceptions and behaviour with regard to patient non-adherence to medicines.
This protocol describes a study to address this need.
The results of this study could guide healthcare professionals as they support patients with taking medicine in their day-to-day clinical practice.
Strengths and limitations of this study
The survey is the largest cross-national survey of healthcare professionals' approach to medication adherence.
Reliance on self-report data may raise concerns regarding the validity of the findings.
doi:10.1136/bmjopen-2011-000355
PMCID: PMC3276023  PMID: 22080529
11.  Follow-Up Study of the Use of Refrigerated Homogenous Bone Transplants in Orthopaedic Operations 
Philip Duncan Wilson was born in Columbus, Ohio. His father was a family physician who held the Chair of Obstetrics in the Sterling Medical School [1]. The young Philip graduated from Harvard College in 1909 and then served as President of his graduating class at Harvard Medical School. He spent two years as a surgical intern at MGH, after which he returned to Columbus to practice. During WWI he was invited back to Boston to join the Harvard Unit under Harvey Cushing, and served with that unit when it was housed in the Lycée Pasteur. (The members of that unit included Marius Smith-Petersen, who also spent many years at the Massachusetts General Hospital and also became AAOS President.) He rejoined MGH on the staff in 1919. In 1925 he published an influential monograph with W.A. Cochrane (formerly of the Edinburgh Royal Infirmary), entitled, “Fractures and Dislocations” [5].
Toward the end of his years in Boston he helped found the American Academy of Orthopaedic Surgeons. In 1934 he was appointed as Surgeon-in-Chief at the Hospital for the Ruptured and Crippled in New York City. Dr. Wilson was active in many organizations, and reorganized and renamed the hospital he served (Hospital for Special Surgery), oversaw the building of a new hospital at its current site on the Cornell University medical campus, and raised money for a large research building. His zest inspired generations, and he was known for his gracious hospitality.
Dr. Wilson was one of three of the first fifteen Presidents (the others being Drs. John C. Wilson, Sr. and Melvin Henderson) whose son (Dr. Philip D. Wilson, Jr.) succeeded him as a President of the American Academy of Orthopaedic Surgeons.
Dr. Wilson had a long interest in bone grafting and wrote numerous research papers, a few of which are referenced here [2–4]. In the article reprinted in this issue [3], he described the rapid increase in use of a bone bank he developed at the Hospital for Special Surgery in 1946: 19 operations using grafts in 1946, 48 in 1947, 106 in 1948, 134 in 1949, and 259 in 1950. He describes his animal experiments with autogenous grafts in which grafts rapidly incorporated. He further describes biopsies of previously implanted autogenous and homogenous bone transplants in patients undergoing serial fusions for scoliosis. The pathologist (Dr. Milton Helpern) commented they found “...no evidence that the cells in the bone transplants survived...” Autogenous grafts, his evidence suggested, incorporated more rapidly that homogenous grafts, but “...in the end the results are the same.” His followup studies suggested successful incorporation of graft in 210 of 248 cases. Philip Duncan Wilson, MD is shown. Photograph is reproduced with permission and ©American Academy of Orthopaedic Surgeons. Fifty Years of Progress, 1983.
References
Philip Duncan Wilson, MD 1886–1969. J Bone Joint Surg Am. 1969;51:1445–1447.Wilson PD. Experiences with a bone bank. Ann Surg. 1947;126:932–945.Wilson PD. Experience with the use of refrigerated homogenous bone. J Bone Joint Surg Br. 1951;33:301–315.Wilson PD. Follow-up study of the use of refrigerated homogenous bone grafts in orthopaedic operations. J Bone Joint Surg Am. 1951;33:307–323.Wilson PD, Cochrane WA. Fractures and Dislocations. Philadelphia, PA: JB Lippincott; 1925.
doi:10.1007/s11999-007-0030-5
PMCID: PMC2505281  PMID: 18196370
12.  EATG training academy STEP-UP: skills training to empower patients 
Journal of the International AIDS Society  2014;17(4Suppl 3):19593.
Introduction
Most existing conventional capacity building and educational programs are currently executed on ad-hoc basis. Such approach no longer responds to the needs and capabilities of patients, supporters and healthcare providers in their engagement with and contribution to response to HIV/AIDS. In contrast, long-term, course-like trainings have considerably broader thematic scope and are conducive to more effective and sustainable learning, exchange of experience and best practices.
Method
Over the period of one year, the Academy trains a cohort of 20 activists (10 from East Europe and Central Asia and 10 from Western and Southern Europe). The Academy goes beyond “treatment only” paradigm. Conceptually, five training modules are grouped under three larger domains: treatment literacy, treatment advocacy and treatment activism, thus covering most of the topics pertinent to the current discourse of HIV and related co-infections. To ensure cascade effect and sustainability of the learning, the trainees are offered participation in pan-European HIV conferences (EACS and HIV Glasgow) and resources for follow-up activities.
Results
The trainees empirically applied the knowledge to the benefits of their communities. In Uzbekistan, a trainee introduced EACS treatment guidelines to fellow medical students and junior doctors. In Armenia and Albania a series of small-scale trainings were held, outreaching to young homeless people who were traditionally excluded from HIV treatment and prevention discourse in the two countries. A trainee from Spain used the materials of the Academy in his work in Mozambique and the Spanish Ministry of Health. Five trainees engaged in a joint European cross-countries project on treatment literacy for young people who are most at risk of infection.
Conclusions
EATG Training Academy is a unique initiative in the WHO Europe region that both trains future treatment activists and addresses treatment literacy, advocacy and advocacy topics. This type of capacity building can respond to existing HIV-related problems more effectively using less limited resources and reaching out to larger communities.
doi:10.7448/IAS.17.4.19593
PMCID: PMC4224788  PMID: 25394098
13.  Funding sources for continuing medical education: An observational study 
Aims:
Medical accreditation bodies and licensing authorities are increasingly mandating continuing medical education (CME) credits for maintenance of licensure of healthcare providers. However, the costs involved in participating in these CME activities are often substantial and may be a major deterrent in obtaining these mandatory credits. It is assumed that healthcare providers often obtain sponsorship from their institutions or third party payers (i.e. pharmaceutical-industry) to attend these educational activities. Data currently does not exist exploring the funding sources for CME activities in India. In this study, we examine the relative proportion of CME activities sponsored by self, institution and the pharmaceutical-industry. We also wanted to explore the characteristics of courses that have a high proportion of self-sponsorship.
Materials and Methods:
This is a retrospective audit of the data during the year 2009 conducted at an autonomous clinical training academy. The details of the sponsor of each CME activity were collected from an existing database. Participants were subsequently categorized as sponsored by self, sponsored by institution or sponsored by pharmaceutical-industry.
Results:
In the year 2009, a total of 2235 participants attended 40 different CME activities at the training academy. Of the total participants, 881 (39.4%) were sponsored by self, 898 (40.2%) were sponsored by institution and 456 (20.3%) by pharmaceutical-industry. About 47.8% participants attended courses that carried an international accreditation. For the courses that offer international accreditation, 63.3% were sponsored by self, 34.9% were sponsored by institution and 1.6% were sponsored by pharmaceutical-industry. There were 126 participants (5.6%) who returned to the academy for another CME activity during the study period. Self-sponsored (SS) candidates were more likely to sponsor themselves again for subsequent CME activity compared with the other two groups (P < 0.001).
Conclusions:
In our study, majority of healthcare professionals attending CME activities were either self or institution sponsored. There was a greater inclination for self-sponsoring for activities with international accreditation. SS candidates were more likely to sponsor themselves again for subsequent CME activities.
doi:10.4103/0972-5229.138152
PMCID: PMC4134625  PMID: 25136190
Accreditation; continuing medical education; continuing medical education credit; funding; sponsorship
14.  Plan for Quality to Improve Patient Safety at the Point of Care 
Annals of Saudi Medicine  2011;31(4):342-346.
The U.S. Institute of Medicine (IOM) much publicized report in “To Err is Human” (2000, National Academy Press) stated that as many as 98 000 hospitalized patients in the U.S. die each year due to preventable medical errors. This revelation about medical error and patient safety focused the public and the medical community's attention on errors in healthcare delivery including laboratory and point-of-care-testing (POCT). Errors introduced anywhere in the POCT process clearly can impact quality and place patient's safety at risk. While POCT performed by or near the patient reduces the potential of some errors, the process presents many challenges to quality with its multiple tests sites, test menus, testing devices and non-laboratory analysts, who often have little understanding of quality testing. Incoherent or no regulations and the rapid availability of test results for immediate clinical intervention can further amplify errors. System planning and management of the entire POCT process are essential to reduce errors and improve quality and patient safety.
doi:10.4103/0256-4947.83203
PMCID: PMC3156507  PMID: 21808107
15.  Preventing food allergy: protocol for a rapid systematic review 
Background
The European Academy of Allergy and Clinical Immunology is developing guidelines about how to prevent and manage food allergy. As part of the guidelines development process, a systematic review is planned to examine published research about the prevention of food allergy. This systematic review is one of seven inter-linked evidence syntheses that are being undertaken in order to provide a state-of-the-art synopsis of the current evidence base in relation to epidemiology, prevention, diagnosis and clinical management, and impact on quality of life, which will be used to inform clinical recommendations. The aim of this systematic review will be to assess the effectiveness of approaches for the primary prevention of food allergy.
Methods
Seven bibliographic databases will be searched from their inception to September 30, 2012 for systematic reviews, randomized controlled trials, quasi-randomized controlled trials, controlled clinical trials, controlled before-and-after studies, interrupted time series and cohort studies. Cohort studies will be included due to an inability to randomize with interventions such as breastfeeding. Studies that focused on the development of either food sensitization (a proxy measure) or food allergy will also be eligible for inclusion. Studies will be critically appraised using the Critical Appraisal Skills Program and Cochrane Risk of Bias tools, as appropriate.
Discussion
There is a lack of rigorous evidence to support recommendations about how to prevent the development of food allergy. It would appear that it is important to see the prevention of food allergy in the context of individual, family and wider factors that may influence its development. There is much left to learn about preventing food allergy, and this is a priority given the high societal and healthcare costs involved. This systematic review will help to further this learning.
doi:10.1186/2045-7022-3-10
PMCID: PMC3621602  PMID: 23537280
Food allergy; lLgE-mediated; Prevention
16.  Pharmacy Management and Health Economics Outcomes 
American Health & Drug Benefits  2014;7(4):237-241.
The following summaries highlight some of the key posters presented at the 26th Annual Meeting of the Academy of Managed Care Pharmacy (AMCP), April 1–4, 2014, in Tampa, FL, focusing on areas of interest for payers, employers, drug manufacturers, providers, and other healthcare stakeholders.
PMCID: PMC4105731  PMID: 25126375
17.  Actin Fusion Proteins Alter the Dynamics of Mechanically Induced Cytoskeleton Rearrangement 
PLoS ONE  2011;6(8):e22941.
Mechanical forces can regulate various functions in living cells. The cytoskeleton is a crucial element for the transduction of forces in cell-internal signals and subsequent biological responses. Accordingly, many studies in cellular biomechanics have been focused on the role of the contractile acto-myosin system in such processes. A widely used method to observe the dynamic actin network in living cells is the transgenic expression of fluorescent proteins fused to actin. However, adverse effects of GFP-actin fusion proteins on cell spreading, migration and cell adhesion strength have been reported. These shortcomings were shown to be partly overcome by fusions of actin binding peptides to fluorescent proteins. Nevertheless, it is not understood whether direct labeling by actin fusion proteins or indirect labeling via these chimaeras alters biomechanical responses of cells and the cytoskeleton to forces. We investigated the dynamic reorganization of actin stress fibers in cells under cyclic mechanical loading by transiently expressing either egfp-Lifeact or eyfp-actin in rat embryonic fibroblasts and observing them by means of live cell microscopy. Our results demonstrate that mechanically-induced actin stress fiber reorganization exhibits very different kinetics in EYFP-actin cells and EGFP-Lifeact cells, the latter showing a remarkable agreement with the reorganization kinetics of non-transfected cells under the same experimental conditions.
doi:10.1371/journal.pone.0022941
PMCID: PMC3151273  PMID: 21850245
18.  Creating an Academy of Medical Educators: How and Where to Start 
HSS Journal  2012;8(2):165-168.
Background
While most faculty members want to improve as teachers, they neither know where their educational strengths and weaknesses lie nor where or how to begin to effect a change in their teaching abilities. The lack of actionable, directed and specific feedback, and sensible and sensitive metrics to assess performance and improvement complicates the attainment of educational excellence.
Purpose
The purpose of this article was to outline a series of specific steps that medical education programs can take to enhance the quality of teaching, promote teaching excellence, elevate the status and value of medical educators, and stimulate the creation of innovative teaching programs and curricula.
Methods
To achieve these goals at the Hospital for Special Surgery, the Academy of Rheumatology Medical Educators was formed. The academy had the following goals: (1) create within our institution a mission which advances and supports educators, (2) establish a membership composed of distinguished educators, (3) create a formal organizational structure with designated leadership, (4) dedicate resources that fund mission-related initiatives and research, and (5) establish a plan for promoting teachers as well as enhancing and advancing educational scholarship.
Results
The Hospital for Special Surgery Academy of Rheumatology Medical Educators was recently formed to address these goals by promoting teaching and learning of musculoskeletal skills in an environment that is supportive to educators and trainees and provides much needed resources for teachers.
Summary
The development of a pilot academy of medical educators represents one of the high-priority goals of those institutions that wish to elevate and enrich their teaching through a structured, proven approach.
doi:10.1007/s11420-012-9280-1
PMCID: PMC3715618  PMID: 23874258
medical education; academy
19.  Surgical Training and Education in Promoting Professionalism: a comparative assessment of virtue-based leadership development in otolaryngology-head and neck surgery residents 
Medical Education Online  2013;18:10.3402/meo.v18i0.22440.
Introduction
Surgical Training and Education in Promoting Professionalism (STEPP) was developed in 2011 to train tomorrow's leaders during residency. It is based on virtue ethics and takes an approach similar to West Point military academy. The purpose of this research was: (i) to compare the virtue profiles of our residents with that of the military cohort using a standardized virtue assessment tool; and (ii) to assess the value of virtue education on residents.
Methods
As part of STEPP, otolaryngology residents participated in a virtue-based validated assessment tool called Virtue in Action (VIA) Inventory. This was completed at the initiation of STEPP in July 2011 as well as 1 year later in June 2012. Comparison of the VIA to a military cohort was performed. Leadership ‘Basic Training’ is a series of forums focused on virtues of initiative, integrity, responsibility, self-discipline, and accountability. A pre- and post-test was administered assessing resident perceptions of the value of this ‘Basic Training’.
Results
Virtues are shared between otolaryngology residents (n=9) and military personnel (n=2,433) as there were no significant differences in strength scores between two military comparison groups and otolaryngology-head and neck surgery (OHNS) residents. There was a significant improvement (p<0.001) in the understanding of components of the leadership vision and a significant improvement in the understanding of key leadership concepts based on ‘Basic Training’. All residents responded in the post-test that the STEPP program was valuable, up from 56%.
Conclusions
A virtue-based approach is valued by residents as a part of leadership training during residency.
doi:10.3402/meo.v18i0.22440
PMCID: PMC3813828  PMID: 24172053
professionalism; residency; virtues; ethics; character training
20.  Professional and Community Satisfaction with the Brazilian Family Health Strategy, Brazil 
Revista de saude publica  2013;47(2):403-413.
Objective
To analyze the strengths and limitations of the Family Health Strategy (ESF) from the perceptions of healthcare professionals and community.
Methods
Between June-August 2009, in the city of Vespasiano, Minas Gerais State, Southeastern Brazil, a questionnaire was applied to evaluate the ESF with 77 healthcare professionals and 293 caretakers of children under five. Health professional ESF training, community access to care, patient communication, and delivery of health education and pediatric care were of main interest in the evaluation. Logistic regression analysis was used to obtain odds ratios (OR) and 95% confidence intervals (CI).
Results
The majority of health care professionals reported their program training was insufficient in quantity, content and method of delivery. Caretakers and professionals identified similar weaknesses (services not accessible to the caretakers, lack of healthcare professionals, poor training for professionals) and strengths (community health worker-patient communications, provision of educational information, and pediatric care). Recommendations for improvement included: more doctors and specialists, more and better training, and scheduling improvements. Caretaker satisfaction with the ESF was found to be related to perceived benefits such as community health agent household visits (OR 5.8, 95%CI 2.8;12.1), good professional-patient relationships (OR 4.8, 95%CI 2.5;9.3), and family-focused health (OR 4.1, 95%CI 1.6;10.2); and perceived problems such as lack of personnel (OR 0.3, 95%CI 0.2;0.6), difficulty with access (OR 0.2, 95%CI 0.1;0.4), and poor quality of care (OR 0.3, 95%CI 0.1;0.6). Overall, 62% of caretakers reported being generally satisfied with the ESF services.
Conclusions
Identifying the limitations and strengths of the ESF from the healthcare professional and caretaker perspective may serve to advance primary community healthcare in Brazil.
doi:10.1590/S0034-8910.2013047003868
PMCID: PMC4112964  PMID: 24037368
(OK) Job Satisfaction; Patient Satisfaction; Family Health Program; Patient Care Team; Health Manpower
21.  Perspectives on clinical leadership: a qualitative study exploring the views of senior healthcare leaders in the UK 
Introduction
Clinicians are being asked to play a major role leading the NHS. While much is written on about clinical leadership, little research in the medical literature has examined perceptions of the term or mapped the perceived attributes required for success.
Objective
To capture the views of senior UK healthcare leaders regarding their perception of the term `clinical leadership' and the cultural backdrop in which it is being espoused.
Setting
UK Healthcare sector
Participants
Senior UK Healthcare leaders
Methods
Twenty senior healthcare leaders including a former Health Minister, NHS Executives, NHS Strategic Health Authority, PCT and Acute Trust chief executives and medical directors, Medical Deans and other key actors in the UK medical leadership arena were interviewed between 2010 and 2011 using a semi-structured interview technique. Using grounded theory, themes were identified and subsequently analysed in an attempt to answer the broad questions posed.
Main outcome measures
Not applicable for a qualitative research project
Results
A number of themes emerged from this qualitative study. First, there was evidence of changing attitudes among doctors, particularly trainees, towards becoming involved in clinical leadership. However, there was unease over the ambiguity of the term ‘clinical leadership’ and the implications for the future. There was, however, broad agreement as to the perceived attributes and skills required for success in healthcare leadership.
Conclusions
Clinical leadership is often perceived to be doctor centric and ‘Healthcare Leadership’ may be a more inclusive term. An understanding of the historical medico-political context of the leadership debate is required by all healthcare leaders to fully understand the challenges of changing healthcare culture. Whilst the broad attributes deemed essential for success as a healthcare leaders are not new, significant effort and investment, including a physical Healthcare Academy, are required to best utilise and harmonise the breadth of leadership talent in the NHS.
doi:10.1177/0141076814527274
PMCID: PMC4093754  PMID: 25013095
leadership; clinical leadership; healthcare leadership
22.  Malnutrition as a Precursor of Pressure Ulcers 
Advances in Wound Care  2014;3(1):54-63.
Significance: Numerous studies have reported associations between declining nutrition status and risk for pressure ulcers. Oral eating problems, weight loss, low body weight, undernutrition, and malnutrition are associated with an increased risk for pressure ulcers. Moreover, inadequate nutrient intake and low body weight are associated with slow and nonhealing wounds. However, the biologic significance of deterioration in nutrition status and consistent methodologies to quantify malnutrition and diminished micronutrient stores as predictors of skin breakdown remains controversial.
Recent Advances: The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) Consensus Statement: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition provide a standardized and measureable set of criterion for all health professionals to use to identify malnutrition. The Agency for Healthcare Research and Quality identified malnutrition as one of the common geriatric syndromes associated with increased risk for institutionalization and mortality that may be impacted by primary and secondary preventions.
Critical Issues: The purpose of this article is to examine the Academy/ASPEN consensus statement on characteristics of adult malnutrition in the context of the National Pressure Ulcer Advisory Panel (NPUAP)/European Pressure Ulcer Advisory Panel (EPUAP) Guidelines on the Prevention and Treatment of Pressure Ulcers.
Future Directions: Moreover, clinicians, and in particular, registered dietitians have the opportunity to integrate the Characteristics of Malnutrition with the NPUAP/EPUAP 2009 Prevention and Treatment Clinical Practice Guidelines, into clinical assessment and documentation using the Nutrition Care Process. Consensus guidelines will provide consistent research criteria yielding more useful data than presently available.
doi:10.1089/wound.2012.0385
PMCID: PMC3899999  PMID: 24761345
23.  The clinical diagnostic accuracy of rapid detection of healthcare-associated bloodstream infection in intensive care using multipathogen real-time PCR technology 
BMJ Open  2011;1(1):e000181.
Background
There is growing interest in the potential utility of real-time PCR in diagnosing bloodstream infection by detecting pathogen DNA in blood samples within a few hours. SeptiFast is a multipathogen probe-based real-time PCR system targeting ribosomal DNA sequences of bacteria and fungi. It detects and identifies the commonest pathogens causing bloodstream infection and has European regulatory approval. The SeptiFast pathogen panel is suited to identifying healthcare-associated bloodstream infection acquired during complex healthcare, and the authors report here the protocol for the first detailed health-technology assessment of multiplex real-time PCR in this setting.
Methods/design
A Phase III multicentre double-blinded diagnostic study will determine the clinical validity of SeptiFast for the rapid detection of healthcare-associated bloodstream infection, against the current service standard of microbiological culture, in an adequately sized population of critically ill adult patients. Results from SeptiFast and standard microbiological culture procedures in each patient will be compared at study conclusion and the metrics of clinical diagnostic accuracy of SeptiFast determined in this population setting. In addition, this study aims to assess further the preliminary evidence that the detection of pathogen DNA in the bloodstream using SeptiFast may have value in identifying the presence of infection elsewhere in the body. Furthermore, differences in circulating immune-inflammatory markers in patient groups differentiated by the presence/absence of culturable pathogens and pathogen DNA will help elucidate further the patho-physiology of infection developing in the critically ill.
Ethics and dissemination
Ethical approval has been granted by the North West 6 Research Ethics Committee (09/H1003/109). Based on the results of this first non-commercial study, independent recommendations will be made to The Department of Health (open-access health technology assessment report) as to whether SeptiFast has sufficient clinical diagnostic accuracy to move forward to efficacy testing during the provision of routine clinical care.
Article summary
Article focus
To highlight the unmet need for accurate and rapid infection diagnostics in the setting of life-threatening infection.
To describe the systematic plans of a clinical diagnostic validity study of a new real-time PCR technology, designed to detect circulating pathogen DNA associated with bloodstream infection.
To describe the clinical standards for sepsis and healthcare-associated infection diagnosis and identify how these standards will be utilised to determine the clinical validity of the new real-time PCR test in critically ill patients.
Key messages
The study will provide the first independent, systematic, clinical validity study of real-time PCR technologies in the focused setting of suspected life-threatening healthcare-associated infections during the provision of routine emergency critical care.
Based on the results of this study, independent recommendations will be made to the UK's Department of Health as to whether the real-time PCR technology has sufficient clinical diagnostic accuracy to move forward to efficacy testing during the provision of routine clinical care.
Strengths and limitations of this study
The study is focused on a carefully delineated clinical cohort at significant risk of developing life-threatening infection.
The study is non-commercial and has been planned systematically by a multidisciplinary team of experts and patient representatives, working on behalf of the key stakeholders within a nationalised healthcare system.
Current clinical infection diagnosis standards may not have a high diagnostic accuracy in all settings and with all infections.
There is a documented high rate of broad-spectrum antimicrobial therapies delivered to critically ill patients empirically which could confound the comparison between culture methods and pathogen DNA-detection methods.
doi:10.1136/bmjopen-2011-000181
PMCID: PMC3191580  PMID: 22021785
Intensive &critical care; adult intensive & critical care; molecular diagnostics; adult intensive & critical care; adult thoracic medicine; adult surgery; Colorectal surgery; inflammatory bowel disease; Nutritional support; wound management
24.  Readability of Patient-oriented Online Dermatology Resources 
Background: Supplemental educational reading material is of no value to patients if it is not read and comprehended. Objective: Using standardized research tools, online patient education materials were comparatively assessed for readability and length in words to identify the strengths and weaknesses of widely utilized sources. Methods: Three sources of patient-education material on the internet (WebMD.com, Wikipedia.org, and MedicineOnline.com) were compared with materials produced by the American Academy of Dermatology for readability utilizing Flesch-Kincaid Grade Level and Flesch Reading Ease Scale. Automated word counts were used to determine the length of each educational piece. Results: The information presented in American Academy of Dermatology electronic pamphlets on the internet is significantly harder to comprehend than MedicineOnline.com, but easier than Wikipedia.org. The latter site proved significantly harder to comprehend than all other sources. The American Academy of Dermatology electronic pamphlets and MedicineOnline.com materials were the most concise, averaging 1,200 words or less, although this was not a statistically significant difference in length compared to other online patient-education resources. No single source of online patient-education material demonstrates optimal features with regard to each of these parameters. Limitations: Only 15 topic areas in the four most commonly accessed sources of patient information were analyzed in this study. Conclusion: No single source of commonly used internet patient-education material demonstrates optimal features with regard to readability, length, and presence of photographic illustrations. These educational materials should target a length of 1,200 words, be illustrated with clinical images, and readability should correspond with the national average reading level.
PMCID: PMC3070466  PMID: 21464884
25.  Role of Pharmacy Education in Growing the Pharmacy Practice Model 
Hospital Pharmacy  2013;48(4):338-342.
The Director’s Forum series is designed to guide pharmacy leaders in establishing patient-centered services in hospitals and health systems. This article focuses on pharmacy academia’s (“Academy”) role in transforming an organization’s pharmacy practice model. Pharmacy students can assume an integrated and accountable role in the practice model by having defined responsibilities for patient care. This role will produce students who are best trained to meet the challenges of pharmacy practice and health care reform. To make the students successful in this role, the pharmacy director must have a specific plan for integrating pharmacy students into the model and establishing relationships with Academy leadership, most importantly with the dean of the school or college of pharmacy. If successfully executed, the relationship between the Academy and the pharmacy department will enhance the mission of developing patient-centered pharmacy services.
doi:10.1310/hpj4804-338
PMCID: PMC3839450  PMID: 24421485

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