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Supplementary Figures 1-3 from Immunotherapeutic Suppression of Indoleamine 2,3-Dioxygenase and Tumor Growth with Ethyl Pyruvate

Background Parental well-being during pregnancy and early parenthood is critical for child development. Environmental stressors can significantly challenge parental well-being. Aims To investigate how COVID-19 and associated restrictions influence mood and parenting confidence of expectant parents and those in early parenthood, identifying barriers and facilitators. Method We used a cross-sectional online survey to collect data from 590 expectant parents and parents of infants (564 women) during the most restrictive phase of lockdown in the UK. We included a mixture of forced-choice and open-ended questions pertaining to mood, perceived social support, media use, online interactions and parenting expectations. Quantitative data were analysed with multiple linear regression and proportional odds models; an inductive thematic analysis was used for qualitative data. Quantitative and qualitative data were qualitatively synthesised. Results Since COVID-19, expectant parents and parents of new-borns reported a decrease in mood and parenting confidence. Barriers included practical difficulties (finding essentials, reliable health information), social difficulties (loss of physical contact, decreased support) and uncertainty during pregnancy. Facilitators included support from others and, for first-time parents, loss of child care resulting in greater parenting confidence. Although online resources and communication were not preferable to face-to-face interactions, technology was a helpful tool for communicating, getting support, and finding essentials and information during lockdown. Conclusions By mid-May 2020, mood and parenting confidence among expectant and parents of new-borns in the UK were significantly reduced. Consideration of barriers and facilitators in healthcare and psychological support provided is likely important for promoting parental mental health and healthy parent–child relationships.

Background: Parents’ well-being during pregnancy and early parenthood is critical for children’s development. Environmental stressors can significantly challenge parents’ well-being.Aims: To investigate how COVID-19 and associated restrictions influence mood and parenting confidence of expectant parents and those in early parenthood, identifying barriers and facilitators.Methods: We used a cross-sectional online survey to collect data from 590 expectant parents and parents of infants (564 females) during the most restrictive phase of the lockdown in the UK. Survey included a mixture of forced-choice and open-ended questions pertaining to mood, perceived social support, media use, online interactions, and parenting expectations. Quantitative data were analysed using multiple linear regression and proportional odds models, while an inductive thematic analysis was employed for qualitative data. Quantitative and qualitative data were qualitatively synthesised.Results: A decrease in mood and parenting confidence were found. Barriers included practical difficulties (finding essentials, reliable health information), social difficulties (loss of physical contact, decreased support), and uncertainty during pregnancy. Facilitators included support from others and for first-time parents, loss of childcare resulting in greater parenting confidence. While online resources and communication were not preferable to face-to-face interactions, technology was a helpful tool for communicating, getting support, and finding essentials and information during lockdown.Conclusion: By mid-May 2020, mood and parenting confidence among expectant and parents of newborns in the UK were significantly reduced. Consideration of barriers and facilitators in healthcare and psychological support provided is likely to play an important part in promoting parental mental health and healthy parent-child relationships.

Ward round is an integral platform for patients and the multidisciplinary team to communicate, assess and plan treatment. With such a key process, it is vital that the effectiveness of the ward round is maximised and that reliable follow of information is addressed. This can be achieved using lean methodology.Aim: To improve the quality of ward rounds, particularly reliability and patient experience.Method: This is a quantitative quality improvement study that used a plan-do-study-act cycle, including process mapping. The improvements were measured by an objective patient survey, staff survey and a checklist.Results: Process mapping identified the use of templates for the ward round plan, nursing and medical summaries. There was an increase in the reliability of ward round relating to flow of information measured by the checklist. Patient experience improved, rated by both patient and staff surveys, after series of changes were put in place.Conclusions: Checklists in the form of templates improved the reliability of information flow for patient treatment. If the multidisciplinary team is clear about what information and tasks are necessary, there will be a more reliable assessment. With the implementation of the plan template, more treatment plans are fully comprehensive enabling the consistent delivery of high quality of care.

Coercion is defined as ‘the application of force to control the action of a voluntary agent’. The use of coercion on mental healthcare patients constitutes an exception to the principle that healthcare is voluntary and based on consent. Coercion is generally unwelcome to patients, and there is a declared international goal to reduce its use. In describing the extent of the use of coercion in general adult settings, it is important to consider the entire care pathway, from the community through inpatient services to discharge, and the interactions that may occur along it. Some measures are more concrete, such as the removal and detention of individuals against their will, use of physical, chemical and/or mechanical restraint and seclusion, which can be measured in terms of frequency and trends over time. Other less tangible forms are more difficult to quantify, including situations which may be termed ‘negotiation’ or ‘leverage’ over care pathway items such as leave and medication (including type and route of administration). The only available data on coercion tend to relate the former.

Efforts to improve cancer care in the developing world will benefit from the identification of simple, inexpensive, and broadly applicable medical modalities based on emergent innovations in treatment, such as targeting mechanisms of tumoral immune tolerance. In this report, we offer preclinical evidence that the low-cost, anti-inflammatory agent ethyl pyruvate elicits a potent immune-based antitumor response through inhibition of indoleamine 2,3-dioxygenase (IDO), a key tolerogenic enzyme for many human tumors. Consistent with its reported ability to interfere with NF-κB function, ethyl pyruvate blocks IDO induction both in vitro and in vivo. Antitumor activity was achieved in mice with a noncytotoxic dosing regimen of ethyl pyruvate shown previously to protect against lethality from sepsis. Similar outcomes were obtained with the functional ethyl pyruvate analogue 2-acetamidoacrylate. Ethyl pyruvate was ineffective at suppressing tumor outgrowth in both athymic and Ido1-deficient mice, providing in vivo corroboration of the importance of T-cell–dependent immunity and IDO targeting for ethyl pyruvate to achieve antitumor efficacy. Although ethyl pyruvate has undergone early-phase clinical testing, this was done without consideration of its possible applicability to cancer. Our findings that IDO is effectively blocked by ethyl pyruvate treatment deepen emerging links between IDO and inflammatory processes. Further, these findings rationalize oncologic applications for this agent by providing a compelling basis to reposition ethyl pyruvate as a low-cost immunochemotherapy for clinical evaluation in cancer patients. Cancer Res; 70(5); 1845–53

Acupuncture has become an accepted and validated part of Western mainstream medicine and is increasingly used by clinicians, midwives, and acupuncturists for reproductive care, induction of labor, and analgesia. Most studies of the effects of obstetrical acupuncture are descriptive, many in foreign languages. Only a few have evaluated efficacy. Results suggest that acupuncture ripens the cervix, initiates labor, reduces labor pain, and shortens the first stage of labor. There is some evidence suggesting that certain acupuncture points have very specific effects on the fetus and uterus, which may be mediated through the hypopituitary-thalamic axis or by local neurovascular stimulation. The substantial maternal hormonal changes occurring just before and during labor offer a unique opportunity to clarify the mechanisms of action of acupuncture. Using a conceptual model based on possible mechanisms of action of the use of acupuncture in obstetrics, the authors propose specific research questions into the physiology of acupuncture administered before and at parturition.

Physicians seek connections to their communities. Some health care and academic leaders believe that facilitating the creation of more such community connections is one way to reverse the trend of waning social and political legitimacy for the U.S. medical profession. For academic health centers (AHCs), such connections can maintain local and state support crucial to their long-term success. Multiple barriers exist to such involvement, especially for physicians in AHCs, where work done beyond direct patient care, administration, and research rarely contributes to the tenure and promotion process. The authors present a case study to show how one department in an AHC, beginning in the late 1990s, has been overcoming these barriers to incorporate the scholarship of community engagement into its mission and structure. The case study incorporates theoretical underpinnings to crystallize the following lessons that the department has learned so far: (1) If academic departments wish community service to be a central part of their mission, they need ways to institutionalize community engagement within organizational structures. (2) Community engagement can be scholarly. (3) If faculty members are to be recognized for their service activities, measures are necessary to determine what constitutes “excellence” and “scholarship” in community service. (4) Scholarship of community engagement goes beyond performing service activities in the community.

This article reviews issues of safety in health care, applied particularly to the interface between conventional medicine and complementary and alternative medicine. These issues include errors in treatment and medical management, adverse effects of pharmaceuticals, and defining risk for patients. For complementary and alternative medicine, especially dietary supplements, problems of quality control, licensing, regulation, and misrepresentation are discussed. An important issue is the interface between conventional and complementary therapies, in terms of drug/herb interactions, laboratory diagnosis, and lack of communication between clinicians about patients. Improvements in safety and quality will come from a commitment to better education and understanding between both types of care.

To assess the quality and clinical applicability of complementary and alternative medicine (CAM) software databases for personal digital assistants (PDAs), a standard challenge of 52 CAM clinical questions was developed. Benchmark answers were identified from standard texts. Aphysician evaluator then used each of 11 PDACAMsoftware programs to answer the challenge questions and assessed the programs for comprehensiveness, accuracy, and ease of use. Breadth of coverage of the challenge questions ranged from 23% to 87% and clinical reliability from 58% to 97%. The two most clearly useful products were the Natural Medicines Comprehensive Database and the Natural Standard. None of the programs covered combination substances, and only the Natural Standard provided some information on therapeutic modalities other than the herbal and supplement aspects of CAM. The use of a standard clinical challenge as an evaluation tool may be a good way to assess reference software in this clinical area.

To assess the association between mentorship and both subsequent research productivity and career development among primary care research fellows.In 1998, using a self-administered questionnaire, the authors surveyed 215 fellows who graduated from 25 National Research Service Award (NRSA) primary care research programs between 1988-1997 to assess quantitative aspects and qualitative domains of their mentorship experience during fellowship training.A total of 139 fellows (65%) responded to mentorship questions a median of four years after their fellowship. Thirty-seven fellows (26.6%) did not have an influential mentor, 42 (30.2%) reported influential but not sustained mentorship, and 60 (43.2%) had influential and sustained mentorship. Individuals with influential mentorship spent more time conducting research (p =.007), published more papers (p =.003), were more likely to be the principal investigator on a grant (p =.008), and more often provided research mentorship to others (72.5% versus 66.7% of those with unsustained mentorship, and 36.4% of those with no influential mentor, p =.008). After controlling for other predictors, influential and sustained mentorship remained an important determinant of career development in research. On qualitative analysis, fellows identified three important domains of mentorship: the relationship between mentor and fellow (such as guidance and support), professional attributes of the mentor (such as reputation), and personal attributes of the mentor (such as availability and caring).Influential and sustained mentorship enhances the research activity of primary care fellows. Research training programs should develop and support their mentors to ensure that they assume this critical role.

BACKGROUND Controversy continues regarding the relation between the quality of Papanicolaou (Pap) smears, especially the presence of endocervical cells (ECC), with the finding of cytologic abnormalities. METHODS As part of a study regarding performance feedback on the quality of Pap smears, data from 56,475 Pap smears obtained by 176 participating clinicians over a 20-month period were analyzed to assess the relation between the presence of ECC, the categorization of global specimen adequacy as “satisfactory” or “satisfactory with limitations,” and the prevalence of atypia and squamous intraepithelial lesions (SILs). RESULTS Atypia was less likely to be found in “satisfactory” Pap smears than in “satisfactory with limitations” quality Pap smears (odds ratio [OR], 0.6; 95% confidence interval [CI], 0.5–0.6; P < 0.001), even though the latter could contain ECC. No association was found between satisfactory Pap smears and cytologic abnormalities. Compared with specimens with no ECC, an ECC count of ≥ 50 on a slide was associated positively with the detection of atypia (OR, 2.1; 95% CI, 1.8–2.4; P < 0.001) or SILs (OR, 1.7; 95% CI, 1.3–2.2; P < 0.001). A similar relation existed between ECC counts of 25–50 (OR, 1.9; 95% CI, 1.1–2.2; P = 0.01) and the detection of SILs. No relation was found between specimens with < 25 ECC and the presence of atypia or abnormalities. CONCLUSIONS The global adequacy criterion of “satisfactory” assigned to a Pap smear does not indicate that there is a greater likelihood of detecting cytologic abnormalities compared with lower quality Pap smears. To the authors' knowledge, previous studies regarding the link between ECC in the Pap smear and cytologic abnormalities have not addressed the relevance of how many ECC are needed to maximize the identification of abnormalities. The data from the current study support the value of obtaining at least 25 ECC as a quality indicator of sampling. [See editorial on pages 103–4, this issue.] Cancer (Cancer Cytopathol) 1999;87:113–7. © 1999 American Cancer Society.

This paper describes the development of a researchable project, arising from the clinical observation of a physiologic phenomenon during labor. Augmentation of labor by breast stimulation has been used in a variety of cultures for centuries. The process of developing a clinical study of augmentation in the modern obstetric environment is discussed, with reference to cultural attitudes of patients and health care workers.

In this article, we describe the development, organization, costs, and evaluation of an innovative continuing medical education program based on the concept of the community practitioner visiting the medical center as combined learner and teacher—the visiting clinician. The concept involved individualized planning of a series of visits to the hospital where the clinician participated in self-selected clinical experiences and also spent time as a teacher of students and residents. Over several years, evaluation showed that these visiting clinicians reported acquisition of new skills and knowledge but, most importantly, a confirmation of the quality of their own work in community practice. This program offers a mechanism for an effective and long-term educational bridge between the teaching hospital and community practitioners.

Introduction Although the frequency of cervical cancer screening has been extensively studied, little is known about how clinicians decide to screen or recall patients for Pap smears. This study reports the management decisions made by office-based clinicians for 10 different Pap smear reports describing adequacy limitations and cytological diagnoses. Methods We surveyed 186 clinicians using a commercial laboratory in the southeastern United States and analyzed results by frequency and comparison statistics. Results Our respondents were 148 clinicians (79.6% response rate) from different specialties. There was variation in reported management of inflammation, atypia, and low-grade abnormalities (LGSIL), in regard to recall for repeat or routine testing as well as arranging colposcopy. In only 3 of 10 Pap smear results did more than 50% of respondents agree on a specific test recall interval. Conclusions The variation in responses from office-based clinicians suggests either uncertainty or different opinions in making recall and treatment decisions for smears of limited quality even when associated with cytologic abnormalities. These differences may have relevance to outcomes, clinician workload, and costs of care in cervical cancer screening.

Recent national reports and guidelines support the value of manual therapy for acute mechanical low back pain. As part of a randomized trial of the management of acute low back pain, a training course in simple manual therapy was developed and implemented. The course, consisting of two sequential 1-day workshops, was developed for family physicians and internists with no prior training in manual therapy. Before and after the course, participants were surveyed on their attitudes and ability to manage low back pain. All participants (33) subsequently used manual therapy in their practices. Most were male (76%), Caucasian (88%), and 21% were in solo practice. Confidence in preparedness to manage low back pain rose from 15% to 70% and perceptions of having effective therapeutic skills rose from 39% to 58%. Busy clinicians can learn and implement simple manual therapy into their practices. The success of the course was built on structured learning with feedback on practical skills.

The incidence of whiplash injuries of the neck has been increasing in recent years as a result of the use of seat belts, changes in automobile design, and growth in traffic loads. Physicians see many patients with this problem, a significant proportion of whom suffer from persistent symptoms. Many patients present a puzzling array of cognitive, neurologic, and musculoskeletal symptoms that challenge the clinician and are further confused by legal and compensation claims. Management is based almost completely on empirical approaches, and much research is needed to clarify this neglected problem. This article reviews and attempts to analyze the current information about the epidemiology, etiology, management, and prognostic issues of persistent whiplash injuries.

A pilot study was undertaken of the medical fees charged for Pap smears for 59 randomly selected practices in North Carolina. The practices consisted of generalist physicians from different specialties and in different geographic locations. There was a sevenfold variability in charges for new patient visits for Pap smears. Geographic location, specialty, and duration of the visit for the Pap smear do not appear to affect the level of fees charged. More extensive and thorough study of charges for cervical cancer screening would be useful, since most cost-effectiveness studies do not take into account the complexity and variability of such charges. The wide variation in charges for Pap smears is relevant to women as consumers of care and the quality of these screening services by generalist physicians.

The current paper provides a narrative of the Health Impact Assessment (HIA) of a greenfield project located in a remote part of Papua New Guinea. HIA, in the context of this project, is presented as one of the processes that a company needs to go through in order to develop a site-specific Health Management System (HMS). The objective of a narrative is to tell a story; in this case the story describes how the HIA was carried out. Many guidelines on HIA exist and HIA reports are available. However, very little information is published and presented about the challenges encountered during the delivery, as well as about the management issues that need to be addressed in order to deliver an HIA in remote regions. Up to now we have focused on creating rules and structures for HIA; however, not enough attention has been given to their implementation, and even less to the consequences for not complying with the recommendations. Furthermore, impact assessments are usually described on their own or within the life cycle of the project. However, there is little information on how this process links with the other ones in the development of a site-specific Health Management System and which kind of choices are made in this regard. Projects always interact with the external environment where they are located. This environment poses health, safety and security risks for the project. At the same time this broadly defined environment, where the project is located, is altered and impacted by the project itself. Therefore, the "project" and "environment/context" are two essential parameters to understand the health challenges that a company need to manage when starting a greenfield project. The paper concludes systemizing the experience of this HIA in key practical tips for people implementing HIA of complex projects in remote locations.

The description of baseline information about the environmental, social, economic and health conditions existing in the project area is one of the key objectives of an impact assessment. It is also one of the key information pieces needed by project proponents and decision makers, in order to assess and monitor project interaction with the local context. The health baseline always relies on qualitative and quantitative data and is ideally compiled using primary and secondary data. The InterOil Baseline Health Survey (BLHS) generated several primary health indicators and provided a point-in-time assessment of the health status of people living in villages within the InterOil project area in Gulf Province, Papua New Guinea (PNG). It attempted to describe and quantify the type and magnitude of health-related problems affecting the catchment population, as well as identify the relevant determinants of health and potential health risks faced by the current and future population. The choice of the health indicators to include in a health baseline was project and context specific. This was an issue addressed at the beginning of the impact assessment process and it was developed taking in consideration the future use of those indicators for monitoring purposes. The health baseline information not only assisted the identification of the potential impacts, but most importantly defined recommendations and community health outreach programs as part of the project management plan. This plan can then be monitored using health indicators comparable with the ones included in the health baseline. Finally, the paper shows thatspecial attention should be given to the use of secondary data to infer any meaningful conclusion about the health status of a specific community. In the case of InterOil if no BLHS would have been conducted, then the existing secondary data for malaria and filariasis would not have been indicative of the communities and much higher than what isfound in reality with risky consequences for the project.

Methods Individuals with moderate to severe migraine were recruited from specialty clinics, family practices, and the university community. After confirmatory clinical evaluation and an 8-week run-in phase, those meeting study criteria (compliant with study procedures, at least 5 migraines per month) were randomized to 8 weekly CST or low-strength static magnet therapy (LSSM) treatments. Study participants were followed for 4 weeks after the conclusion of therapy. Primary outcome measures included headache frequency and headache-specific quality of life (HIT-6). Secondary headache-specific measures include headache-related disability (MIDAS), headache intensity, and abortive medication use.

This article describes how a system of care operated by a county government agency used a fiscal crisis as the opportunity to reform its children’s system. A cross-system response to the crisis is outlined that includes a system of care framework coupled with a business model, inter-departmental collaboration and leadership, the use of strategic reinvestment strategies, and a quality improvement system that focuses on key indicators. Implementation of the system change is described with a specific focus on cross-system entry points, financing strategies that re-allocate funds from deep-end programs to community-based services, and management oversight through the use of performance indicators to monitor and support effectiveness. This article examines the results of the system change, including the diversion of youth from system penetration, the reduction in residential treatment bed days, the re-allocation of these savings to community-based services, and the outcomes of children who were diverted from residential care and served in the community. The article offers a number of recommendations for other communities contemplating system change.

Changes in nurse education in the UK and the introduction of a new pre-registration nursing programme have led to developments in education methods. This article describes the creation of learning communities at Thames Valley University as a means of adapting to the new curriculum.

Developing valid control groups that generate similar perceptions and expectations to experimental complementary and alternative (CAM) treatments can be challenging. The perceived credibility of treatment and outcome expectancy often contributes to positive clinical responses to CAM therapies, thereby confounding efficacy data. As part of a clinical feasibility study, credibility and expectancy data were obtained from subjects suffering from migraine who received either CranioSacral therapy (CST) or an attention-control, sham, and low-strength magnet (LSSM) intervention.The objective of this study was to evaluate whether the LSSM intervention generated similar levels of subject credibility and expectancy compared to CST.This was a two-arm randomized controlled trial.Sixty-five (65) adults with moderate to severe migraine were the subjects of this study.After an 8-week baseline, subjects were randomized to eight weekly treatments of either CST (n=36) or LSSM (n=29). The latter involved the use of a magnet-treatment protocol using inactive and low-strength static magnets designed to mimic the CST protocol in terms of setting, visit timing, body positioning, and therapist-subject interaction.A four-item, self-administered credibility/expectancy questionnaire, based on a validated instrument, was completed after the first visit.Using a 0-9 rating scale, the mean score for perceived logicality of treatment was significantly less for LSSM (5.03, standard deviation [SD] 2.34) compared to CST (6.64, SD 2.19). Subject confidence that migraine would improve was greater for CST (5.94, SD 2.01) than for LSSM (4.9, SD 2.21), a difference that was not statistically significant. Significantly more subjects receiving CST (6.08, SD 2.27) would confidently recommend treatment to a friend than those receiving LSSM (4.69, SD 2.49).Although LSSM did not achieve a comparable level of credibility and expectancy to the CST, several design and implementation factors may have contributed to the disparity. Based on analysis of these factors, the design and implementation of a future study may be improved.

Epoxy resin is widely used in high voltage apparatus as insulation due to its excellent mechanical, electrical and chemical properties. In recent years, researches on epoxy resin/nanocomposites have shown that the presence of nano-size filler in epoxy resin system can improve electrical, thermal and mechanical properties significantly. In the present paper, the epoxy resin containing nanosize SiO2 and Al2O3 fillers were prepared and the influence of nanosize filler on nanocomposites electrical properties was investigated. The epoxy resin (LY556), commonly used in power apparatus, was used as the base material and nano-sized fillers were mechanically mixed into the epoxy resin. The influence of filler type, filler size and filler concentration on nanocomposites ac breakdown strength and space charge accumulation were examined. In addition, traditional epoxy resin/microcomposites were also prepared and tested and the results were compared with those obtained from epoxy resin/nanocomposites. The present results show that the presence of nano-sized fillers affects space charge accumulation and ac breakdown strength shows a slight reduction. The dielectric properties are strongly influenced by the filler size type and concentration.

Back mice are subcutaneous fibroadenomatous nodules that cause low back symptoms. Previous case reports do not provide systematic descriptions of the clinical presentation or long-term follow-up of this problem. This retrospective case series reports syndrome characteristics and treatment outcomes for injection therapy for "back mice." We completed telephone interviews, chart reviews, and written questionnaires for a convenience sample of 35 participants. Participants reported the following symptoms: pain radiating to the lower leg (37%), leg numbness or paresthesias (14%), and a median of 8 weeks of pain before treatment (range 3 weeks to 10 years). Thirty-one participants (89%) received lasting relief from injection of local anesthetic and corticosteroid. Injection therapy relieved both local and radiating symptoms but often did not eliminate the nodules. Thirty participants (86%) were "satisfied" or "very satisfied" with the treatment. There were no adverse events reported. Back mice can cause radiating pain that can be confused with other low back or leg syndromes. Injection treatment seems to be effective, long lasting, and well tolerated. Physicians should search for these nodules in patients with unexplained low back pain and try injection therapy before initiating expensive therapy.

Background Migraine affects approximately 20% of the population. Conventional care for migraine is suboptimal; overuse of medications for the treatment of episodic migraines is a risk factor for developing chronic daily headache. The study of non-pharmaceutical approaches for prevention of migraine headaches is therefore warranted. Craniosacral therapy (CST) is a popular non-pharmacological approach to the treatment or prevention of migraine headaches for which there is limited evidence of safety and efficacy. In this paper, we describe an ongoing feasibility study to assess the safety and efficacy of CST in the treatment of migraine, using a rigorous and innovative randomized controlled study design involving low-strength static magnets (LSSM) as an attention control intervention. Methods The trial is designed to test the hypothesis that, compared to those receiving usual care plus a treatment with low-strength static magnets (attention-control complementary therapy), subjects receiving usual medical care plus CST will demonstrate significant improvement in: quality-of-life as measured by the Headache Impact Test (HIT-6); reduced frequency of migraine; and a perception of clinical benefit. Criteria for inclusion are either gender, age > 11, English or Spanish speaking, meeting the International Classification of Headache Disorders (ICHD) criteria for migraine with or without aura, a headache frequency of 5 to 15 per month over at least two years. After an 8 week baseline phase, eligible subjects are randomized to either CST or an attention control intervention, low strength static magnets (LSSM). To evaluate possible therapist bias, videotaped encounters are analyzed to assess for any systematic group differences in interactions with subjects. Results 169 individuals have been screened for eligibility, of which 109 were eligible for the study. Five did not qualify during the baseline phase because of inadequate headache frequency. Nineteen have withdrawn from the study after giving consent. Conclusion This report endorses the feasibility of undertaking a rigorous randomized clinical trial of CST for migraine using a standardized CST protocol and an innovative control protocol developed for the study. Subjects are able and willing to complete detailed headache diaries during an 8-week baseline period, with few dropouts during the study period, indicating the acceptability of both interventions. Trial Registration ClinicalTrials.gov NCT00665236

Expert testimony in malpractice cases is often subjective and biased. Decision-analytic techniques might provide an objective basis for such testimony.Case report. This article reports the case of a patient with chest pain that resulted in a malpractice suit alleging a delay in diagnosis of coronary artery disease.The case occurred in a private practice; the expert witnesses and the decision analysis originated from a university teaching hospital.A decision tree and threshold analysis were used to define the thresholds of disease probability at which either testing or treatment should be implemented. The expert testimony of two witnesses that exercise stress testing was the standard of care was compared with the results of the decision analysis.Decision analysis supported the view that cardiac catheterization would have been the more appropriate test.Techniques of decision analysis provide a structured and quantitative basis for empirical judgment and may help to minimize current problems with expert testimony.

PURPOSE To assess the educational value of an objective structured clinical examination (OSCE) administered in three consecutive years (1992-93 to 1994-95) to first-year residents in a family practice residency. METHOD Each year an OSCE was administered early in a family practice residency based at the University of North Carolina at Chapel Hill School of Medicine. The OSCE encompassed eight to ten stations, each 15 minutes long: ten minutes for tasks and five minutes for feedback. After the OSCE, focus groups with participating faculty and residents assessed the strengths and weakness of specific stations as well as the overall OSCE structure. Each year the residents' OSCE scores were correlated with their scores on the American Board of Family Physicians In-Training Examination (ITE). Pearson product--moment correlation coefficients were calculated for both the composite ITE scores and the clinical set problem scores. Test reliability was measured by Cronbach's alpha. In the spring of 1995 the faculty completed global evaluations of all the residents in the program at the time, including 16 of the 17 residents who had participated in the OSCEs. The faculty rated the residents in four areas, and a four-point scale was based on the percentile ranges a resident's rating could fall into for each area. Correlation coefficients were calculated for the OSCE scores and the faculty's perceptions of the residents' overall performance. RESULTS The OSCE scores correlated significantly with the faculty's global assessments of knowledge and clinical skills, but not with in-training examination scores. Concurrent validity and reliability estimates did not support using an OSCE for decisions about the residents' competency. The faculty valued the opportunity to observe basic skills for the whole group of residents; the residents found the experience educational but stressful and valued the immediate performance feedback included at each station. CONCLUSION The OSCE is a useful tool for teaching basic clinical skills and for forming initial impressions of interns' clinical styles and abilities, but it should be used with caution for summative assessments.

This paper presents a detailed summary of the JSF STOVL Hot Gas Ingestion (HGI) sub-scale test program. It focuses on the System Demonstration and Development (SDD) phase of the JSF Program, where significant advances in the fidelity of testing have been made. It documents the improvements and refinements made to the dedicated test facility and powered wind tunnel model required for HGI testing. The paper covers an introduction to JSF and HGI, wind tunnel model hardware development, propulsion system calibrations, validation and understanding of the STOVL flow-field including comparison to full-scale data and test facility improvements. These improvements are also given perspective as the paper explains their practical effect in increasing the fidelity and confidence in the sub-scale test data, which will ultimately be used to support flight clearance for the F-35B aircraft. The improvements in test efficiency enable a more comprehensive database to be gathered within a given time frame.

This paper describes the problem of Hot Gas Ingestion (HGI) for vertical landing aircraft, and how it is measured and understood during aircraft development programmes. The particular problem of the F-35B JSF is discussed, with regard to the engine driven lift fan and the additional suction source this puts on the airframe. Although the majority of HGI testing for JSF has been, and will continue to be, performed without lift fan suction, it was considered important to find some way of characterising the ingestion experienced by the lift fan as a means of reducing risk to the whole programme. The solution was the development of a Turbine Powered Simulator (TPS), which fitted within the correct physical envelope in the aircraft model. The paper describes the conceptual design of the TPS, the detailed design of the compressor and some of the development work necessary to realise the required performance. The developed TPS has been tested "in anger" in the BAE Systems HGI test facility. It's performance, and that of the instrumentation and data logging system, allowed the collection of data which has significantly improved understanding of lift fan ingestion, and has thus reduced the HGI risk that the project has to account.

Supernumerary status, for pre-registration student nurses, should have fundamentally changed the way they learn in practice. Research suggests, however, that for many students the apprenticeship model still exists and that supernumerary status has created new challenges for learning in practice. Common themes found in the literature on supernumerary status are: confusion over the meaning of supernumerary status, the effect of supernumerary status on becoming part of the team, importance of the mentor, power relationships and operationalising supernumerary status. These themes are explored further with reference to the international literature and recommendations made as to how nurse education can respond to the challenges posed in order to ensure the quality of student learning in practice.

Background: Community service is an integral part of American society. Although Family Medicine advocates community service through community medicine, few data exist on family physicians’ involvement in voluntary community service activities or roles as community advocates. Methods: A questionnaire was mailed to 489 North Carolina family physicians, including a 20% random sample of those in community practice and all statewide faculty physicians. The survey assessed types and amount of volunteer activity, attitudes toward volunteer work, and factors that support or inhibit participation in community service. Results: The overall response rate was 54%. Most respondents reported strong interests in community service before medical school and residency, yet few reported any relevant training during medical education. More than 85% of faculty and community practice family physicians reported participating in volunteer service in the previous year (70.8 mean hours for faculty vs 45.5 mean hours for community practice; P = .06). Family physicians also reported a wide variety of lifetime volunteer activities (mean number of different faculty physician activities 20.8 vs mean number of different community practice physician activities 16.7, P = .00). Less than 50% of both physician groups reported that their practice or program publicly supports those performing community service. Conclusions: The great majority of family physicians in North Carolina regularly participate in one or more volunteer community service activities, frequently without organizational recognition. Data about the scope of service expected by communities and provided by physicians may assist the discipline in clarifying the place of volunteer community service in medical education, promotion guidelines and practice.

This study compared the training programs and career paths of family medicine graduates in the National Research Service Award (NRSA) Program for Research in Primary Medical Care with general internal medicine and general pediatric peers.We mailed a survey to NRSA fellows graduating from 23 programs nationally between 1988-1997. Personal characteristics, fellowship experience, current professional activities, and academic productivity were compared among primary care disciplines.Of 215 NRSA participants, 146 (68%) completed the survey. Of the 131 primary care respondents, 25% were family physicians. During the fellowship, family physician trainees spent significantly less time in hands-on research activity (32% +/- 12%) than internists and pediatricians (39% +/- 17%). Family physician graduates also had less post-fellowship mentoring and were less likely to hold clinician/researcher faculty positions in academic centers. Family physician faculty spent far more time on clinical work and less time on research. Only 12.5% of family physician fellowship graduates published one or more articles per year, compared with 36.5% of their peers, and 30% had published nothing since graduation.Family physician graduates of this research training program did not achieve academic success comparable to their peers. Family physicians need more protected time for conducting research in their faculty positions and more sustained mentorship.

OBJECTIVE: Little is known about the impact of fellowship training in primary care on subsequent research productivity. Our goal was to identify characteristics of research fellows and their training associated with subsequent publications and research funding. DESIGN: Mail survey in 1998. SETTING AND PARTICIPANTS: 1988–1997 graduates of 25 National Research Service Award primary care research fellowships in the United States. OUTCOME MEASURES: 1) Publishing 1 or more papers per year since the beginning of fellowship, or 2) serving as principal investigator (PI) on a federal or non-federal grant. RESULTS: One hundred forty-six of two hundred fifteen program graduates (68%) completed the survey. The median age was 38 years, and 51% were male. Thirty-two percent had published 1 or more papers per year, and 44% were PIs. Male gender (odds ratio [OR], 3.6; 95% confidence interval [95% CI], 1.4 to 9.2), self-reported allocation of 40% or more of fellowship time to research (OR, 4.4; 95% CI, 1.8 to 11.2), and having an influential mentor during fellowship (OR, 5.0; 95% CI, 1.5 to 17.2) were independently associated with publishing 1 or more papers per year. Fellows with funding as a PI were also more likely to have an influential mentor (OR, 3.0; 95% CI, 1.3 to 7.2). CONCLUSION: Primary care fellows who had influential mentors were more productive in research early after fellowship. Awareness of the indicators of early research success can inform the policies of agencies that fund research training and the curricula of training programs themselves.