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The chemical recovery of a defaced serial number is a common forensic science practice, however it is not understood how proficient experts perform in correctly identifying recovered serial numbers. Understanding the accuracy of experts and how they compare to novices in character recognition can help to establish a baseline for this expertise. In this study an expert-novice comparison assessment was completed involving 118 test plates, each stamped with six randomised alphanumeric characters. The plates were defaced and chemically recovered before being viewed by multiple participants over six time intervals. A total of 3169 character inspections were completed. An assessment of confidence and error rates were calculated for both expert (trained) and novice (untrained) participants. Errors were counted when a participant interpreted a different character to that of the ground truth and believed the result was accurate for reporting. The results showed a similar (2.3 % and 2.4 %) error rate for the cohorts, however a statistical difference in confidence levels was recorded, demonstrating the more conservative nature of experts. This study aims to assist in validating practitioner interpretations, through addressing some forensic science criticisms, such as establishing error rates to routine scientific practices.

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Nipple sparing mastectomy with free tissue transfer for breast reconstruction offers excellent aesthetic outcomes but poses a challenge in monitoring the buried flap. Venous anastomotic flow couplers directly monitor buried flaps without the need for monitoring skin paddles. In a two year period we used the Synovis GEM™ flow coupler on 24 DIEP flaps. In our practice, flow couplers are effective in monitoring buried free flaps for breast reconstruction. The avoidance of a second procedure to remove a skin paddle improves patient experience and nullifies the additional flow coupler cost. One patient needed return to theatre when a Doppler wire became dislodged early in the series. There were no other issues with flap monitoring and no flap failures. We offer our tips to optimise flow coupler use.

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A radiological assessment was carried out on the release of positron-emitting radioactive gases from a roof-level stack at a central London site. Different modelling approaches were performed to investigate the range of radiation doses to representative persons. Contributions from plume inhalation, gamma shine and immersion to effective dose were taken into account. Dry and wet surface deposition on the roof, and exposure from contamination on the skin of roof-workers, added only a mean 4.7% to effective dose and were neglected. A 1:200 scale model, consisting of the stack and surrounding buildings, was tested in a wind tunnel to simulate pollutant dispersion in the near-field region i.e. rooftop. Concentration field measurements in the wind tunnel were converted into effective dose, including for roof-workers installing glass cladding to the stack building. Changes in the building shape, from addition of the cladding layer, were investigated in terms of the near-field flow pattern and significant differences found between the two cases. Pollutant concentrations were also modelled using Air Dispersion Modelling System (ADMS) and the results used to calculate the effective dose using the same meteorological data set and source release terms. Sector averaged wind tunnel dose estimates were greater than the ADMS figure by approximately a factor of two to three. Different stack release heights were investigated in the wind tunnel and ADMS simulations in order to determine the best height for the replacement flue stack for the building. Other techniques were investigated: building wake models, modified Gaussian plume methods and uniform dilution into a hemispherical volume to show the wide variation in predicted dose possible with different approaches. Large differences found between simpler analytic approaches indicated that more robust radiological assessments, based on more complex modelling approaches, were required to achieve satisfactory estimates of radiation dose to representative groups in adjacent buildings and on the building rooftop.

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A patient with a narrowly excised squamous cell carcinoma on the scalp underwent a wider excision that involved burring of the underlying calvarium. The defect was reconstructed with a superficial temporal artery pedicled flap, which unfortunately failed. The patient had multiple co-morbidities, limiting reconstructive options. The failed flap was therefore maintained as a 'biological dressing' for several weeks. During this time, the patient was reviewed regularly in the dressing clinic and did not develop a wound infection. Six weeks later, he was taken back to theatre and the flap was debrided under local anaesthesia. Beneath the flap, there was sufficient healthy granulation tissue over the site of previous bony debridement to permit split skin grafting. We advocate this technique as a useful method for managing difficult wounds in complex patients with multiple co-morbidities where other reconstructive techniques are limited.

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BACKGROUND: Methionine adenosyltransferase I/III (MATI/III) deficiency is the most common genetic cause of persistent isolated hypermethioninemia. Patients and Methods : This is a retrospective data analysis of 62 newborns with elevated methionine detected by newborn screening between January 2000 and June 2013. The clinical, biochemical, and molecular findings of a subset of these children with MAT1A mutations associated with MATI/III deficiency are presented. RESULTS: Of the 62 newborns with elevated methionine, 12 were identified as having classical homocystinuria; 37 were false-positives; and 13 were found to have isolated persistent hypermethioninemia in the absence of biochemical markers of homocystinuria, abnormal liver function studies, or other causes of elevated methionine. These 13 individuals underwent genetic testing for changes in the MAT1A gene, associated with MATI/III deficiency. Three of 13 were found to have the common autosomal dominant R264H mutation, one was found to be a compound heterozygote for two novel pathogenic mutations, and three were found to be heterozygotes for previously reported mutations shown to cause autosomal recessive MATI/III deficiency when present in homozygous or a compound heterozygous configuration. The remaining six patients had variants of unknown clinical significance or novel mutations. For the majority of individuals, methionine persisted above the normal range but trended downward over time. None of these 13 individuals was started on a low-methionine diet, and all have age-appropriate growth and development. CONCLUSION: These cases show that individuals with even single changes in the MAT1A gene may have elevations in methionine identified by newborn screening, which may persist for months after birth without any clinical consequences.

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This case report describes an interesting incidental finding on an orthopantomogram: bilateral radio-opaque objects in the mandibular rami region. The origin of the objects remains unidentified; however, the authors have tentatively identified these as being susuk by a process of exclusion of other possibilities.

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BACKGROUND: To determine whether osteopathic medical students, fellows, residents, and practicing physicians differ in their ability to identify inanimate objects and if these skills relate to palpatory experience. METHODS: Fifteen commonly known objects were fixed to a board and blinded with a cotton cloth. In Part I of testing, participants were asked to identify 9 objects, with choices provided. In Part II participants were asked to identify 6 objects using one word only. Part III consisted of identifying the shape of an object in Part II. RESULTS: Eighty-nine osteopathic medical students, fellows, residents, and practicing physicians participated in the study. Overall, correct identification of objects was higher in Part I with choices than in Part II without choices available. No statistically significant difference was found among osteopathic medical students, fellows, residents, and practicing physicians in the correct identification of the objects. CONCLUSIONS: Accuracy in tactile identification of objects among varying levels of palpatory experience was not found. Correlation with clinical palpation cannot be made as it requires a subset of palpatory skills not tested in this study. Accuracy and measurement of palpation should be studied further to demonstrate if palpatory experience improves palpatory accuracy.

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AIM: Previous studies have demonstrated that raised preoperative neutrophil to lymphocyte ratio (NLR) is associated with poor prognosis in colorectal cancer (CRC). The aim of this study was to assess whether preoperative NLR could predict patients at risk of recurrence of CRC. METHOD: All consecutive patients who underwent surgical resection for CRC over a 2-year period at our institution were analysed. Demographic data including CRC recurrence were prospectively collected from our institutional cancer database. CRC recurrence was diagnosed on radiological and endoscopic histopathological data. Preoperative NLR was calculated on baseline blood results, with a value >5 being a poor prognostic factor. Parametric survival analysis was used to identify risk factors for CRC recurrence. Hazard ratios (HRs) were calculated for gender, CRC stage using Jass score, preoperative NLR and CRC site. P < 0.05 was considered statistically significant. RESULTS: In all, 297 patients (157 men) underwent CRC resection at a median age of 70 years (range 23-93); 164 patients had colon cancer, 111 rectal cancer and 22 recto-sigmoid cancer. The distribution by stage of CRC was 30.2% for stage 1, 23.8% for stage 2, 19.5% for stage 3 and 26.5% for stage 4. Over a median follow-up period of 3.35 (0.1-8) years, 59 (19.8%) patients had recurrent CRC. Multivariate analysis revealed CRC stage (HR 8.69, 95% CI 3.85-19.6, P < 0.0001) and NLR >5 (HR 1.81, 95% CI 1.07-3.07, P = 0.028) to be significant and independent risk factors predictive of recurrent CRC. CONCLUSION: These data suggest that preoperative NLR >5 is predictive of CRC recurrence.

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INTRODUCTION: Problem based learning (PBL) has gained wide acceptance in undergraduate education, but less so in postgraduate education. Qualitative research methodologies can help us gain insight and understanding of the students' experience in undertaking such programmes. AIM: To evaluate the experiences of postgraduate students undertaking a PBL based postgraduate programme. METHODS: Focus groups and semi-structured interviews were used to investigate students' experiences. The qualitative data were coded, the codes were grouped into categories and a coding framework developed. From this a construct is proposed to give insight into students' experiences. The validity of this construct was examined by reviewing the literature. RESULTS: Students entered the programme with high expectations, but soon found they had challenges to overcome. They came to realise that they were on a journey, rather than undertaking a sequence of separate individual learning events. PBL led to significant tensions both within the individuals and the group, caused by the conflict between appreciating PBL as a 'good thing' and yet finding that ;it just doesn't seem to work'. The fear of failure in a high stakes setting only exacerbated these tensions. The literature review revealed an inconsistent approach to the use of PBL and its evaluation in a postgraduate/continuing medical education setting. However it did provide evidence of similar findings in qualitative studies, supporting the construct developed. CONCLUSION: We have proposed a construct to help in understanding the PBL experience for students undergoing a 'high stakes' orthodontic postgraduate programme with a core of PBL.

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OBJECTIVE: The primary objective of this prospective clinical trial was to assess the clinical bond failure rates of orthodontic brackets bonded using a self-etching primer (SEP), compared with brackets bonded using a conventional acid-etched technique with control adhesive (Transbond). A secondary aim was to investigate whether characteristics of the operator, patient or tooth bonded had any influence on bracket failure. DESIGN: Single-centre randomized controlled clinical trial. Thirty-four patients were bonded, each being randomly assigned to either the test or control adhesive. SETTING: NHS Hospital Orthodontic Department, Chester, UK. SUBJECTS: Orthodontic patients requiring fixed appliance treatment. MAIN OUTCOME MEASURES: Bond failure. MAIN OUTCOME RESULTS: Failure rates over the initial 6-month period were 2.0% (Transbond) and 1.7% (SEP) with no statistically significant difference between the two groups. Over the duration of the fixed appliance treatment, bond failure rates increased, but remained acceptable at 7.4 % (TB) and 7.0% (SEP), respectively. When operator, patient and tooth characteristics were analysed, only the bracket location was found to be significant. Maxillary brackets were more likely to fail than mandibular brackets (RR 0.47%; 95% CI 0.22, 1.03). The failure rate for brackets in our study was low when compared with previous studies. CONCLUSIONS: Both the acid-etched control and self-etching primer in combination with adhesive pre-coated brackets were successful for clinical bonding. Their combined failure rate was lower than that reported in similar trials.

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INTRODUCTION: To compare the variations in consenting practice amongst trainees and consultant surgeons for laparoscopic cholecystectomy with specific reference to the documentation of significant risks of surgery. PATIENTS AND METHODS: A proforma was devised which included significant and/or commonly recognised complications of laparoscopic cholecystectomy. This was then cross-referenced with the consent forms for the 80 patients included in the study and the documented risks explained in each case were noted. RESULTS: The results showed that there is considerable variation between the three grades of clinicians involved in obtaining a patient's consent for laparoscopic cholecystectomy. There was a clear difference in emphasis of the significant complications depending on the seniority of the consenter. Over 80% of the consents in this study were still being obtained by junior staff. CONCLUSIONS: More often than not, patients are not provided with consistent information to make an informed choice. We suggest that a preprinted consent form will provide a more uniform approach to consenting practice for laparoscopic cholecystectomy.

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Virtual learning environments (VLEs) are attractive solutions for the delivery of education on-line. Orthodontic education online has the potential to alleviate some of the problems caused by increasing demands on academic staff, the impact of the European work time directives and changes in junior doctors' hours. All act to constrain the effective training of orthodontic postgraduates. The design of a VLE is driven by modern concepts in learning and teaching, the structure, content and assessment methods will help determine the range of behaviours any programme hopes to encourage. This paper aims to provide information on how a modular specialist-training programme in the United Kingdom has been developed and enhanced by a VLE.

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This paper aims to encourage a debate on the learning outcomes that have been developed for orthodontic specialist education. In outcome-based education the learning outcomes are clearly defined. They determine curriculum content and its organization, the teaching and learning approaches, the assessment techniques and hope to focus the minds of the students on ensuring all the learning outcomes are met. In Orthodontic Specialist Registrar training, whether constructive alignment can be achieved depends on the relationship between these aspects of the education process and the various bodies responsible for their delivery in the UK.

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Developments in teaching and learning have implications for every orthodontist. This paper describes some of the theories of teaching and learning that have led to a quiet revolution in higher education. Developments have included the incorporation of self-directed and problem-based learning concepts, together with a more active and interactive role for the learner. The importance of these changes for orthodontic education is discussed.

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This controlled retrospective study aimed to identify the contribution of skeletal and dental changes in the correction of Class II division 1 malocclusions using Fränkel's functional regulator II (FRII), with reference to a concurrently recruited control group. One hundred and thirty-eight patients with Class II division 1 malocclusions were identified, those accepting treatment forming the study group and those declining treatment the control group. The study group (n = 70) were treated with a Fränkel appliance. Pre- and post-treatment observation cephalometric radiographs were analysed and compared. Mean values for both skeletal and dental variables in the control group were remarkably consistent throughout the study period; however, this masked individual variations in this group. The skeletal variables in the study group that showed statistically significant differences from the control group were SNB, ANB, BaNA and ANS-Me, but none of these was sufficiently large to be regarded as clinically significant. Dental variables showed clinically and statistically significant differences, including a 10 degree reduction in UI-Max and 3.1 degree increase in LI-Mand. The Fränkel appliance was thus found to be effective in producing desirable occlusal and dental changes in the majority of patients treated.

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