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To create a simple simulated tonsil-tying model to help trainees gain surgical skills during limited training opportunities.
Methods
A tonsil-tying trainer was constructed using basic hospital items that are easily attainable in a basic hospital setting. Feedback was obtained from consultants, registrars and senior house officers.
Results
A simple, low-cost and effective low-fidelity model for deep knot tying in tonsillectomy is presented. The model is modifiable for the progressing trainee and allows a degree of objective feedback with the potential for subjective feedback from a trainer. The model is easy to prepare using typical basic hospital ward equipment.
Conclusion
This model provides practice of placing a Boyle–Davis gag, and the use of tools and a head light. It is adjustable for tonsil-tying practice at a variety of depths with different vessel sizes and conditions (e.g. bleeding). Lastly, basic objective feedback without significant technical challenges is possible.
Retropharyngeal and parapharyngeal infections can be managed surgically or conservatively. A trial of medical treatment before considering computed tomography (CT) imaging may be appropriate.
Methods
This is a retrospective review of patients with retropharyngeal and parapharyngeal infections between October 2022 and April 2023. Descriptive and statistical analysis compared surgically and conservatively managed patients.
Results
There were 33 patients (median age 58 months). CT imaging was acquired for 30 of 33 patients (90.9 per cent) and 25 had a CT scan within 24 hours of presentation. Fourteen patients (42.4 per cent) were managed surgically. The mean duration of antibiotics for surgically and conservatively managed patients was not significantly different (19.9 vs 21.4 days, p = 0.73). Larger lesions were observed on the CT scans of surgically treated patients (22.8 vs 15.6 mm, p = 0.01).
Conclusion
Management of paediatric retropharyngeal and parapharyngeal infections can be surgical or conservative. We propose a management algorithm that allows an initial trial of intravenous antibiotics before CT imaging for selected patients.
‘Positional goods’, a term coined by Fred Hirsch, is an important concept in economics, social sciences and philosophy; however, it is used in different ways. This paper recovers Hirsch’s concept of positional goods as scarce goods that are fixed or near-fixed in supply and argues for the usefulness of this concept. Hirsch’s concept may have explanatory power beyond the concept used by most economists – that of Robert Frank. Moreover, Hirsch’s concept is more explanatorily basic and useful than the concept used by most philosophers – that of Brighouse and Swift.
Thirty-five years have passed since the killing of the South African refugee Jerry Masslo in Villa Literno in 1989 to the death of the Indian labourer Satnam Singh in Latina in 2024, marked by exploitation, violence, and abuses in the Southern Italian countryside. Only a few journalistic reports have documented this situation, and the article aims to fill this historiographical gap with a timely investigation, calling for the start of an international debate on the inhuman working conditions of foreigners in the countryside of developed countries. The article highlights some variables that have remained steady over time: the absence of public policies to regularise agricultural labour, the widespread presence of informal settlements in the countryside with risks to the safety of farm labourers, the low wage levels that violate people’s dignity, the persistent illegality in recruiting labour through ‘caporalato’ (forced labour), deaths at work due to exploitation and climate change. These are elements of critical analysis that call for an in-depth reflection on how to improve the working conditions of labourers in the rural economy today. The contribution of foreigners, as emerges from the quantitative analysis in the article, is irreplaceable for the well-being of developed societies. This is why history has an essential ethical and civic mission in highlighting the conditions of severe exploitation in which they are forced to work.
Comparative histopathological and ultrastructural investigations were performed on the livers of 2 fish species, namely, flounder (Platichthys flesus (L.)) naturally infected with the nematode Anisakis simplex (s.l.) (Rudolphi, 1809) larvae (L3) and tuvira (Gymnotus inaequilabiatus) (Valenciennes, 1839) harbouring the nematode Brevimulticaecum sp. (L3) (Shikhobalova and Mozgovoi, 1952). The intensity of infection by A. simplex (s.l.) larvae (L3) in flounders ranged from 3 to 10 parasites per organ. The worms were encapsulated by the peritoneal visceral serosa on the external surface of the liver. Infected P. flesus livers showed hepatocyte cytoplasmic rarefaction and cell swelling. A few immune cell types, such as macrophages, limited numbers of mast cells (MCs), lymphocytes and some epithelioid cells, were observed within the granuloma. The intensity of infection by Brevimulticaecum sp. (L3) in G. inaequilabiatus ranged from 4 to over 340 larvae per organ, and the nematode larvae were encircled by round-to-oval granulomas. Each granuloma possessed 3 concentric layers of cells and tissue: an inner layer in close proximity to the Brevimulticaecum sp. (L3) cuticle, formed by densely packed layers of epithelioid cells showing several desmosomes between each other; a middle layer of numerous MCs entrapped in a thin fibroblast-connective mesh; and an outer layer of fibrous connective tissue with thin, elongated fibroblasts. High numbers of macrophages and macrophage aggregates were scattered within the granuloma. This is the first study to compare the cellular nature of granulomas and the immune responses in the livers of paratenic fish hosts of 2 nematode species.
This study is to evaluate the results obtained in a group of implanted otosclerotic patients and compare them with a matching group of non- otosclerosis cochlear implant patients.
Methods
Pre-operative computed tomographic scans, intra-operative findings, type of electrode used and difficulties of 17 patients with otosclerosis were documented. Post-operative complications, facial nerve stimulation, electrode dislocation and audiological and speech outcomes were documented and the data analysed.
Results
Surgical difficulties were directly related to the advanced stage of the disease. No major complications were reported in this cohort. No significant difference was found between both groups one year after surgery; the mean pure tone average was 35 dB ± 4.43, speech reception threshold was 40 ± 4.96 and speech discrimination score was 80 per cent ± 12.55 in the otosclerotic group.
Conclusion
Cochlear implantation is a safe and effective management for advanced otosclerosis patients even after stapes surgery.
This study explores whether DNA methylation (DNAm) mediates the association between lean body mass (LBM) and cognition, as well as whether LBM mediates the association between DNAm and cognition. Based on the data of 59 monozygotic twin pairs, mediation analyses were performed using causal inference test method and mediation analyses. Average causal mediation effect (ACME), average direct effect (ADE), and total effect (TE) were calculated. Among the CpGs associated with LBM, five located within PDGFRB and RP11 genes (ACME: −0.0972−0.0463, |ACME/ADE|: 10.44%−18.30%) negatively mediated the association between LBM and cognition, while one in the PAX2 gene (ACME: 0.3510, |ACME/TE|: 11.84%) positively mediated the association. Besides, the methylation risk score (MRS) of RP11 gene (ACME: −0.0517, |ACME/ADE|: 10.64%) and MRS of all CpGs (ACME: −0.0511, |ACME/ADE|: 10.53%) negatively mediated the association of LBM with cognition. For another, LBM negatively mediated the association between the DNAm level of one CpG within UBXN6 and cognition (ACME: −0.0732, |ACME/TE|: 20.78%), while positively mediated the association between the DNAm level of four CpGs within FOXI2 and cognition (ACME: 0.2812−0.4496, |ACME/TE|: 18.15%−27.29%). It was found the DNAm in PDGFRB, RP11 and PAX2 partially mediates the association between LBM and cognition, and the association between DNAm in UBXN6 and FOXI2 with cognition is also partially mediated by LBM.
This paper revisits the relationship between tax evasion and tax rates in a heterogeneous-agent, incomplete-markets model. Extending the foundational works of Allingham and Sandmo (1972) and Yitzhaki (1974), we explore how financially constrained households use tax evasion to mitigate the adverse effects of market imperfections. We show that deterrence policies, such as audit probabilities and penalties, exacerbate the effects of borrowing constraints. Importantly, increasing income tax rates can sometimes alleviate these negative impacts when individuals evade taxes. We identify three mechanisms shaping underreporting: the direct effect, the threshold effect, and the income effect. These help explain when and why the Yitzhaki puzzle arises. Numerical results reveal a non-monotonic relationship between tax rates and underreporting, underscoring the relative strength of these effects and offering fresh insights into the Yitzhaki puzzle.
The medical workforce in psychiatry is increasingly diverse, but not necessarily in its senior leadership in the UK’s National Health Service (NHS). We aimed to describe the characteristics of psychiatrists with board-level responsibility in mental health trusts in England in 2024, comparing the current picture with that of 2016 and 2020, using publicly available data.
Results
The proportion of medical directors who are female has not changed, so women remain underrepresented, while the proportion who are international medical graduates has increased substantially, so they are no longer underrepresented. Although fewer in number, intellectual disability psychiatrists are underrepresented.
Clinical implications
Greater attention will need to be paid to developing female medical leaders if representative leadership is to be achieved.
Gel’fand–Dorfman algebras (GD algebras) give a natural construction of Lie conformal algebras and are in turn characterized by this construction. In this article, we define the Gel’fand–Dorfman bialgebra (GD bialgebra) and enrich the above construction to a construction of Lie conformal bialgebras by GD bialgebras. As a special case, Novikov bialgebras yield Lie conformal bialgebras. We further introduce the notion of the Gel’fand–Dorfman Yang–Baxter equation (GDYBE), whose skew-symmetric solutions produce GD bialgebras. Moreover, the notions of $\mathcal {O}$-operators on GD algebras and pre-Gel’fand–Dorfman algebras (pre-GD algebras) are introduced to provide skew-symmetric solutions of the GDYBE. The relationships between these notions for GD algebras and the corresponding ones for Lie conformal algebras are given. In particular, there is a natural construction of Lie conformal bialgebras from pre-GD algebras. Finally, GD bialgebras are characterized by certain matched pairs and Manin triples of GD algebras.
This study investigated the factors influencing the mental health of rural doctors in Hebei Province, to provide a basis for improving the mental health of rural doctors and enhancing the level of primary health care.
Background:
The aim of this study was to understand the mental health of rural doctors in Hebei Province, identify the factors that influence it, and propose ways to improve their psychological status and the level of medical service of rural doctors.
Methods:
Rural doctors from 11 cities in Hebei Province were randomly selected, and their basic characteristics and mental health status were surveyed via a structured questionnaire and the Symptom Checklist-90 (SCL-90). The differences between the SCL-90 scores of rural doctors in Hebei Province and the Chinese population norm, as well as the proportion of doctors with mental health problems, were compared. Logistic regression was used to analyse the factors that affect the mental health of rural doctors.
Results:
A total of 2593 valid questionnaires were received. The results of the study revealed several findings: the younger the rural doctors, the greater the incidence of mental health problems (OR = 0.792); female rural doctors were more likely to experience mental health issues than their male counterparts (OR = 0.789); rural doctors with disabilities and chronic diseases faced a significantly greater risk of mental health problems compared to healthy rural doctors (OR = 2.268); rural doctors with longer working hours have a greater incidence of mental health problems; and rural doctors with higher education backgrounds have a higher prevalence of somatization (OR = 1.203).
Conclusion:
Rural doctors who are younger, male, have been in medical service longer, have a chronic illness or disability, and have a high degree of education are at greater risk of developing mental health problems. Attention should be given to the mental health of the rural doctor population to improve primary health care services.
Routine immunization programs may reduce antibiotic use, but few studies have comprehensively examined their impact on antibiotic utilization. We aimed to explore temporal trends in vaccination and antibiotic use among young children in the United States.
Design:
Ecological study using the Merative® MarketScan Commercial Claims and Encounters database.
Methods:
We analyzed claims data on pediatric vaccine uptake (pneumococcal conjugate, Haemophilus influenzae type b, diphtheria-tetanus-pertussis, and influenza) and antibiotic prescriptions and antibiotic-treated respiratory tract infections among US children <5 years during 2000–2019. Vaccination status was assessed annually, and children were categorized based on receipt of all four vaccines, 1–3 vaccines, or no vaccines. Antibiotic prescriptions were classified by spectrum and drug class. Respiratory infections included otitis media, pharyngitis, pneumonia, sinusitis, and viral infections.
Results:
Among 6.7 million children, vaccine uptake increased from 32.5% receiving all four vaccines in 2004 to 66.8% in 2019. During this period, overall antibiotic prescriptions decreased from 1.89 to 1.01 per person-year, with the greatest reductions in macrolides (73.3%) and broad-spectrum antibiotics (57.0%). Antibiotic-treated respiratory tract infections declined from 2.43 to 1.61 episodes per person-year, with the largest decreases in sinusitis (64.7%) and pharyngitis (39.8%).
Conclusions:
The findings suggest a temporal association between routine childhood immunization uptake and reduced antibiotic utilization. Although immunization programs are primarily aimed at protecting children from vaccine-preventable diseases, their potential role in complementing antimicrobial stewardship efforts and other factors influencing antibiotic reduction warrants further investigation through more rigorous study designs.
During nematode surveys conducted to investigate the biodiversity of plant-parasitic nematodes in Mediterranean olive groves with different management strategies (organic and conventional), a nematode population of the genus Neothada was detected in southern Spain. Application of integrative taxonomical approaches clearly demonstrated that it is a new species described herein as Neothada olearum sp. nov., also representing the first report of the genus in Spain. The new species is amphimictic, characterised by a short body (563–774 μm); cuticle widely annulated (2.5–3.0 μm); total number of body annuli 214–226; 16 longitudinal ridges giving a tessellate body surface; stylet without distinct basal knobs (9.0–11.0 μm); and tail elongate-conoid, with tip bluntly rounded. The results of molecular analysis of D2-D3 28S rRNA, ITS rRNA, partial 18S rRNA, and cytochrome oxidase c subunit 1 (COI) gene sequences support for the new species status and clearly separated from N. major and other species within Neothada. Phylogenetic analyses of ribosomal and mitochondrial markers of this study suggested that Neothada is a monophyletic genus, clearly separated from Thada.
This paper studies voter turnout and selective abstention on voting days with more than one election or referendum. We extend the rational choice model to a setting with multiple concurrent votes. The model is based on a voter’s net benefit, which includes a vote’s salience and information costs. It explains how the net benefit of different concurrent votes enters a voter’s utility function and thereby affects turnout and selective abstention, the tendency to vote in one but not all votes held on the same day. We test our theoretical predictions using data on concurrent propositions in Switzerland from 1988 to 2016. Our results suggest that the proposition with the highest net benefit and the sum of the net benefits of all concurrent propositions are relevant determinants of the individual turnout decision. We also find that a proposition’s net benefit explains variation in selective abstention.
To mitigate the risk of harm to themselves or others, people with mental disorders may require compulsory admission to hospital for in-patient treatment. In England and Wales this is authorised under the Mental Health Act 1983 (MHA). Patients have the right to appeal against this involuntary detention at a hearing before the First-tier Tribunal (Health Education and Social Care Chamber) Mental Health, and psychiatrists may be called on to provide written and oral evidence to the tribunal. The purpose of this article is to help psychiatrists, particularly trainees, understand the sections of the MHA involved, the patient’s right of appeal, the role of the tribunal, their own role as a professional witness, and how to improve the quality of evidence they provide.
How do authoritarian actors navigate the liberal international order, adopting democratic facades without committing to democratic principles? And why is it so difficult for the international normative system to debunk their pretence when it comes to the use of democratic values? This paper explores this question by introducing ‘profilicity’ and ‘performativity’ as key concepts to understand how autocratic regimes build powerful profiles within a liberal system that values authenticity. Unlike conventional theories, which assume that engagement with liberal norms requires genuine commitment, profilicity reveals that strategic image-building can be just as effective. Through this lens, we see how autocracies exploit liberalism’s own ideals, using performative adaptation to secure status and reshape norms. This paper suggests that the liberal order’s emphasis on sincerity may itself be a strategic weakness, one that autocratic actors skilfully navigate in a world increasingly driven by profiles over principles.