In India, cardiothoracic (CT) surgery training follows a 3+3-year model, where 3 years of general surgery residency with certification (MS/DNB) is required for entering 3 years of thoracic surgery residency (MCh/DNB). There are two certifying boards at the national level. One being the Medical Council of India (MCI), which oversees the major accreditation process involving the undergraduate and postgraduate medical education in India, and the other being the National Board of Examinations (NBE), which was formed for the purpose of establishing a uniform standard of postgraduate medical education. Recently, the latter body has come up with an alternative model for thoracic surgery residency in India. This model includes an integrated 6-year residency, with lesser emphasis on general surgical skills and greater exposure to CT surgery.Changes to the current model of training for CT surgery is the need of the hour and should be initiated very soon by the MCI to meet the future demand for CT surgeons in India. An integrated training program is essential to create a new generation of cardiovascular specialists. Future directions to achieve this goal must include modifications to the undergraduate programs so as to infuse interest for CT surgery in the young minds of medical students. With a teeming population of more than 1.1 billion people, the Indian health-care machinery is struggling to cope up with the rising burden due to both communicable and chronic diseases. Many studies on Indian immigrants and cross-sectional studies from India have shown a high prevalence of coronary artery disease (CAD) in the Indian population and this figure is several times higher than in industrialized nations . Hence, An estimate from the extrapolated results of Global Burden of Diseases study done in 2000 showed that around 30 million patients may be suffering from CAD in India . ConcretThe first thoracic surgery residency program in India was established in the year 1958 by Dr. Reeve H. Betts at Christian Medical College and Hospital (CMC) in Vellore, a city in south India . InitialOn completing surgical residency, the prospective candidates have the options of joining either an MCh (Master of Chirurgiae) program, accredited by the Medical Council of India (MCI), or the DNB  program, accredited by the National Board of Examinations (NBE). The MCI is the primary organization for the accreditation process of undergraduate and postgraduate medical training in India. The NBE, set up in 1975, runs a parallel system of postgraduate education, with uniform selection criteria, curriculum, and examination format for training positions offered all over India  is primarily in cardio vascular surgical departments, with rotations in allied specialties, such as cardiac anesthesia, pulmonary medicine, and critical care unit. A surgical log book has to be maintained and a minimum number of procedures as provided in the curriculum have to be performed either independently or under supervision. Research methodology is part of the training similar to other Indian postgraduate courses. A candidate is required to present a dissertation, publish a paper in an indexed journal, and make two paper presentations at a national or international conference in the specialty. At the end of 6 years of training, having met all of the above-mentioned criteria, a candidate is eligible to practice thoracic surgery in India.The main advantage in this model is that the total period of residency spent in general surgery is limited to 9 months, during which core surgical skills are gained by the trainees. As mentioned earlier, this paves the way for a greater emphasis on learning skills relevant to thoracic surgery and allied specialties. An additional 6th year of rotation, in sub-specialties, such as pediatric cardiac surgery, video-assisted thoracic surgery, etc., at other institutes of excellence, provides ample opportunities for the trainees to learn advanced, state-of-the-art CT procedures. This would provide ample exposure in using these new tools to build a career as future cardiovascular specialists. Also, specific training in allied specialties, such as nuclear medicine, diagnostic radiology, cardiac anesthesia, and critical care will be an important add-on to their training, thus leading to a holistic approach to patient care. The most striking aspect of this unique integrated curriculum is having the entire residency dedicated to what the trainees will be doing for the rest of their careers, thus leading to better trained surgeons and more gratification for the trainees.There have been notable advancements in technology in recent times and conventional open surgical treatments are giving way to less invasive strategies. Management protocols are frequently employing percutaneous devices , robotic and videoscopic/thoracoscopic/endoscopic tools for minimal access approaches. The next generation of CT surgeons must be proficient in traditional open surgical procedures as well as being at ease using these new state-of-the-art procedures, and the integrated program may be the best platform to achieve this goal.However, longer duration of training from the point of obtaining MBBS qualification and the necessity to make an early career choice of specialization are factors that can make this training model difficult for the prospective trainees. New graduates are relatively immature when tasked with choosing their future specialty as CT surgery. The major limiting factor is lack of familiarity with CT surgery, its scope, and its challenges. To overcome this hurdle and to infuse interest for CT surgical career in these young minds, programs could be created to expose them to academic CT surgery through active mentorship, operative skills training, and individual academic pursuits. Allen et al. in their study of a cohort of 18 medical students, showed success in these pursuits, as demonstrated by the high academic productivity of their students and their 80% matriculation rate to surgical residencies .Unlike in the United States, where the integrated residency model was introduced 5 years earlier, it has been only 2 years since the introduction of a similar model in India. Moreover, the CT courses accredited by the MCI still follow the standard 3+3 years of residency training. A limited number of institutes accredited by the NBE still follow the standard model. In this scenario, one has to wait and see if this new training format meets with success as in the United States and whether the primary accreditation body, MCI, will try to implement the format in its programs. Modifications should be made to the undergraduate curriculum so as to stimulate interest in the CT specialty at a much earlier phase. In conclusion, to achieve its goals, this new format of training should ensure the complete and efficient transference of advanced surgical skills from the mentor to the CT trainees.


Research ethics guidelines are essential for conducting medical research. Recently, numerous attempts have been made to establish national clinical research documents in the countries of the Middle East. This article analyzes these documents.Thirteen Arab countries in the Middle East were explored for available national codes, regulations, and guidelines concerning research ethics, and 10 documents from eight countries were found. We studied these documents, considering the ethical principles stated in the Declaration of Helsinki, the Council for International Organizations of Medical Sciences (CIOMS) guidelines, and the International Conference of Harmonization - Guidelines for Good Clinical Practice (ICH-GCP). Our paper comprises a complete list of protections, such as confidentiality, informed consent, ethics committees, and others.This study found different levels and kinds of research ethics regulations and guidelines in the countries examined. Two groups can be distinguished: the countries in the first group have one or more research ethics regulations or guidelines, while the countries in the second group have not yet established any. Most of the documents showed various degrees of deficiencies in regard to ethical protection. The majority of the documents that were examined refer to one or more international documents on biomedical research ethics.Recently, a lot of efforts have been made in many countries in the Middle East. However, compared with international documents, most of the research ethics documents in use in this region demonstrate numerous deficiencies. As it relates to these documents, extensive differences could be observed in regard to development, structure, content, and reference to international guidelines. In recent decades, there has been increased awareness of ethical issues because of the extensive expansion of clinical research and trials. There has also been growing debate over the ethical challenges faced by different societies. Accordingly, scholars have begun to consider how to offer protection to the research community, resulting in the creation of research ethics guidelines in many countries .Ethical guidelines did not truly appear until after World War II. Prior to this point, efforts to regulate human experimentation—such as the codes of Thomas Percival in England 1794)—were few and exceptional 794—were . In 1847Statistics between 2006 and 2010 show a 4 percent rise in the global number of drug trials conducted in the Middle East, which was the largest increase in any region of the world. Conversely, the number of drug trials in North America decreased by 11 percent in the same period . Many faAs a result of this increase in clinical research in the Middle East, many ethical issues involving the use of human subjects in these countries have been brought to the attention of ethicists in the region. In a study conducted among members of research ethics committees in Egypt, 92% of interviewees ranked the development of appropriate national guidelines as a major challenge . MoreoveIn this paper, we reviewed the relevant guidelines, regulations, and ethical codes of the Arab countries in the Middle East; investigated whether each country had national regulations or guidelines on research ethics; determined whether ethical principles are stated in these guidelines and, if so, which ones; and then compared them with each other and with the major international guidelines.Using direct access to the websites of various governmental agencies in each country, we conducted a review of the available online direct data sources for guidelines on research ethics and clinical research laws and the indirect data sources included in the codes of ethics. The websites of ministries of health, ministries of higher education, medical councils, the food and drug administrations, research centers, medical unions, and national committees of bioethics in the 13 member nations of the League of Arab States in the Middle East . The couOur study selection included all national codes or guidelines  available online that addressed research ethics either exclusively or partially. We critically examined all these national codes and guidelines, considering the protections mentioned in the Declaration of Helsinki, the CIOMS guidelines, and the ICH-GCP. Owing to their wide acceptance around the world, we selected the Declaration of Helsinki and the ICH-GCP for comparison. We selected the CIOMS guidelines for the same reason, but also because they were crafted specifically with the aim of applying the Declaration of Helsinki to developing countries in a way that reflects the conditions and needs of biomedical research in those countries, and due to the implications for the multinational or transnational research in which they may be partners . A list All relevant documents, written in either English or Arabic, were eligible for inclusion.Our study approach included both qualitative descriptions  and compWe retrieved 10 guidelines from eight different countries. Three of the guidelines came from Saudi Arabia. No national guidelines could be found in the remaining five countries.After the establishment of the first international and Western clinical research guidelines, it required a few decades for decision makers in the Arab countries in the Middle East to begin thinking about their own guidelines. The first attempts at crafting clinical research regulations appear as summarized chapters in the general medical ethics guidelines: in Lebanon, the “Law of Medical Ethics” (1994) , in SaudThe Jordanian “Law of Clinical Studies” (2001)  was the Ten years after establishing universal ICH-GCP guidelines (1995), the first local GCPs began to appear in the region through the Saudi Food and Drug Authority’s (SFDA) “Clinical Trial Requirement Guidelines”   and the Kuwait’s “Ethical Guidelines for Biomedical Research” (2009)  and QataMany differences exist in terms of whether countries in the Middle East have research ethics guidelines. We classified the countries into two main groups. The countries in the first major group already have guidelines and can be divided into two subgroups according to whether they have special national research ethics guidelines (A)—as is the case for Saudi Arabia, Qatar, Bahrain, Kuwait, the UAE, and Jordan—or whether they have general documents that contain some paragraphs about research ethics (B), as in Egypt and Lebanon.The second major group contains countries that have no special guidelines but either refer to international guidelines, as in Syria ,21 and IEven though the guidelines used in Group A countries have similar names, their structures are not the same. All of them use the words ‘guidelines’ and ‘research’ or ‘trials’ in their titles. Additionally, the UAE’s guideline adds ‘good clinical practice’ to its title , which seems reasonable because the UAE’s guideline uses the ICH-GCP structure and contains similar chapters, such as a glossary, principles, requirements for the approval of clinical trials, goals, medical institutes, protection of subjects participating in the clinical trial, and responsibilities of the investigator.This GCP structure is also used by the SFDA guidelines (I in Table The Bahraini (draft 2009)  and QataEgypt and Lebanon do not have special guidelines; however, both countries have medical documents containing an abstracted chapter concerning clinical research.Saudi Arabia is the only country that has three different documents referring to the regulation of research ethics. The first document (I) is a general guide and contains a chapter concerning biomedical research on both humans and animals, referring specifically to the main principles of clinical research. The second document (II) is an official legal document, stated by the council of ministers.Of the 10 documents related to biomedical research ethics that were found, five are guidelines, three are national laws, and two are medical codes. Two of the three laws (Saudi Arabia and Jordan) focus on medical research, while the third (Lebanon) is a general medical law.Each guideline contains at least two or more protections. The Qatari guideline contains the most protections at 19, followed by the Saudi “Clinical Trial Requirement Guidelines” with 15 protections. The Saudi “Ethics of the Medical Profession,” as well as the Jordanian and Lebanese guidelines come at the end of the list, with only five, three, and two protections, respectively  made advanced steps in this regard compared with non-GCC countries , which is the only manual related to research ethics available in the region (This version is in Arabic only. An English copy is expected to be published soon) .Second, we do not include the ongoing efforts to establish guidelines in many countries, such as in Egypt, Jordan and Saudi Arabia, where it is expected that new guidelines will appear in the coming years.Third, our paper does not report information on the process of ethical review at the national level or on what mechanisms are used to encourage adherence to regulations or guidelines.Recently, notable efforts to establish national research ethics guidelines have been made in many countries in the Middle East. However, compared with international documents, most of the research ethics documents in use in this region demonstrate numerous deficiencies. Many differences among the documents can be observed in the development, structure, content, and reference to international guidelines. Guidelines from GCC countries are more developed compared with guidelines from other countries in the Middle East. Greater efforts are required to develop better regulations and guidelines in most countries in the Middle East.The authors declare that they have no competing interests.All authors participated in the design of the study. GA wrote the first draft. All authors have discussed all points in the first draft and in all subsequent drafts. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6939/13/34/prepub


Due to a problem of identification, how to estimate the distinct effects of age, time period and cohort has been a controversial issue in the analysis of trends in health outcomes in epidemiology. In this study, we propose a novel approach, partial least squares (PLS) analysis, to separate the effects of age, period, and cohort. Our example for illustration is taken from the Glasgow Alumni cohort. A total of 15,322 students  received medical screening at the Glasgow University between 1948 and 1968. The aim is to investigate the secular trends in blood pressure over 1925 and 1950 while taking into account the year of examination and age at examination. We excluded students born before 1925 or aged over 25 years at examination and those with missing values in confounders from the analyses, resulting in 12,546 and 12,516 students for analysis of systolic and diastolic blood pressure, respectively. PLS analysis shows that both systolic and diastolic blood pressure increased with students' age, and students born later had on average lower blood pressure . PLS also shows a decreasing trend in blood pressure over the examination period. As identification is not a problem for PLS, it provides a flexible modelling strategy for age-period-cohort analysis. More emphasis is then required to clarify the substantive and conceptual issues surrounding the definitions and interpretations of age, period and cohort effects. One longstanding problem and controversy in observational research, such as epidemiology and sociology, surrounds how to estimate the distinct impacts of age, time period, and cohort on the changes in, for example, attitudes, behaviors and health outcomes in the population There have been many attempts to overcome this estimation (identification) problem in age-period-cohort analysis Another approach is to construct higher-order variables for those with perfect collinearity Although traditional regression analysis  implemented in statistical software packages requires that the data matrix for covariates is full-rank, this is not a requirement for statistical methods for data dimension reduction, such as principal component regression and partial least squares (PLS) regression Details of the Glasgow Alumni cohort have been described elsewhere Record linkage and follow-up of the Glasgow Alumni Cohort was under the ethics approval by the Multicentre Research Ethics Committees in the UK: MREC/99/0/9, “Influence of early life nutritional status, adolescent and adult diet on cancer incidence and mortality: a retrospective cohort study of Glasgow University students”, approved in March 2000. There was no consent collected at the time, as it is a historical cohort started 60 years ago; but this deemed acceptable by the ethics committees, if data used in an anonymised form - as they are throughout the analysis.t that maximise the covariance between the outcome (SBP or DBP in this study) and tp variables, x1, x2,…, px, each PLS component ti, is a weighted composite of p covariates:t, and therefore xi in equation (1) is usually scaled to have unit variance and zero mean.PLS seeks to select components ti that can be extracted is equal to the dimension (i.e. the rank) in the covariate matrix consisting of ix. For instance, in this study, there are only two dimensions in the data matrix consisting of age, the year at examination, and the year of birth; consequently, only two PLS components can be extracted from the three variables.In contrast to PCA, PLS extracts components by taking into account their relationships with the outcomes. In PCA, the extraction of components is independent of the outcome variables, whereas in PLS, components are extracted explicitly for their association with the outcomes. The extraction of PLS components operates under the same constraints as with PCA: (i) the sum of the squared weights is unity, i.e. PLS components are ordered according to the amount of variance in the outcome that is explained by them, i.e. the first PLS component has greater covariance with the outcome than the second PLS component, and the second has greater covariance than the third, etc. In PLS, the first PLS component explains most of the outcome variance.ix is then derived from the sum of products of the regression coefficients for PLS components and the weight for each ix. For example, when the outcome SBP is regressed on the two PLS components, the equation is given as:β1 and β2 are the regression coefficients for PLS components 1 and 2, respectively, and ε is the residual error term. The PLS regression coefficient for age is therefore The PLS regression coefficient for each R2, are equivalent to those from PCA regression . The advantage of PLS over PCA is that the first few components explain most of the covariance between the outcome and covariates.Note that if all PLS components are used as new covariates, the results from the PLS regression, such as regression coefficients and From a mathematical perspective, identification is a problem for the age-period-cohort analysis using ordinary least squares regression and related methods, because the inverse of the covariate matrix does not exist. However, whilst the inverse of a matrix without full rank does not exist, for a matrix without full rank, a mathematical technique, namely singular value decomposition (SVD), can still be used to obtain unique components of original variables, which are weighted compositions of original covariates 2) as a criterion for selecting PLS components. This gives us a measure of predictive ability, the predictive residual error sum of squares (PRESS) To employ PLS is to maximise the covariance between the outcome and new composites, so it is justifiable to use the increments in the explained variance in the outcome (e.g. changes in Rhttp://chirouble.univ-lyon2.fr/~ricco/tanagra/en/tanagra.html) with 1000 nonparametric bootstraps to obtain 95% confidence intervals.We first undertook sex-specific linear PLS regression for SBP and DBP by including the age at examination (16 to 25), the year of examination (1948 to 1968) and the year of birth (1925 to 1950) as continuous covariates. As PLS penalizes variables with small variances (e.g. age at examination), covariates are scaled to have unit variance 2 in the PLS model for SBP in men with one component was 3.45%, which is about 92% of the variance in SBP that could be explained by the three covariates. For the other models, the second component added little to the explained variance in blood pressure. Men born later in this cohort had lower SBP than those born earlier . Men who attended the university later had lower SBP than those who attended earlier . DBP for men born later was lower than that for those born earlier , and for those who attended the university later was 0.15 mmHg/per year lower than those who attended earlier. SBP for women born later was lower than for those born earlier . Women who attended the university later had lower SBP than those who attended earlier . Women who were born (or attended the university) later had lower DBP than those who were born (or attended the university)  earlier.The component selection statistic, PRESS, identified only one component for the restricted cubic splines PLS analysis for the associations of blood pressure with Birthyear and Examyear with Age entered as a continuous variable. The previous analysis of the Glasgow Alumni cohort found substantial downward trends in blood pressure occurred in male and female students after confounding factors were controlled for Research aiming at solving the collinearity problem in age-period-cohort analysis has generated an extensive literature, and most approaches have tried to accommodate the collinearity problem within the scope of traditional regression analyses. From a statistical viewpoint, an additional constraint can be made to make the effects of age, period, and cohort estimable, but the problem is that there are too many potential constraints. Hence, the more pertinent issue is rather that of interpretation with regard to the chosen constraint. As explained in the The cohort effect is usually attributed to the impact of early environment, such as nutrition in pregnancy and early childhood In this study, we also found that there seemed to be differences in trends for DBP, where the decreasing trends in exam year and birth year were less notable in women than in men, but for SBP, men and women had similar trends. Women had on average had lower DBP than men by about 10 mmHg, and whilst healthy diets or other factors were associated with improved blood pressure, there might be a physiological limit on how much reduction in blood pressure can be attained due to such factors.total effects of age, period and cohort, which has meaning and utility. This is a similar idea to that suggested recently by O'Brien of the partitioning of the total variance Many studies in the age-period-cohort analysis literature aim to resolve the identification problem in order to estimate the “unique” contribution of the three components The major difference between PLS and other modelling strategies is that it is straightforward to incorporate all perfectly collinear variables into the same model. Some approaches proposed in the literature can only be applied to aggregated data There is an extensive literature in epidemiology and social sciences as to how to estimate age, cohort and period effects. Whilst some of the debates and controversies focused upon the identification issue in the estimation Appendix S1Supporting appendix(DOC)Click here for additional data file.


Physicians face a new challenge; the self-educated patient. The internet is an important source that patients use to become self-educated. However, the individual choice for best treatment is difficult. The aim of this study was to investigate what kind of information is offered to total hip arthroplasty patients by internet and what information is appreciated by them.Websites of orthopedic departments of all hospitals in the Netherlands were evaluated. In addition, a cohort of 102 patients, diagnosed with arthritic joint disorders, filled in an online survey and gave their opinion concerning the importance of this information.Eighty different orthopedic websites of hospitals were identified. Websites presented information regarding the orthopedic staff surgeon (76%) and the postoperative rehabilitation process (66%). They also offered referral to other orthopedic websites (61%), the opportunity to make an outpatient appointment (21%), and the opportunity to submit an online question (15%). Patients rated the presence of information regarding prosthesis survival as very important (> 70%). However, the information on the type of prosthesis used by the hospital, and survival data of the prosthesis, were only present in ~ 9% and 5% respectively, of the websites.The content of health information on websites of hospitals is highly variable for total hip arthroplasty. Information regarding the hip implant and prosthesis survival is highly appreciated by patients, however, mostly absent on orthopedic websites in the Netherlands. The internet provides an enormous potential for orthopedic surgeons to inform the self-educated patient. A new challenge physicians are currently facing is the self-educated patient. Today, patients are much better informed on their disease and the condition that affects them than before. These new, self-educated patients are the consequence of cultural changes and improved access to the World Wide Web -5. The iThese self-educated patients can be of real value to physicians, as they are able to have a critical discussion on the suggested choice of treatment. However, the self-educated patient also warrants careful consideration. The quality and content of health information on the internet is highly variable . As a coThe aim of this study was to investigate what kind of online information is available for patients facing a total hip arthroplasty on websites of hospitals in the Netherlands, and to investigate what information is appreciated by them.In consultation with orthopedic surgeons of our department, we developed a screening list of items that orthopedic surgeons expected to be of special interest to patients facing a total hip arthroplasty. With use of this screening list, the websites of all hospitals in the Netherlands were evaluated on the presence of information related to total hip arthroplasty. The online screening was performed by JB in the period March to April 2009. The websites of 8 Dutch university medical centers, 85 general, and 35 categorical hospitals were screened. Hospitals with multiple locations were registered as one hospital if the website covered all locations. When each location exhibits a separate website, the website was considered as a different website and was screened and analyzed separately.very unimportant information' and score-5; 'very important information'. At the end of the survey, in an open question, patients were asked whether they had suggestions for additional topics that they felt important to be informed about. All the survey data was obtained anonymous by an independent researcher and was analyzed using descriptive statistics.In association with the Dutch Rheumatic Patients Organization and the Dutch Polyarthrosis Peer Association, the items on our screening list were evaluated. Both patient organizations invited a panel of members. All involved panel members suffered from arthritic joint disorders. Panel members received an electronic invitation in which they were asked to fill in an online survey. The online survey consisted of questions that measured the importance of the topics on the screening list. The importance of information was rated on a five point scale, with score-1; 'In the Netherlands, all hospitals have a website available. Because several hospitals displayed internet-sites that covered multiple locations, a total of 97 different websites of hospitals were located. Of these 97 websites, 80 websites had a link to an orthopedic website or a link to a websites of orthopedic partnership. Seventeen hospitals who did not have an orthopedic department, or did not provide orthopedic services, were excluded.Seventy-six percent of the 80 orthopedic websites presented information about the orthopedic surgeons that worked at the hospital. This information comprised a photograph, the name of the surgeon, and, in some cases, his or her sub-specializations. Information regarding the rehabilitation process was present on 66 percent of orthopedic websites. This information could be retrieved from an electronic information brochure, available on 46 percent of websites, or was described on the website in detail. Sixty-one percent of the orthopedic websites offered referral to other orthopedic websites. These links gave access to minimally two other websites with orthopedic-related information. The opportunity to arrange an online consult was provided by 15 percent of orthopedic websites. This information comprised the opportunity to send an online question to one of the orthopedic surgeons. Twenty-one percent of websites offered the opportunity to make an outpatient appointment by internet , and information on a special type of hip prosthesis, the so-called resurfacing hip. Detailed information with respect to cemented total hip arthroplasty was present on 21 percent of the websites, 21 percent presented information on resurfacing prosthesis, 19 percent on uncemented prosthesis, and 3 percent on hybrid hip prosthesis. This information comprised an image of the prosthesis and a short description of the operation. Nine percent of the orthopedic websites mentioned what type of implant; cemented, uncemented, resurfacing or hybrid prosthesis was preferably implanted by the hospital or partnership of orthopedic surgeons. One website presented specific information on which type of stem and cup their centre would like to implant. Four websites (five percent) provided specific information on the expected survival of their implants. These websites cited own results or referred to published data elsewhere. One website presented not only the survival of their prosthesis, but they also referred to survival data from literature of other prosthesis not implanted by them  and the Dutch Polyarthrosis Peer Association (n = 81). All items on the screening list, except the opportunity to make an online appointment, were rated by 80 percent of the patients as important to very important information. The most important aspect patients preferred to be informed about was the survival rate of the actual implanted prosthesis. All participating patients would like to be informed about this topic by hospital websites, and 71 percent of patients rated this information as This study investigated the extent of total hip arthroplasty related information available on orthopedic websites of hospitals in the Netherlands. The content of health information on websites of hospitals is highly variable for total hip arthroplasty. Information regarding the hip implant and prosthesis survival is highly appreciated by patients, however, mostly absent on orthopedic websites in the Netherlands. Orthopedic websites evaluated were better at providing information on the rehabilitation process, the orthopedic surgeon, and offering referral to other orthopedic websites, as evident from more than 60 percent of the websites.Our report is based on a complete review of all hospital websites in the Netherlands. The review focuses on a type of surgery that is done frequently in the Netherlands (more 25.000 hip implants a year). With more than one million operations performed each year worldwide, total hip arthroplasty is considered one of the most successful procedures in modern orthopedic surgery . Total hMore recently, orthopedic surgeons, hospitals, and orthopedic device manufacturers have started to advertise their products and services directly to end-users ,8. DirecThere is no doubt that online information plays an eminent role in the propagation of health related information. Results from the National Trends Survey 2003) showed that 63.7% of the US adult population looked for health related information for themselves or relatives at least once in the previous 12 months and half of the population reported searching online first before talking to their physicians  showed t. The numHowever, research on choice behavior of patients has shown that offering relevant information alone is not enough to influence the choice of consumers dramatically -18. OtheThe most remarkable finding of our study was that the survival data of the used prosthesis was in general not available on websites of hospitals in the Netherlands. At the moment, the survival of the hip implant is not a clinical indicator of performance in orthopedic total hip surgery in the Netherlands. Orthopedic departments are not required to report this information to national health authorities. Available data on infection parameters, decubitus ulcers, and hospital readmissions are apparently considered more important by policymakers. In contrast, the reported long-term survival of a hip prosthesis can be an important indicator of clinical performance of a department, as satisfying long-term prosthesis survival is what it is all about.Our study does not investigate additional information on total hip arthroplasty that is provided to out-patients by orthopedic surgeons during a hospital visit. In clinical practices, patients may receive more oral and detailed written information about the type of prosthesis, the surgical procedure, and implant survival during their visit.According to our online survey, patients do not only want to be informed about the operational technique, type of hip implant or rehabilitation process, but also the length of the waiting list, pain management and complications of having surgery performed table . In our The generalization of our findings may be limited, because the evaluation was done only on websites of hospitals in the Netherlands. Therefore, our conclusions do only apply to situations comparable to the Netherlands.Online information of good quality is crucial for patients to become self-educated. The content of health information on websites of hospitals is highly variable for total hip arthroplasty. Orthopedic surgeons have the opportunity to improve the information provided on total hip arthroplasty via the internet. Information on prosthesis survival is important and highly appreciated by patients, however, this information is mostly absent on orthopedic websites in the Netherlands.The authors declare that they have no competing interests.JB performed the online screening of websites, participated in the analysis and interpretation of the data, and drafted the manuscript. BS conceptualized the study, assisted with data interpretation, provided feedback throughout the drafting of this article, and has read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/83/prepub


Objective. To evaluate the occurrence of two periorbital complications of surgery for Chronic Suppurative Otitis Media (CSOM) and discuss the potential pathophysiologic mechanisms. Materials and Methods. This is a retrospective review of the CSOM surgeries performed between Oct, 2005, and Jan, 2011, in our hospital. The early postoperative conditions of the patients were scrutinized to identify periorbital ecchymosis and subconjunctival hemorrhage. Results. Eight cases out of 756 patients were noted to have periorbital ecchymosis, and two of the patients also had simultaneous subconjunctival hemorrhage. All cases in which the complications occurred had undergone tympanoplasty, and in three patients mastoidectomy had also been performed. The age of the affected patients ranged from 24 to 70 years old. In all of them the condition ensued the day after the surgery and became better within 5 to 10 days. Complete recovery took approximately 1 month. Conclusion. Periorbital ecchymosis and subconjunctival hemorrhage are rare but safe complications of ear surgeries. The conditions are self-limiting and no management is necessary. Chronic Suppurative Otitis Media (CSOM) is a fairly common disease, and it is usually managed with surgery. In most otology wards the most common surgical procedures are those performed on patients with CSOM and, like any other medical intervention, complications can happen. These complications include those related to anesthesia, as well as otologic and intracranial complications. Problems related to the skin and wound healing such as infection, hematoma, and dehiscence are considered minor complications in CSOM surgeries. There have been various case reports on rare, out of the ordinary mishaps, in these surgeries. Here, we describe periorbital ecchymosis with or without subconjunctival hemorrhage as a rather rare complication of ear surgeries. Although a familiar condition in nose and sinus operations to the extent of our knowledge, periorbital problems in otologic surgeries were first brought up by Rudnick et al. who described 4 cases of periorbital edema and cellulitis in 97 patients with cochlear implants . Herein,This is a retrospective review of the occurrence of periorbital ecchymosis and/or subconjunctival hemorrhage as a complication following ear surgeries including tympanoplasty with or without mastoidectomy in our university hospital, which is a tertiary referral medical center. Intravenous cephalosporin antibiotics were given prophylactically to all patients just before surgery and then given orally after surgery for an additional 5 days. The postoperation protocol at our centre is as follows: a compressive bandage is applied for all cases in the operation room and a first reevaluation is performed on the day after surgery when the bandage is changed and the next visits are on the third and seventh day at the time of removal of the bandage and sutures, respectively. Then periodic monthly examinations are performed for up to 3 months. The follow-up visits are arranged according to the patient's condition. The surgeries evaluated here were performed between Oct, 2005, and Jan, 2011. Cases with the mentioned ocular complications were taken into consideration, and the clinical features were reviewed. The intensity of edema, periorbital ecchymosis, and subconjunctival hemorrhage was determined visually according to the authors' classification . All casThe total number of patients included in the study was 756, their mean age was 31.3 ± 12.0 years . Of the patients, 468 (61.9%) and 288 (38.1%) were female and male, respectively. The types of operations the patients underwent were as follows: tympanoplasty (412 cases), tympanoplasty with mastoidectomy (244 cases), modified radical mastoidectomy (63 cases), and ossiculoplasty (37 cases). Eight cases were noted to have periorbital ecchymosis Figures  and 2. Tnot in the operating room and the conditions worsened within 2 to 3 days. None of the patients suffered from disturbances in visual acuity although mild to moderate edema was an accompanying feature of the ecchymosis. It took around 5 to 10 days for the ecchymosis to be partially resorbed, but complete resolution of edema and discoloration mostly occurred within 1 month. None of the patients complained from pain, tenderness, itching, tearing, or limitation of ocular motility. No systemic symptoms, such as fever, chill, fatigue, headache, or rhinorrhea were observed.In all cases the first presentation of the complications was on the day after surgery Periorbital edema and ecchymosis have several etiologies such as fractures of the base of the skull , fractures of the facial bones, rhinoplasty, endoscopic sinus surgery, sinusitis, superficial eyelid cellulitis, preseptal infections, and allergic reactions. In these conditions different mechanisms have been proposed to describe how the edema or ecchymosis is induced. Most of these mechanisms pivot around the vascular, lymphatic, and soft tissue anatomy of the periorbital area. There are also various explanations for blood accumulation around the eye following ear surgeries, some of which will be covered below.The skin of the eyelids is not thick, and there is only a thin layer of connective tissue between the skin and the underlying muscular layer. This lean and loose layer of connective tissue is where accumulation of fluid, such as blood, happens following injuries . The artIn addition to the eyelids and the blood supply to the region, the fascia layers and planes in the area between ear and eye deserve consideration as to their role in the development of periorbital ecchymosis. There are three basic layers which are a continuation of each other: the Superficial Muscular Aponeurotic System , the galea (in the forehead); and the temporoparietal fascia (in the temple). The SMAS acts as a carrier for superficial fat layers in the midface, where true and false retaining ligaments create a complex network connecting the dermis to the fascia layers through the superficial fat. In the temple, the superficial fat is sparser and there are no retaining ligaments , so in tnot infectious and is self-limiting [no one with periorbital ecchymosis.Rudnick et al. reported 4 cases of periorbital edema and preseptal cellulitis in 97 pediatric cochlear implantees . As orbilimiting . Aside fIn all of the patients who developed ecchymosis the surgical approach was postauricular, and a graft was harvested from the temporalis fascia. One possibility is that injury to some branches of the superficial temporal vein caused disorder in the venous drainage of the periorbital area and that the elevated hydrostatic pressure resulted in extravasation of red blood cells and ecchymosis formation. Individual anatomic variation of the vascular structure in the periauricular and periorbital area would account for the rarity of the condition. Graft harvesting was the one common event in these 8 patients, and mastoid drilling was done in only 3 of them. None of these patients had systemic hypertension or were taking anticoagulants or acetylsalicylic acid.Various external factors that are not central to the surgical procedure may also play a role in the development of ecchymosis. However, while a tight bandage and dressing may have a role in the development of edema, unilateral ecchymosis seems unlikely to be caused by such circular pressure around the skull. The presumption of direct trauma to the area is also not acceptable. Vigorous coughing during extubation is another possible source of subconjunctival hemorrhage but the likelihood of it happening on the same side as the surgery and with concomitant ecchymosis in the periorbital skin makes it unlikely in the present subjects. Several otologists do some elaborate soft tissue manipulation in the area just above the external ear canal which is the root of zygoma and believe that it is necessary for a better exposure to the middle ear or for mastoid drilling. Going too far anteriorly in the zygoma root may endanger the vessels closer to the orbit. In contrast to ear surgery, periorbital edema and ecchymosis are well known in rhinoplasty. Considering the location of the osteotomies there is a high risk of damage to the angular vessels or their small branches, and this probably explains the mechanism of periorbital changes during rhinoplasty . Techniqhardly explain our cases.One last point to consider is the adverse effects of anesthesia. It seems unlikely that anesthesia plays a role in periorbital changes following ear surgeries. Some symptoms such as bilateral blurred vision have been proposed which seem to be related to the anticholinergic side effect of some anesthetic agents. Corneal abrasion as a result of careless eye coverage may also happen more frequently in head and neck surgeries , 13. ButPeriorbital edema and ecchymosis with accompanying subconjunctival hemorrhage are rare complications of tympanoplasty or mastoid surgeries. Although they may be worrisome to the patients and their families, these are self-limiting and essentially none dangerous conditions. As an otologist being aware of the potential for the development of these complications prevents redundant diagnostic or therapeutic measures.


Mining has played a central role in the development of South Africa – from the importation of European labour through to the migrant labour system that characterised apartheid, our mineral resources have molded our political, social, and economic paradigms over the last 140 years. The current turmoil on the mines emphasises this legacy and its centrality in our history. The mining industry not only shaped the early development of legislation to protect the health of workers in the 1900s, but it also allowed South African researchers to produce groundbreaking research in mining-related respiratory diseases throughout the last century. Gill Nelson's work is located within this context and provides new directions for mining-related occupational respiratory diseases.The history of mining in South Africa dating back to the late nineteenth century is synonymous with silica exposure, silicosis, and tuberculosis. Under pressure to protect the large number of the newly arriving European mineworkers, following the conclusions of the 1902 Milner Commission of Enquiry into Phthisis  remains a significant exception to this. PATHAUT is one of the leading autopsy surveillance systems globally and is a major resource for researchers. PATHAUT has assumed almost legendary status in the world of occupational respiratory disease research, thanks to iconic researchers such as JC Wagner and his fellow workers, who, using the early guises of the autopsy service, described the first ever autopsy cases of mesothelioma  and prog3 . This compares to the low levels of silicosis seen on coalmines, with radiological prevalences ranging from 2 to 4% , and aut3 .Although the numbers of asbestos-related diseases were expectedly low, given the rigorous review of exposure data adopted by Nelson, it is interesting that there were, in actual fact, ANY cases with asbestosis or asbestos pleural disease – both of which require substantial exposure over a long period of time. While cases of mesotheliomas have been documented in environmentally exposed people, asbestosis itself cannot be attributed to environmental exposure. Nelson provides exposure information to support the assertion that this is work-related.The studies by Nelson build on our depth of existing knowledge of mine related respiratory diseases, particularly in South Africa. Her findings on asbestos related diseases among diamond miners and silicosis among platinum miners, whilst very preliminary, forces researchers to have open minds when investigating known diseases or known exposures. Certainly, the findings of disease in these miner populations are small and the assessment of exposure limited, but clearly the findings suggest the need for more work. Nelson implies that if we do not monitor for these outcomes, we are not likely to detect them. As Nelson points out, in order to ensure these diseases are not missed, we need to improve our medical surveillance programmes, and more importantly, better describe exposure in these working populations. Mining companies have a responsibility of assessing the different types of exposure, and ensuring that exposure levels are monitored and effectively controlled as a first step to addressing our epidemics of silicosis and mine-related respiratory diseases.


First-year students negotiate new professional culture with a certain amount of excitement and anxiety. There are different approaches for offering guidance. In this study, the authors present Weill Cornell Medical College's experience with an advising program for first- and second-year students.Fifty faculty advisors were each assigned 1–3 first-year students who they would follow for 2 years. The responsibilities were outlined to both faculty and students. The program was evaluated using an anonymous questionnaire.For the two classes surveyed (2011 and 2012), most students met their advisors once. For both classes, the most frequently discussed issues were general adjustment to medical school, academic life, and the professional life of the advisor. Summer research and career opportunities were also discussed. Most students were satisfied with the advising program. Satisfaction increased with an increase in visits. Most students who did not meet their advisors established an advisor relationship on their own.An advising program was established at Weill Cornell Medical College that satisfied most of the students. It is important to evaluate its format regularly, from both student and advisor perspectives, in order to ensure its continued success. First-year students starting in medical school negotiate a new professional culture with a certain amount of excitement and anxiety. The literature suggests that many medical schools use different formats with some degree of success. Examples of these formats include using focus groups to identify important parameters ; allowinOver the years, Weill Cornell Medical College (WCMC) has offered several different components in an overall advisory system. For many years, we have had a very successful residency application advisory system in the third year that has resulted in excellent residency matches. The advisors in that system are specialty specific and work with students who have already decided on their individual choices of specialty. In cases involving academic difficulties, the Offices of Student Affairs and of Academic Affairs facilitate students receiving advice from course directors, which has been our most successful means of addressing any student's academic problems. Students who feel they are having any type of emotional problem utilize a Student Mental Health Service with full confidentiality. More informal opportunities for students to meet faculty include evening panels, sponsored by the Alumni Association, where alumni share their experiences in different specialties. Recently, we initiated a series of parties that are hosted each month by a different group of basic science or clinical departments. Also, first-year medical students are assigned to a second-year medical student to advise them on a smooth transition to medical school.Students, however, often expressed a need for a general advisory system to start early in medical school that might assist them in later career decisions, impart the experiences of currently practicing physicians, and increase their awareness of what awaits them as they complete medical school and pursue specific specialties. Students also noted that there was no good way of obtaining a general faculty advisor unless the student took the initiative to seek out such an advisor.In the late 1990s, as we revised our curriculum, we established a system of advisory ‘guilds’. Each had a cohort of faculty that met with an assigned group of students throughout medical school. These meetings were to provide greater interaction between students and faculty. Each group of faculty consisted of physicians from multiple medical specialty areas. Meetings could include formal presentations, such as panels, open forums, and small-group discussions. The advisory faculties were also available for students seeking individual advice. The group interactions were supposed to familiarize students with a number of faculty members in a non-classroom setting and would hence increase the level of comfort that students would feel in seeking advice. This initiative, however, was not successful for a number of reasons, including difficulties in arranging meeting times with large groups of faculty, irregular attendance at any meetings or forums because of patient care demands, and persistent problems with faculty needing more specific definitions of what kind of advisory role they were to have. Students often complained that the goals of the system were not well defined. The guild system approach did not improve our general advisory system.In an attempt to improve our advisory system, and in recognition of newly articulated imperatives to assist students more proactively in developing their professional identities , we initThe associate dean for student affairs and the program director identified approximately 50 busy, well-liked, and successful faculties who knew the medical college well and were interested in spending time with students. Their advisory role was outlined in a standard telephone interview. The advisors would make initial telephone or e-mail contact with 1–3 first-year medical students who they would advise for 2 years. They were asked to provide reassurance as the students became accustomed to medical school, to facilitate the students’ exploration of opportunities and introduce them to possible mentors as their interests evolved, and to be their advocates if problems developed. They also would help the students understand their new professional responsibilities. To facilitate the development of a one-to-one relationship, the advisors were reimbursed for taking their advisees to lunch individually as a first meeting.During orientation in September of the first year, the program responsibilities of the advisors were outlined for the students, and they were told that they would each receive contact information for their randomly assigned, generic, faculty advisor.Early in October, letters were sent to advisors and students outlining the program and providing contact information (telephone numbers and e-mails). Students were told to contact their advisors if they did not hear from them within 2 weeks. If they were still unable to set up a meeting, they were asked to notify the program director, who would facilitate the meeting.In February, all students received an e-mail from the program director with copies to the advisors to suggest that it was time to start planning their summer experiences. In June, the associate dean and the program director asked the first-year class to complete an anonymous questionnaire to evaluate the advising program.Survey data were collected during the first year for the Class of 2011 and were compared with similar data collected for the Class of 2012. The questionnaire was distributed to the students at the end of a lecture. Students were asked to complete it before they left the room. We performed all analyses using SPSS version 15.0 .The study was approved by the Weill Cornell Medical College Institutional Review Board.N=103) and 53 students from the Class of 2012 (N=103) completed the questionnaire. For the Class of 2011, 83.5% (66/79) met with advisors  failed to notify either the associate dean for student affairs or the program director. A small number of these students did acknowledge that their advisors had tried to contact them: 30.8% (4/13) in the Class of 2011 and 20.0% (3/15) in the Class of 2012 . Also, aFour comments recurred frequently in the questionnaires. Both classes requested being matched to an advisor based on interest: 11.4% (9/79) for the Class of 2011 and 22.6% (12/53) for the Class of 2012. Both classes requested more frequent meetings between advisors and advisees: 10.1% (8/79) for the Class of 2011 and 11.3% (6/53) for the Class of 2012. Although 10.1% of the Class of 2011 requested scheduling meetings so that students do not intrude on faculty, the Class of 2012 did not comment on this. The students also wanted more contact between advisors and advisees: 7.6% (6/79) for the Class of 2011 and 5.7% (3/53) for the Class of 2012.The published reports cited in this article discuss a continuum between mentoring and advising, illustrating many different formats that can achieve success. Each of them has a slightly different focus. The 50 first- and second-year advisors in our early advising program are male, female, Asian, Hispanic, African American, and Caucasian. They come from various clinical and research backgrounds and vary in academic rank. Gender, race, and academic discipline are not factors in their selection. They are chosen because they have a strong history of involvement with students, an in-depth knowledge of the medical center, and a willingness to participate. Although students from both classes have requested that advisors and advisees be matched by interest, it is not possible to guarantee that this can be done for more than 100 students. In addition, student interests change over time. Matching advisors by interest could create an awkward situation if a student's interest changes. The student might feel uncomfortable informing his or her advisor, and the advisor might not be willing to accept the student's loss of interest in his or her field. The generic advisors, on the other hand, are prepared to accommodate students’ evolving curiosity and identify the right mentor to facilitate their professional development once their interests have solidified.The students were in favor of more frequent contact and meetings with their advisors. They requested scheduling meetings so that students did not intrude on the faculty. The data suggest an association between frequency of meetings and satisfaction with the program. Faculty chosen as advisors tended to be busy people who were nationally and internationally known in their fields, so that they would be excellent role models. Anecdotally, some students were reluctant about contacting them because they thought they were intruding in their busy, professional life. Some of the advisors thought that students who did not contact them were disinterested in the advising relationship. It seems important to foster a one-to-one relationship so that students having problems will feel comfortable talking with their advisors.The associate dean and the program director were available to facilitate contact between advisors and advisees when this was difficult. It was surprising how few students took advantage of this. However, it was encouraging to find out that the majority of students who were unable to make contact with their assigned faculty advisor were able to establish an advising relationship with a faculty member of their own choosing.One limitation in our study could be the sample size. We administered the questionnaire to both classes at the end of a lecture and asked them to complete it before they left the room. Although the demographic characteristics of the classes were similar, the number of responses from the Class of 2012 (53) was considerably smaller than the number from the Class of 2011 (79). The smaller sample size might in some part account for the different results in the two classes. It was not possible to evaluate the non-responders in this anonymous study. In spite of the sample size, we were able to gain insight into additional factors that might be incorporated into a more successful advisory program.There has been very little turnover in the cohort of 50 advisors. The faculty who have left the program did so because they left the medical center. The program director speaks to all of the advisors just before the start of the academic year to remind them of their obligations and confirm their commitment.An important strength of our advising system is the annual review, which includes the anonymous questionnaire as well as both focus-group discussions with the medical students and feedback via a structured interview with the advisors. This allows us to continuously monitor the program and make appropriate adjustments as needed. For example, in response to the annual review, we developed a list of resources for first-year advisors and five suggested topics for discussion. These include transition to medical school, stress management, wellness, professionalism, and summer opportunities. This feedback will allow us to put in place an enhanced structured advising program that will include an evaluative component.In accordance with emerging views and recommendations that medical schools pay more attention to facilitating the professional development of medical students, it is a good time to rethink the many models that have been used thus far and improve them. We believe that early advising, beginning in year one, is an important feature of successful programs.Differences in satisfaction responses between medical student classes in areas such as career, summer research, and the ‘big picture of medicine’ suggest that a developmentally appropriate, scripted advising system, in which discussions are tailored to the experiential level of the student, may have value. Traditionally, attendance at early advising systems has not been made mandatory in the same way that attendance at other required course components has, and this is reflected in the variability of the data showing if and how often students connected with advisors. Interestingly, the high number of students who did not connect with their assigned advisors but who found advisors on their own suggests that there is a need for advising by all students in one way or another. The combination of the perceived need for advising by students, the potential value of developmentally appropriate and regularly scheduled opportunities for self-reflection, and addressing aspects of the hidden curriculum  that are


Hospitals are cornerstones for health care in a community and must continue to function in the face of a disaster. The Hospital Incident Command System (HICS) is a method by which the hospital operates when an emergency is declared. Hospitals are often ill equipped to evaluate the strengths and vulnerabilities of their own management systems before the occurrence of an actual disaster. The main objective of this study was to measure the decision making performance according to HICS job actions sheets using tabletop exercises.This observational study was conducted between May 1st 2008 and August 31st 2009. Twenty three Iranian hospitals were included. A tabletop exercise was developed for each hospital which in turn was based on the highest probable risk. The job action sheets of the HICS were used as measurements of performance. Each indicator was considered as 1, 2 or 3 in accordance with the HICS. Fair performance was determined as < 40%; intermediate as 41-70%; high as 71-100% of the maximum score of 192. Descriptive statistics, T-test, and Univariate Analysis of Variance were used.None of the participating hospitals had a hospital disaster management plan. The performance according to HICS was intermediate for 83% (n = 19) of the participating hospitals. No hospital had a high level of performance. The performance level for the individual sections was intermediate or fair, except for the logistic and finance sections which demonstrated a higher level of performance. The public hospitals had overall higher performances than university hospitals (P = 0.04).The decision making performance in the Iranian hospitals, as measured during table top exercises and using the indicators proposed by HICS was intermediate to poor. In addition, this study demonstrates that the HICS job action sheets can be used as a template for measuring the hospital response. Simulations can be used to assess preparedness, but the correlation with outcome remains to be studied. Disasters, both natural and man-made, and the number of people affected by them have increased over the past decades ,2. The iThe Incident Command System (ICS) is a standardized on-scene, all-hazards incident management approach designed specifically to allow responders to adopt an integrated organizational structure equal to the complexity and demands of any single incident or multiple incidents without being hindered by jurisdictional boundaries ,6. The IThe ICS was adapted in 1991 for use in the hospital based response to disasters, and duly renamed to the Hospital Emergency Incident Command System (HEICS) ,11. HEICHEICS/HICS is a method by which the hospital operates when an emergency is declared . It is tThe lack of internationally accepted standards of performance makes it difficult to evaluate the outcome of health care in a disaster . Also, nThe vulnerability of Iran, with respect to natural disasters, especially earthquakes -28, neceThe infrequent occurrence of major disasters is one reason that health care organizations remain ill equipped to systematically evaluate the strengths and vulnerabilities of their emergency management systems and programs . SimulatThere has not previously, to our knowledge, been any previous study regarding the impact of the implementation of HICS on hospital performance with respect to response to a real or simulated disaster. The main objective of this study was to measure the decision making performance according to HICS job actions sheets using tabletop exercises.This observational study was conducted in Iran, between May 1st 2008 and August 31st 2009. Hospitals that had implemented a hospital response system in accordance with the HICS and had a basic training course adapted to the HICS and were able to conduct a tabletop exercise were included. Twenty three hospitals were included in this study, due to financial constraints. None of these was excluded. Fourteen of the 23 hospitals were public and 9 were university hospitals. In Iran, there are three types of hospitals; university hospitals, private hospitals, and non-governmental (public) hospitals that belong to different organizations e.g. social security organizationAffiliation , size , use of a HICS advanced training course, the presence of a hospital command centre, and a hospital disaster plan, were assessed for each participating hospital.A tabletop exercise was developed for each hospital. Tabletop exercises are simulated situations. Participants discuss the problems at hand, in depth, and make decisions regarding emergency responses, accordingly. One of the most important goals of a tabletop exercise is to compel the participant to make problem solving decisions. The decisions are documented to serve as a reference with which to evaluate the exercise ,36,37.Each exercise was based on a risk map of the area. The most likely hazard for each given hospital was chosen as the disaster scenario for the exercise.Each scenario was run for a maximum of 2 hours. There are 28 standardized scenarios in the HICS-2006 including earthquake, fire and chemical emergencies. The content of these scenarios was extended with respect to geographical information, characteristics of the disaster, and process of influx of disaster casualties. A facilitator, one of the evaluators, initiated the discussion and directed the participants toward in-depth problem solving. All positions of the HICS were assessed according to the 5 main sections  using the job action sheets, during both the exercise and the evaluation process [The scoring according to the job action sheets was done by a group of three evaluators. The evaluators were medical doctors, who had worked in the field of HICS and HDP, for at least 6 years. They had international experiences from training programs and visits of hospital using HICS. The same group of evaluators was used to for all 23 exercises. There was a team discussion after each exercise. The about scoring of HICS performance by the evaluators was completed in consensus.The HICS job action sheets were used as the performance indicators for decision making .Descriptive statistics was performed. Measures of central tendency were used for HICS and its main sections performance scores. The HICS scores were normally distributed except for the scores for the planning section, as tested by a normal probability plot . A t-tesThe SPSS 17  was used for data analysis.The public hospitals had implemented the HICS earlier than the university (community) hospitals; and had also been provided with a budget with which to conduct relevant training programs.Background information for the participating hospitals is presented in Table The lowest total HICS score was 56 and the highest was 119, with a mean of 85 (± 15 SD). The logistic and financial/administration sections received the highest scores, and the planning section had the lowest score Table .HICS performance was intermediate for 19 hospitals (83%). No hospital had a high level of performance. The performance level of the different individual sections was fair to intermediate, except for the logistics and finance/administration sections which had a high level of performance in 3 and 5 hospitals, respectively  as compared to hospitals with only the basic course (77.1 ± 13.3), although the difference was not significant (P = 0.07).There was no significant difference between small and medium hospitals (P = 0.09). No large hospitals participated in the study.Public affiliation was the only independent predictor of the HICS performance (P = 0.04) in a regression model including medium size, public affiliation, advanced course, and earthquake scenario.This study showed that the decision making performance, as measured by the indicators proposed by the Hospital Incident Command System (HICS), during tabletop exercises was intermediate for the majority of the participating hospitals and poor in a few, while none showed a high performance. Previous studies evaluating hospital management during simulated disasters demonstrated a similar level of performance ,39-41. HThe performance at public hospitals was significantly higher than that of university hospitals. There are, to our knowledge, no previous studies on performance as measured by HICS and hospital affiliation. However public hospitals did not appear to be superior to other hospitals, with respect to disaster preparedness as measured by practice variation, plan characteristics, and surge capacity in a previous study ,43.HICS was implemented at public hospitals approximately one year before that of university hospitals. In addition, there is more financial support for training courses and drills at public hospitals as compared to university hospitals. Thus, public hospitals have a longer experience of HICS and are also better funded, which may explain our results. Previous studies demonstrated that funding, standards, and experience in disaster management are the improving factors for hospital disaster preparedness .Training courses had no significant impact on HICS performance according to the current study. Also a review from 2004 showed no support for training courses influencing performance . More reThe hospital size did not affect the performance as measured by HICS according to our results. There are, however, previous studies suggesting that size is an important function of hospital capacity in disaster response -48. HoweHICS was implemented in Iran in 2007. Therefore, one may infer that the lack of high performance may be explained by an insufficient understanding of HICS and also an incompatibility of HICS with the pre-existing management structure. However, we believe that the intermediate to low performance is a consequence of the lack of a comprehensive hospital disaster plan and a hospital command centre (HCC). There are, however, to date, no studies on the effect of implementing a disaster plan on HICS performance.A limitation of this study is that it is performed in Iran which restricts the generalizability of our results. However, the HICS and its job action sheets are standardized and used worldwide. Despite the lack of internationally accepted standards of performance for disaster health management ,30 the HAn additional limitation is that we have not measured inter-rater reliability. We did, however, have a team discussion after each exercise and the evaluators independently came to the same HICS score. Another limitation is that the cut-off levels for the performance levels are arbitrary. However, they were based on expert consensus. Standardizing these cut-off levels requires prospective outcome based studies.Additionally, there were too few participating hospitals to allow for the testing the impact of different scenarios for the same hospital. Only one scenario was used for each hospital, which limits the results to these hazards. Other hazards would be of interest, such as hazardous materials, fire and power shortage. However, the hazard chosen for each hospital was that of highest risk.Using tabletop exercises may of course be questioned with respect to the validity of assessing hospital preparedness -36. HoweThe decision making performance in the participating Iranian hospitals, as measured during tabletop exercises and using the Hospital Incident Command System (HICS), was intermediate to poor. The performance was better in the public hospitals as compared to university hospitals and was shown to be independent of the hospital size.The HICS job action sheets can be used as a template for measuring the hospital response. We believe that a comprehensive hospital disaster plan should include not only managerial and operational elements of hospital preparedness, but also an appropriate command system suited to the specific hospital organisation.Simulations can be used to assess preparedness, but the correlation with outcome remains to be studied.HICS: Hospital Incident Command SystemThe authors declare that they have no competing interests.ARD was involved in the study design, data collection, analysis, and manuscript writing. MC contributed to the analysis of the data and to the writing of the manuscript. VH and MK were involved in the study design and took an active part in the data collection and the interpretation of the results. GO participated in the study design, writing-up and finalization of the manuscript. LK participated in the study design, analysis and the manuscript writing, revision and editing. All authors read and approved the final manuscript.Indicators of decision making performance of Hospital Incident Command System in five different sections; achieved results on each indicator given 0, 1, 2, or 3 points.Click here for file