Effectiveness of insole use in rheumatoid feet: a randomized controlled trial

OBJECTIVES

To assess the effectiveness of foot orthoses with regard to pain, function, quality of life, and global perceived effect in patients with rheumatoid arthritis (RA).

METHOD

A double-blind randomized controlled trial (RCT) was carried out. Eighty women with RA were randomly assigned to an experimental group (EG) or a control group (CG). The EG used an insole with metatarsal and medial arch supports and the CG used a flat insole for 6 months. Evaluations performed at baseline and after 45, 90, and 180 days by a blinded assessor were: foot pain while walking and at rest, function, quality of life, and global perceived effect with treatment.

RESULTS

The groups were homogeneous for all parameters at baseline. A statistically significant improvement (p < 0.001) was found in the EG regarding pain while walking (mean difference: -2.2 for the right foot and -2.1 for the left foot) and at rest (mean difference: -0.3 for the right foot and -0.5 for the left foot) in comparison to CG. There were no differences in any other observed measures. The time of insole use correlated with foot pain and function in the EG.

CONCLUSIONS

Foot orthoses with metatarsal and medial arch supports decreases pain during walking and at rest in both feet in patients with RA. Time of insole use correlated with improvements in pain and function.

Increasing medical students' engagement in public health: case studies illustrating the potential role of online learning

BACKGROUND

The value of e-learning in medical education is widely recognized but there is little evidence of its value in teaching medical students about public health. Such evidence is needed because medical students' engagement with public health has been low. We present three recent case studies from UK medical schools to illustrate diverse ways in which online approaches can increase medical students' engagement with learning public health.

METHODS

A comparative case study approach was used applying quantitative and qualitative data to examine engagement in terms of uptake/use amongst eligible students, acceptability and perceived effectiveness using an analytic framework based on Seven Principles of Effective Teaching.

RESULTS

Across the three case studies, most (67-85%) eligible students accessed online materials, and rated them more favourably than live lectures. Students particularly valued opportunities to use e-learning flexibly in terms of time and place. Online technologies offered new ways to consolidate learning of key public health concepts. Although students found contributing to online discussions challenging, it provided opportunities for students to explore concepts in depth and enabled students that were uncomfortable speaking in face-to-face discussions to participate.

CONCLUSIONS

E-learning can be applied in diverse ways that increase medical student engagement with public health teaching.

Molecular-scale remnants of the liquid-gas transition in supercritical polar fluids

An electronically coarse-grained model for water reveals a persistent vestige of the liquid-gas transition deep into the supercritical region. A crossover in the density dependence of the molecular dipole arises from the onset of nonpercolating hydrogen bonds. The crossover points coincide with the Widom line in the scaling region but extend farther, tracking the heat capacity maxima, offering evidence for liquidlike and gaslike state points in a "one-phase" fluid. The effect is present even in dipole-limit models, suggesting that it is common for all molecular liquids exhibiting dipole enhancement in the liquid phase.

Are you prepared to take the risk: Extending governance for perioperative roles

In the 25 years since the Oxford Heart Centre in England appointed the first British nurse to be formally trained as a non-medically qualified surgical assistant, the number of nurses and allied health professionals (AHPs) undertaking advancing surgical roles has increased in order to backfill the deficit of a surgical workforce (Quick and Hall 2014). Despite initial concerns over nurses and AHPs undertaking roles and responsibilities which were previously performed solely by doctors, the role of non-medical surgical assistants has been shown to maintain surgical services, provide an additional career route for nurses, and enhance patient care (Abraham 2011, Quick 2013, Jones et al 2012). In the early days however, a lack of role specific regulation, practice guidelines and a variety of educational standards led to variances in job titles and role responsibilities for nurses and AHPs performing surgical assistance (Box 1).

The impact of bariatric surgery on quality of life: a systematic review and meta-analysis

This study aims to review the obesity literature in order to assess the impact of bariatric surgery on quality of life and the between-study variation by examining the standardized mean magnitude of effect in change in the levels of quality of life. The following databases EMBASE, PubMed, PsycINFO, CINAHL, the Cochrane Library and Web of Science were systematically searched for studies examining change in quality of life in adults receiving bariatric surgery for obesity. Seventy-two studies were included with a total of 9,433 participants treated for obesity with bariatric surgery. The average impact of bariatric surgery on quality of life corresponded to an effect size of 0.88 (95% CI: 0.80-0.96), indicating that bariatric surgery has a significant positive influence on quality of life in general. The impact varied considerably across studies with bariatric surgery showing a significantly greater positive influence on physical quality of life compared to mental quality of life. Bariatric surgery is effective in improving quality of life, especially when looking at physical well-being. Greater focus on the psychological well-being of the person undergoing surgery for obesity may lead to a better post-surgery prognosis for more people.

Growth in neurofibromatosis 1 microdeletion patients

Microdeletions of the entire NF1 gene and surrounding genomic region occur in about 5% of patients with neurofibromatosis 1 (NF1). NF1 microdeletion patients usually have more cutaneous and plexiform neurofibromas and a higher risk of developing malignant peripheral nerve sheath tumors than other people with NF1. Somatic overgrowth has also been observed in NF1 microdeletion patients, an observation that is remarkable because most NF1 patients are smaller than average for age and sex. We studied longitudinal measurements of height, weight, and head circumference in 56 patients with NF1 microdeletions and 226 NF1 patients with other kinds of mutations. Although children with NF1 microdeletions were much taller than non-deletion NF1 patients at all ages after 2 years, the lengths of deletion and nondeletion NF1 patients were similar in early infancy. NF1 microdeletion patients tended to be heavier than other NF1 patients, but height or weight more than 3 standard deviations above the mean for age and sex was infrequent in children with NF1 microdeletions. Head circumference and age of puberty were similar in deletion and non-deletion NF1 patients. The pattern of growth differs substantially in deletion and non-deletion NF1 patients, but the pathogenic basis for this difference is unknown.

Optimization of image quality and patient dose in radiographs of paediatric extremities using direct digital radiography

OBJECTIVE

The purpose of this study was to evaluate the effect of beam quality on the image quality (IQ) of ankle radiographs of paediatric patients in the age range of 0-1 year whilst maintaining constant effective dose (ED).

METHODS

Lateral ankle radiographs of an infant foot phantom were taken at a range of tube potentials (40.0-64.5 kVp) with and without 0.1-mm copper (Cu) filtration using a Trixell Pixium 4600 detector (Trixell, Morains, France). ED to the patient was computed for the default exposure parameters using PCXMC v. 2.0 and was fixed for other beam qualities by modulating the tube current-time product. The contrast-to-noise ratio (CNR) was measured between the tibia and adjacent soft tissue. The IQ of the phantom images was assessed by three radiologists and a reporting radiographer. Four IQ criteria were defined each with a scale of 1-3, giving a maximum score of 12. Finally, a service audit of clinical images at the default and optimum beam qualities was undertaken.

RESULTS

The measured CNR for the 40 kVp/no Cu image was 12.0 compared with 7.6 for the default mode (55  0.1 mm Cu). An improvement in the clinical IQ scores was also apparent at this lower beam quality.

CONCLUSION

Lowering tube potential and removing filtration improved the clinical IQ of paediatric ankle radiographs in this age range.

ADVANCES IN KNOWLEDGE

There are currently no UK guidelines on exposure protocols for paediatric imaging using direct digital radiography. A lower beam quality will produce better IQ with no additional dose penalty for infant extremity imaging.

The end for the ‘Roman Sandal’: an observational study of methods of securing chest drains in a deployed military setting

Introduction

There is ongoing debate regarding the optimal method of securing chest drains in trauma patients. Various courses describe methods for chest drain insertion, but little has been published to identify the best method to secure the drain.

Aim

This article aims to examine differences in approach to securing chest drains and the security of the methods used.

Method

Whilst in a deployed medical treatment facility, 26 clinicians from various specialties and nationalities were asked to secure a pre-placed drain. A 32F drain was placed in a manikin and the clinicians were given a chance to prepare their equipment. They were given a choice of suture and their attempts were observed by one of the researchers. The attempts were timed and photographed. A second researcher, who had not observed the technique, then assessed the security of the drain.

Results

15/26 clinicians used a ‘Roman Sandal’ technique with 5/26 proving to be insecure. Other techniques used showed no failure. The rate of consultant‐secured failure was 12.5% compared to 40% for registrars and 33% for General Duties Medical Officers.

Conclusions

The type of suture used made no difference, but the traditional ‘Roman Sandal’ method was insecure. Knots tied close to the skin and those that bit into the drain were shown to be most effective.

Prevalence, natural course and predictors of depression 1 year following traumatic brain injury from a population-based study in New Zealand

OBJECTIVE

Depression is common post-TBI, yet has not been studied longitudinally, nor at a population level. This study examined prevalence of depression in a population-based sample across the first year post-TBI.

DESIGN AND METHODS

Prospective follow-up of 315 adults (>16 years) with assessments (Hospital Anxiety Depression Scale, DSM-IV criteria) at 1-, 6- and 12-months post-TBI. Demographic and injury-related predictors of depression at 1-year post-TBI were also explored.

RESULTS

The number of individuals identified as depressed reduced significantly between baseline and 12-months post-TBI from 21-12.4% using the HADS and 49-34% using DSM-IV criteria; with only 10 of the 28 individuals initially meeting criteria on the HADS continuing to do so at 12-month follow-up. Meeting HADS depression criteria was linked to pre-morbid depression and/or anxiety; while those meeting DSM-IV criteria were older, but not significantly so.

CONCLUSIONS

The findings suggest depression is common post-TBI and that clinicians/researchers use caution in its diagnosis, as existing criteria have significant overlap with common TBI sequels.

Pharmacist's review and outcomes: Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK)

PURPOSE

The purpose was to describe clinical pharmacist interventions across a range of critical care units (CCUs) throughout the United Kingdom, to identify CCU medication error rate and prescription optimization, and to identify the type and impact of each intervention in the prevention of harm and improvement of patient therapy.

MATERIALS AND METHODS

A prospective observational study was undertaken in 21 UK CCUs from November 5 to 18, 2012. A data collection web portal was designed where the specialist critical care pharmacist reported all interventions at their site. Each intervention was classified as medication error, optimization, or consult. In addition, a clinical impact scale was used to code the interventions. Interventions were scored as low impact, moderate impact, high impact, and life saving. The final coding was moderated by blinded independent multidisciplinary trialists.

RESULTS

A total of 20517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. This resulted in an overall intervention rate of 16.1%: 6.8% were classified as medication errors, 8.3% optimizations, and 1.0% consults. The interventions were classified as low impact (34.0%), moderate impact (46.7%), and high impact (19.3%); and 1 case was life saving. Almost three quarters of interventions were to optimize the effectiveness of and improve safety of pharmacotherapy.

CONCLUSIONS

This observational study demonstrated that both medication error resolution and pharmacist-led optimization rates were substantial. Almost 1 in 6 prescriptions required an intervention from the clinical pharmacist. The error rate was slightly lower than an earlier UK prescribing error study (EQUIP). Two thirds of the interventions were of moderate to high impact.

Trier social stress test in Indian adolescents

OBJECTIVE

To test the Trier Social Stress Test for children (TSST-C) in a cohort of Indian adolescents.

DESIGN

Cohort study.

SETTING

Holdsworth Memorial Hospital, Mysore, India.

PARTICIPANTS

Adolescent children (N=273, 134 males; mean age 13.6 yrs) selected from an ongoing birth cohort; 269 completed the test.

INTERVENTION

Performance of 5-minutes each of public- speaking and mental arithmetic tasks in front of two unfamiliar 'evaluators'.

OUTCOME MEASURES

Salivary cortisol concentrations were measured at baseline and at regular intervals after the TSST-C. Continuous measurements of heart rate, finger blood pressure, stroke volume, cardiac output and systemic vascular resistance were carried out before, during and for 10 minutes after the TSST-C using a finger cuff.

RESULTS

Cortisol concentrations [mean increment (SD): 6.1 (6.9) ng/mL], heart rate [4.6 (10.1) bpm], systolic [24.2 (11.6) mmHg] and diastolic blood pressure [16.5 (7.3) mmHg], cardiac output [0.6 (0.7) L/min], stroke volume [4.0 (5.6) mL] and systemic vascular resistance [225 (282) dyn.s/cm5] increased significantly (P<0.001) from baseline after inducing stress.

CONCLUSIONS

The TSST-C produces stress responses in Indian adolescents of a sufficient magnitude to be a useful tool for examining stress physiology and its relationships to disease outcomes in this population.

If it does not significantly change HbA1c levels why should we waste time on it? A plea for the prioritization of psychological well-being in people with diabetes

Despite improvements in pharmacological treatments and methods of care and care delivery, the burden of living with diabetes remains an ongoing challenge, as many people with diabetes are at increased risk of mental health disorders, psychological disturbances and functional problems associated with living with diabetes. Person-centred collaborative care that also meets the psychological needs of the individual is not available to many people with diabetes. The present article examines the role of psychological factors in the onset of diabetes and in relation to living with diabetes. It is argued that the pursuit of psychological well-being is worthy of individual attention in the care of people with diabetes and should not be contingent upon attainment of somatic indices of health. The barriers to attaining this goal are examined, including the costs of treating (or not treating) psychological problems in people with diabetes. Recommendations on how to improve diabetes care are offered, including psychological interventions that are both evidence-based and cost-effective.

The end for the 'Roman Sandal': an observational study of methods of securing chest drains in a deployed military setting

INTRODUCTION

There is ongoing debate regarding the optimal method of securing chest drains in trauma patients. Various courses describe methods for chest drain insertion, but little has been published to identify the best method to secure the drain.

AIM

This article aims to examine differences in approach to securing chest drains and the security of the methods used.

METHOD

Whilst in a deployed medical treatment facility, 26 clinicians from various specialties and nationalities were asked to secure a pre-placed drain. A 32F drain was placed in a manikin and the clinicians were given a chance to prepare their equipment. They were given a choice of suture and their attempts were observed by one of the researchers. The attempts were timed and photographed. A second researcher, who had not observed the technique, then assessed the security of the drain.

RESULTS

15/26 clinicians used a 'Roman Sandal' technique with 5/26 proving to be insecure. Other techniques used showed no failure. The rate of consultant-secured failure was 12.5% compared to 40% for registrars and 33% for General Duties Medical Officers.

CONCLUSIONS

The type of suture used made no difference, but the traditional 'Roman Sandal' method was insecure. Knots tied close to the skin and those that bit into the drain were shown to be most effective.

Listen while you work? The attitude of healthcare professionals to music in the operating theatre

Although the playing of music is commonplace in the operating theatre, there is nothing in the literature examining whether staff feel this is beneficial. Questionnaires were distributed amongst a random selection of staff in practice at a district general hospital: medical staff from a range of surgical specialities, anaesthetists, and all grades of perioperative staff (nurse/operating department practitioners/healthcare assistants) were encouraged to participate. There were 121 health professionals in total working in the operating theatres. The authors compared the responses to each question amongst the respondents, to check for the tendency to correlate. Out of the 52 health professionals who responded, 36 stated that music is played in their theatre either every day, or two to three times a week. Only five respondents felt that this was too often. Fifteen percent of medical staff were of the opinion that the nursing staff controlled the choice of music. Nursing staff were almost evenly split in thinking that nursing staff, surgical staff and the whole theatre team controlled the choice of music. The majority of both nursing and medical staff felt that they enjoyed their work more and performed better when music was played in theatre. The study concluded that the majority of theatre staff found listening to music while they work a positive experience. The potential for music to have a distracting or detrimental effect on a minority of individuals should always be considered.