Patient Power: A feasibility study on the impact of providing a bedside notepad to encourage patients to ask questions following surgery

Objective

This study aimed to evaluate a behaviour change strategy to enhance the patient voice in the early post-operative setting.

Methods

The Patient Power notepad was evaluated in an uncontrolled, single-group, mixed-methods trial including a patient evaluation survey and staff phone interviews.

Results

Patients thought that the notepad was well-designed and prompted them to think of and ask questions. They strongly agreed that healthcare practitioners answered health-related questions fully and carefully. Staff reported that the notepad not only provided an easy mechanism through which patients and their families could communicate with their healthcare team, but it also created a permissive environment where questions were encouraged.

Conclusion

The Patient Power notepad provided an easy, acceptable and scalable intervention to encourage patients to engage more in their healthcare and specifically to ask questions about their care. By providing a structured tool for capturing patient concerns, symptoms, and questions, this innovation holds the potential to enhance patient satisfaction, treatment adherence, and overall healthcare outcomes.

Innovation

By facilitating comprehensive information exchange and the potential to promote shared decision-making, this innovation has the potential to improve patient satisfaction, treatment adherence, and overall healthcare outcomes.

Optimising acute non-critical inter-hospital transfers: A review of evidence, practice and patient perspectives

INTRODUCTION

Patients who present to hospital with an acute non-critical illness or injury, which is considered outside the capability framework of that hospital to treat, will require inter-hospital transfer (IHT) to a hospital with a higher level of capability for that condition. Delays in IHT can negatively impact patient care and patient outcomes.

OBJECTIVE

To review and synthesis academic evidence, practitioner insights and patient perspectives on ways to improve IHT from regional to metro hospitals.

DESIGN

A rapid review methodology identified one review and 14 primary studies. Twelve practitioner interviews identified insights into practice and implementation, and the patient perspectives were explored through a citizen panel with 15 participants.

FINDINGS

The rapid review found evidence relating to clinician and patient decision factors, protocols, communication practices and telemedicine. Practitioner interviews revealed challenges in making the initial decision, determining appropriate destinations and dealing with pushback. Adequate support and communication were raised as important to improve IHT. The citizen panel found that the main concern with IHT was delays. Citizen panel participants suggested dedicated transfer teams, education and information transfer systems to improve IHT.

DISCUSSION AND CONCLUSION

Common challenges in IHT include making the initial decision to transfer and communicating with other health services and patients and families. In identifying the appropriateness of transferring acute non-critical patients, clear and effective communication is central to appropriate and timely IHT; this evidence review indicates that education, protocols and information management could make IHT processes smoother.

The frequency and nature of barriers to escalation of care in two Australian teaching hospitals

BACKGROUND

Nurses and junior doctors are often the first clinicians to recognise signs of deterioration in patients. However, there can be barriers to having conversations about escalation of care.

OBJECTIVES

The aim of this study was to study the frequency and nature of barriers encountered during discussions related to escalation of care for deteriorating hospitalised patients.

METHODS

This was a prospective observational study with daily experience sampling surveys related to escalation of care discussions. The study setting involved two teaching hospitals in Victoria, Australia. Consented doctors, nurses, and allied health staff members involved in routine care of adult ward patients participated in the study. The main outcome measures included the frequency of escalation conversations and the frequency and nature of barriers encountered during such conversations.

RESULTS/FINDINGS

31 clinicians participated in the study and completed an experience sampling survey 294 times, mean (standard deviation) = 9.48 (5.82). On 166 (56.6%) days, staff members were on clinical duties, and escalation of care discussions occurred on 67 of 166 (40.4%) of these days. Barriers to escalation of care occurred in 25 of 67 (37.3%) of discussions and most frequently involved lack of staff availability (14.9%), perceived stress in the contacted staff member (14.9%), perceptions of criticism (9.0%), being dismissed (7.5%), or indication of lack of clinical appropriateness in the response (6.0%).

CONCLUSIONS

Discussions related to escalation of care by ward clinicians occur in almost half of clinical days and are associated with barriers in one-third of discussions. Interventions are needed to clarify roles and responsibilities and outline behavioural expectations on both sides of the conversation and enable respectful communication amongst individuals involved in discussions of escalation of patient care.

How effective are interventions in optimizing workplace mental health and well-being? A scoping review of reviews and evidence map

OBJECTIVES

Mental well-being is critical to quality of life. Workplace mental well-being is crucial to ensure employee health, satisfaction, and performance. Mental ill-health is a global challenge, costing workplaces $17 billion per year. Workplaces have realized the need for investment in interventions to promote mental health and well-being in their workforce. However, given their limited resources, workplace personnel responsible for program implementation need evidence-based guidance on which interventions influence which outcomes.

METHODS

This study employed a scoping review methodology in order to produce an evidence map and includes reviews of workplace mental well-being interventions. The search strategy focused on peer-reviewed articles with the primary aim of investigating workplace mental health interventions. Reviews were assessed for quality using AMSTAR 2. The evidence map includes interventions (rows) and outcomes (columns), with the relative size of the reviews underpinning each intersection represented by circles and the direction of evidence represented by color.

RESULTS

Eighty reviews were deemed eligible from 4795 citations. The resulting evidence map includes 17 intervention types designed to influence 12 outcomes. Interventions with the highest quality evidence were mindfulness, education and information provision, and individual psychological therapies. The most common outcomes were burnout / stress reduction and mental well-being. Interventions tended to focus on individual level factors rather than organizational or system-level factors.

CONCLUSION

The evidence-base for workplace mental health interventions is broad and extensive. There is an apparent knowledge-to-practice gap, presenting challenges to implementing workplace mental health programs (ie, what interventions have the highest quality evidence). This study aims to fill the gap by providing an interactive evidence-map. Future research should look to fill the gaps within the map including the lack of organization and system level factors and especially economic evaluations.

Improved Constraints on Primordial Gravitational Waves using Planck, WMAP, and BICEP/Keck Observations through the 2018 Observing Season

We present results from an analysis of all data taken by the BICEP2, Keck Array, and BICEP3 CMB polarization experiments up to and including the 2018 observing season. We add additional Keck Array observations at 220 GHz and BICEP3 observations at 95 GHz to the previous 95/150/220  GHz dataset. The Q/U maps now reach depths of 2.8, 2.8, and 8.8  μK_{CMB} arcmin at 95, 150, and 220 GHz, respectively, over an effective area of ≈600 square degrees at 95 GHz and ≈400 square degrees at 150 and 220 GHz. The 220 GHz maps now achieve a signal-to-noise ratio on polarized dust emission exceeding that of Planck at 353 GHz. We take auto- and cross-spectra between these maps and publicly available WMAP and Planck maps at frequencies from 23 to 353 GHz and evaluate the joint likelihood of the spectra versus a multicomponent model of lensed ΛCDM+r+dust+synchrotron+noise. The foreground model has seven parameters, and no longer requires a prior on the frequency spectral index of the dust emission taken from measurements on other regions of the sky. This model is an adequate description of the data at the current noise levels. The likelihood analysis yields the constraint r_{0.05}<0.036 at 95% confidence. Running maximum likelihood search on simulations we obtain unbiased results and find that σ(r)=0.009. These are the strongest constraints to date on primordial gravitational waves.

Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review

Background

Involving patients in their healthcare using shared decision-making (SDM) is promoted through policy and research, yet its implementation in routine practice remains slow. Research into SDM has stemmed from primary and secondary care contexts, and research into the implementation of SDM in tertiary care settings has not been systematically reviewed. Furthermore, perspectives on SDM beyond those of patients and their treating clinicians may add insights into the implementation of SDM. This systematic review aimed to review literature exploring barriers and facilitators to implementing SDM in hospital settings from multiple stakeholder perspectives.

Methods

The search strategy focused on peer-reviewed qualitative studies with the primary aim of identifying barriers and facilitators to implementing SDM in hospital (tertiary care) settings. Studies from the perspective of patients, clinicians, health service administrators, and decision makers, government policy makers, and other stakeholders (for example researchers) were eligible for inclusion. Reported qualitative results were mapped to the Theoretical Domains Framework (TDF) to identify behavioural barriers and facilitators to SDM.

Results

Titles and abstracts of 8724 articles were screened and 520 were reviewed in full text. Fourteen articles met inclusion criteria. Most studies (n = 12) were conducted in the last four years; only four reported perspectives in addition to the patient-clinician dyad. In mapping results to the TDF, the dominant themes were Environmental Context and Resources, Social/Professional Role and Identity, Knowledge and Skills, and Beliefs about Capabilities. A wide range of barriers and facilitators across individual, organisational, and system levels were reported. Barriers specific to the hospital setting included noisy and busy ward environments and a lack of private spaces in which to conduct SDM conversations.

Conclusions

SDM implementation research in hospital settings appears to be a young field. Future research should build on studies examining perspectives beyond the clinician-patient dyad and further consider the role of organisational- and system-level factors. Organisations wishing to implement SDM in hospital settings should also consider factors specific to tertiary care settings in addition to addressing their organisational and individual SDM needs.

Trial Registration

The protocol for the review is registered on the Open Science Framework and can be found at https://osf.io/da645/, DOI 10.17605/OSF.IO/DA645.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01142-y.

Simulation-based training for increasing health service board members' effectiveness: a cluster randomised controlled trial

OBJECTIVES

There is a paucity of research on how to improve the functioning of health service boards, despite their importance in influencing patient care. We examined the impact of simulation-based training on health service board members' perceptions of their skills in communicating during board meetings and of board meeting processes.

DESIGN

Prospective, cluster randomised controlled trial.

SETTING

Health service boards in Victoria, Australia.

PARTICIPANTS

Twelve boards were randomised, and pre- and post-intervention data were collected and analysed from 57 members of these boards.

INTERVENTIONS

Boards were randomly allocated to either a treatment condition in which they received a 2-hour simulation-based training session or to a wait list control condition.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome variables were board members' perceptions regarding: (1) their skill and confidence in communicating during board meetings and (2) processes at their board meetings. Measures were collected in the intervention group before and 3 months post-training and compared with a wait list control group.

RESULTS

Skills and confidence in communicating during board meetings was higher after training (control marginal mean=5.11, intervention marginal mean=5.42, mean difference=0.31, 90% CI (-0.03 to 0.66), one-sided p=0.068, d=0.40). Board meeting processes were also improved after training (control marginal mean=4.97, intervention marginal mean=5.37, mean difference=0.40, 90% CI (0.14 to 0.65), one-sided p=0.005, d=0.54).

CONCLUSIONS

Simulation-based training appeared to improve board members' skills and confidence, and perceptions of board meeting processes. A larger scale trial is needed to examine possible impacts on patient outcomes.

TRIAL REGISTRATION

Open Science Framework: http://osf.io/jaxt6/; Pre-results.

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives

Background

Communication failures involving test results contribute to issues of patient harm and sentinel events. This article aims to synthesise review evidence, practice insights and patient perspectives addressing problems encountered in the communication of diagnostic test results.

Methods

The rapid review identified ten systematic reviews and four narrative reviews. Five practitioner interviews identified insights into interventions and implementation, and a citizen panel with 15 participants explored the patient viewpoint.

Results

The rapid review provided support for the role of technology to ensure effective communication; behavioural interventions such as audit and feedback could be effective in changing clinician behaviour; and point-of-care tests (bedside testing) eliminate the communication breakdown problem altogether. The practice interviews highlighted transparency, and clarifying the lines of responsibility as central to improving test result communication. Enabling better information sharing, implementing adequate planning and utilising technology were also identified in the practice interviews as viable strategies to improve test result communication. The citizen panel highlighted technology as critical to improving communication of test results to both health professionals and patients. Patients also highlighted the importance of having different ways of accessing test results, which is particularly pertinent when ensuring suitability for vulnerable populations.

Conclusions

This paper draws together multiple perspectives on the problem of failures in diagnostic test results communication to inform appropriate interventions. Across the three studies, technology was identified as the most feasible option for closing the loop on test result communication. However, the importance of clear, consistent communication and more streamlined processes were also key elements that emerged.

Review registration

The protocol for the rapid review was registered with PROSPERO CRD42018093316.

Traumatic spinal cord injury in Victoria, 2007-2016

OBJECTIVE

To investigate trends in the incidence and causes of traumatic spinal cord injury (TSCI) in Victoria over a 10-year period.

DESIGN, SETTING, PARTICIPANTS

Retrospective cohort study: analysis of Victorian State Trauma Registry (VSTR) data for people who sustained TSCIs during 2007-2016.

MAIN OUTCOMES AND MEASURES

Temporal trends in population-based incidence rates of TSCI (injury to the spinal cord with an Abbreviated Injury Scale [AIS] score of 4 or more).

RESULTS

There were 706 cases of TSCI, most the result of transport events (269 cases, 38%) or low falls (197 cases, 28%). The overall crude incidence of TSCI was 1.26 cases per 100 000 population (95% CI, 1.17-1.36 per 100 000 population), and did not change over the study period (incidence rate ratio [IRR], 1.01; 95% CI, 0.99-1.04). However, the incidence of TSCI resulting from low falls increased by 9% per year (95% CI, 4-15%). The proportion of TSCI cases classified as incomplete tetraplegia increased from 41% in 2007 to 55% in 2016 (P < 0.001). Overall in-hospital mortality was 15% (104 deaths), and was highest among people aged 65 years or more (31%, 70 deaths).

CONCLUSIONS

Given the devastating consequences of TSCI, improved primary prevention strategies are needed, particularly as the incidence of TSCI did not decline over the study period. The epidemiologic profile of TSCI has shifted, with an increasing number of TSCI events in older adults. This change has implications for prevention, acute and post-discharge care, and support.

Changing prescribing behaviours with educational outreach: an overview of evidence and practice

BACKGROUND

General practitioners (GPs), or family practitioners, are tasked with prescribing medications that can be harmful to the community if they are inappropriately prescribed or used (e.g. opioids). Educational programs, such as educational outreach (EO), are designed to change the behaviour of health professionals. The purpose of this study was to identify the efficacy of EO programs at changing the prescribing behaviour of GPs.

METHODS

This study included an evidence and practice review, comprising a rapid review supplemented by interviews with people who are familiar with EO implementation for regulation purposes. Seven databases were searched using terms related to health professionals and prescribing. Systematic and narrative reviews published in English after 2007 were included. Non-statistical analysis was used to report intervention efficacy. Three government representatives participated in semi-structured interviews to aid in understanding the relevance of review findings to the Victorian context. Interviews were transcribed verbatim and thematically analysed for emerging themes.

RESULTS

Fourteen reviews were identified for the evidence review. Isolated (e.g. EO program delivered by itself) and multifaceted (e.g. EO program supplemented by other interventions) programs were found to change prescribing behaviours. However, limited evidence suggests that EO can successfully change prescribing behaviours specific to GPs. Isolated EO can successfully change health professional prescribing behaviours, although cheaper alternatives such as letters might be just as effective. Multifaceted EO can also successfully change health professional prescribing behaviours, especially in older adults, but it remains unclear as to what combination of interventions works best. Success factors for EO reported by government representatives included programs having practical rather than didactic foci; making EO compulsory; focussing EO on preventing adverse events; using monetary or professional development incentives; and in-person delivery.

CONCLUSIONS

Educational outreach can successfully change prescribing behaviours but evidence specific to GPs is lacking. Key characteristics of EO that could optimise success include ensuring the EO program is tailored, involves practical learning and uses incentives that are meaningful to clinicians.

Simulation-based training for increasing health service board members' effectiveness: protocol for a cluster-randomised controlled trial

INTRODUCTION

Research indicates that health service boards can influence quality of care. However, government reviews have indicated that board members may not be as effective as possible in attaining this goal. Simulation-based training may help to increase board members' ability to effectively communicate and hold hospital staff to account during board meetings.

METHODS AND ANALYSIS

To test effectiveness and feasibility, a prospective, cluster-randomised controlled trial will be used to compare simulation-based training with no training. Primary outcome variables will include board members' perceived skill and confidence in communicating effectively during board meetings, and board members' perceptions of board meeting processes. These measures will be collected both immediately before training, and 3 months post-training, with boards randomly assigned to intervention or control arms. Primary analyses will comprise generalised estimating equations examining training effects on each of the primary outcomes. Secondary analyses will examine participants' feedback on the training.

ETHICS AND DISSEMINATION

Research ethics approval has been granted by Monash University (reference number: 2018-12076). We aim to disseminate results through peer-reviewed journal publication, conference presentation and social media.

TRIAL REGISTRATION NUMBER

Open Science Framework: http://osf.io/jaxt6/; Pre-results.

HOspitals and patients WoRking in Unity (HOW R U?): telephone peer support to improve older patients' quality of life after emergency department discharge in Melbourne, Australia-a multicentre prospective feasibility study

OBJECTIVES

To ascertain the feasibility and acceptability of the HOW R U? programme, a novel volunteer-peer postdischarge support programme for older patients after discharge from the emergency department (ED).

DESIGN

A multicentre prospective mixed-methods feasibility study.

SETTING

Two tertiary hospital EDs in metropolitan Melbourne, Australia.

PARTICIPANTS

A convenience sample of 39 discharged ED patients aged 70 years or over, with symptoms of social isolation, loneliness and/or depression.

INTERVENTION

The HOW R U? intervention comprised weekly social support telephone calls delivered by volunteer peers for 3 months following ED discharge.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were feasibility of study processes, intervention acceptability to participants and retention in the programme. Secondary outcomes were changes in loneliness level (UCLA-3-3-item Loneliness Scale), mood (5-item Geriatric Depression Scale) and health-related quality of life (EQ-5D-5L and EQ-VAS) postintervention.

RESULTS

Recruitment was feasible, with 30% of eligible patients successfully recruited. Seventeen volunteer peers provided telephone support to patient participants, in addition to their usual hospital volunteer role. HOW R U? was well received, with 87% retention in the patient group, and no attrition in the volunteer group.The median age of patients was 84 years, 64% were female, and 82% lived alone. Sixty-eight per cent of patients experienced reductions in depressive symptoms, and 53% experiencing reduced feelings of loneliness, and these differences were statistically significant Patient feedback was positive and volunteers reported great satisfaction with their new role.

CONCLUSION

HOW R U? was feasible in terms of recruitment and retention and was acceptable to both patients and volunteers. The overall results support the potential for further research in this area and provide data to support the design of a definitive trial to confirm the observed effects.

TRIAL REGISTRATION NUMBER

ANZCTRN12615000715572; Results.

Caring for older patients in the emergency department: Health professionals' perspectives from Australia - The Safe Elderly Emergency Discharge project

OBJECTIVE

To explore health professionals' perspectives about caring for community-dwelling older patients in the ED.

METHODS

This exploratory qualitative study was undertaken with emergency nursing, medical and allied health staff from the ED of a large metropolitan public hospital in Melbourne. Nine focus groups (n = 54) and seven interviews were conducted between 2013 and 2014. Data were thematically analysed.

RESULTS

Health professionals described tailoring their approach when caring for older patients, including adopting a specific communication approach (i.e. increased voice volume, slower rate of speech). Caring for older patients was perceived as challenging given the need to balance the expectations of family members to deal with associated complex needs and limited time for transitional care planning in the ED. The environment and equipment were perceived as unsuitable, alongside a lack of geriatric-specific knowledge; contributing to what health professionals described as a poor fit between the ED system and older patients' needs.

CONCLUSION

The growing number of older patients presents numerous challenges for emergency health professionals and necessitates a tailored approach to care. Understanding health professionals' perspectives about caring for older patients can inform strategies that may improve the quality of care. Creating older person-friendly areas, improving transitional care and providing staff with specific education would foster an environment that promotes person-centred care, safety, independence and functional wellbeing.

Experiences With Navigating and Managing Information in the Community Following Spinal Cord Injury

Background: People living with spinal cord injury (SCI) have reported difficulties managing information in the community, which can negatively impact their functional independence and ability to prevent secondary complications. Objective: This exploratory qualitative study aimed to describe the experiences of people living with SCI with navigating and managing information in the community from their perspective. Methods: Participants were recruited through the Australian Quadriplegic Association. Twenty-two semi-structured in-depth interviews were conducted with purposively selected participants to ensure representation of age, gender, SCI level, and compensation status. Data were thematically analyzed using a framework approach. Results: People living with SCI reported using multiple, complementary sources of information to prevent and manage secondary conditions. Over time, they learned to appraise the content, relevance, timing, and sources of information. Information delivered by health professionals in the rehabilitation setting was appraised as lacking personalization, but it acted as a springboard to search for more relevant information. Participants described the process of becoming experts about their condition to overcome the lack of knowledge of many general practitioners, guide their own care, and act as a source of information for others. Due to a lack of information provision, some participants missed health improvement opportunities and experienced frustration at the uncertainty of their future with SCI. Conclusion: Greater support is required for individuals with SCI to navigate information sources in the community. Rehabilitation is an opportune time to provide education related to finding and appraising information. Improved access to community health providers with SCI knowledge is also required.

Melatonin as a treatment for mood disorders: a systematic review

OBJECTIVE

Melatonin has been widely studied in the treatment of sleep disorders and evidence is accumulating on a possible role for melatonin influencing mood. Our aim was to determine the efficacy and acceptability of melatonin for mood disorders.

METHOD

We conducted a comprehensive systematic review of randomized clinical trials on patients with mood disorders, comparing melatonin to placebo.

RESULTS

Eight clinical trials were included; one study in bipolar, three in unipolar depression and four in seasonal affective disorder. We have only a small study on patients with bipolar disorder, while we have more studies testing melatonin as an augmentation strategy for depressive episodes in major depressive disorder and seasonal affective disorder. The acceptability and tolerability were good. We analyzed data from three trials on depressive episodes and found that the evidence for an effect of melatonin in improving mood symptoms is not significant (SMD = 0.37; 95% CI [-0.05, 0.37]; P = 0.09). The small sample size and the differences in methodology of the trials suggest that our results are based on data deriving from investigations occurring early in this field of study.

CONCLUSION

There is no evidence for an effect of melatonin on mood disorders, but the results are not conclusive and justify further research.

HOspitals and patients WoRking in Unity (HOW R U?): protocol for a prospective feasibility study of telephone peer support to improve older patients' quality of life after emergency department discharge

INTRODUCTION

Older people presenting to an emergency department (ED) have a higher likelihood of social isolation, loneliness and depression; which are all associated with negative health outcomes and increased health service use, including higher rates of ED attendance. The HOW R U? study aims to ascertain the feasibility and acceptability of a postdischarge telephone support programme for older ED patients following discharge. The intervention, which aims to improve quality of life, will be delivered by hospital-based volunteers.

METHODS AND ANALYSIS

A multicentre prospective uncontrolled feasibility study will enrol 50 community-dwelling patients aged ≥70 years with symptoms of loneliness or depression who are discharged home within 72 hours from the ED or acute medical ward. Participants will receive weekly supportive telephone calls over a 3-month period from a volunteer-peer. Feasibility will be assessed in terms of recruitment, acceptability of the intervention to participants and level of retention in the programme. Changes in level of loneliness (UCLA-3 item Loneliness Scale), mood (Geriatric Depression Scale-5 item) and health-related quality of life (EQ-5D-5L and EQ-VAS) will also be measured postintervention (3 months).

ETHICS AND DISSEMINATION

Research ethics and governance committee approval has been granted for this study by each participating centre (reference: 432/15 and 12-09-11-15). Study findings will inform the design and conduct of a future multicentre randomised controlled trial of a postdischarge volunteer-peer telephone support programme to improve social isolation, loneliness or depressive symptoms in older patients. Results will be disseminated through peer-reviewed journal publication, and conference and seminar presentation.

TRIAL REGISTRATION NUMBER

ACTRN12615000715572, Pre-results.

Advanced diagnostic imaging and surgical treatment of an odontogenic retromasseteric abscess in a guinea pig

A two-year-old guinea pig presented for difficulty chewing. Examination and diagnostic imaging, including computed tomography and magnetic resonance, revealed an odontogenic retromasseteric abscess associated with a mandibular cheek tooth. Treatment included removal of the abscess and marsupialisation of the surgical site for repeated debridement and healing by second intention. Unique features of this case included the use of advanced diagnostic imaging and utilisation of marsupialisation for surgical correction.

Prepuce and partial penile amputation for treatment of preputial gland neoplasia in two ferrets

Preputial tumours in ferrets are frequently malignant and therefore warrant prompt investigation. As many cases do not respond favourably to surgery, even in combination with radiation therapy, wide surgical resection has been recommended. Such a procedure may necessitate partial or total penile resection but outcomes have thus far not been well described. The current case series describes two ferrets in which surgical resection, including penile amputation, was performed using 10 and 5 mm margins, respectively. In the first case, no recurrence of preputial gland adenocarcinoma was noted for 32 months postsurgery, whereas multiple attempts at surgery and radiation therapy were unsuccessful in the second. These cases suggest that margins of at least 1 cm may help achieve a better outcome. Penile amputation for the treatment of preputial tumours appears to be well tolerated by ferrets, as demonstrated by these cases.

New opportunities for nurses in medical education: facilitating valuable community learning experiences

A new 4 week community programme, developed through a successful Department of Health Bid in partnership with the Community NHS Trust, provides a vital clinical learning block for all medical students at the Leicester/Warwick Medical school. The course owes its success to the pivotal role played by nurses. Working with an Academic co-ordinator the course was operationalised in the county's market towns and provided student access to the work of the entire front line community workforce in the care of people with life limiting diseases and disabled people. Senior nurses in each locality led the work with both community hospital and community nurses sharing their expertise with a wide range of front line health and social care professionals. The lead nurses and their teaching teams attended university training days prior to developing a locality student programme and played a key role in identifying preparing and supporting suitable patients for student learning. Students highly praised the work of the lead nurses who supported their learning throughout the course. All nurses felt the educational involvement was worthwhile, having overcome identified barriers and with funding support nurses have been able to assimilate the teaching into their annual workload.

Delivering quality improvements in patient care: the application of the Leicester Model of interprofessional education

BACKGROUND

This paper places the importance of evidence-based models of interprofessional education (IPE) within the context of a changing National Health Service (NHS). The coalition government has placed integrated care at the heart of its vision for England's health system. Its principles are to put patients at the centre of the NHS, empower clinicians to lead commissioning and change the emphasis of measurement to quality clinical outcomes. As a result, NHS services are being increasingly tendered along evidence-based care pathways and commissioners are introducing payment by results tariffs, requiring providers to achieve quality outcomes as a requirement of full payment.

AIM

We argue that in preparing the health and social care workforce for outcome-based practice, the development of technical skills should be complemented with skills for effective teamworking and collaborative practice.

METHODS

This paper shares the achievements of the Leicester Model of IPE which is underpinned by theoretical models of learning and implemented entirely in clinical practice; mixed research methods demonstrate that its learning potential is as relevant today as when it was first implemented in 1996.

RESULTS

Our extensive research evidence demonstrates that students and healthcare professionals undertaking these programmes are enabled to perceive care pathways from service and providers perspectives; they gain valuable insights into how teams balance task- and patient-related issues, offer clarity about the team's effectiveness and gain new insights into collaborative opportunities to address patients' needs.

CONCLUSION

We demonstrate that models such as ours offer evidence-based solutions which will support the achievement of quality outcomes for service providers, many of whom are reviewing their business plans to address the financial implications of payment by results. The current NHS reforms provide a hugely important lever in which IPE can come of age - in return we need to ensure that our NHS colleagues are informed of its potential.

Habitual physical activity and body composition of black township adolescents residing in the North West Province, South Africa

Objective

It is known that stunting and obesity affect a large proportion of children in the world, and these can be affected by the physical activity levels of the children. In the present study, we evaluated the association between physical activity, physical development and body composition in black adolescent children.

Design

Cross-sectional study.

Setting

Black township schools in the North West Province, South Africa.

Methods

Three-hundred and thirteen grade 8 children were included in the Physical Activity in Youth study. Anthropometric measurements, body composition measures and maturity level as assessed by Tanner stages were determined in these children. In addition, Previous Day Physical Activity Recall questionnaires were administered on the children to record the various activities they undertake daily.

Results

The demographic characteristics of the children showed a high level of homogeneity. A high prevalence of stunting (16.3%) was observed in the children, which was higher in boys than in girls (21.6 vs. 12.3%). Also prevalent was overweight/obesity (8.6%), but this was higher in girls than in boys (13.4 vs. 1.6%). The children also showed a reduction in levels of physical activity with advancement in maturity; furthermore, boys showed a more central form of fat deposition whilst girls showed more gynoid deposition.

Conclusions

The study revealed that physical activity plays a role in determining body composition, and further indicated that physical activity is associated with favourable body composition measures. Children who were more active were likely to have less fat deposits.

Calibration of the borated ion chamber at NIST reactor thermal column

In boron neutron capture therapy and boron neutron capture enhanced fast neutron therapy, the absorbed dose of tissue due to the boron neutron capture reaction is difficult to measure directly. This dose can be computed from the measured thermal neutron fluence rate and the (10)B concentration at the site of interest. A borated tissue-equivalent (TE) ion chamber can be used to directly measure the boron dose in a phantom under irradiation by a neutron beam. Fermilab has two Exradin 0.5 cm(3) Spokas thimble TE ion chambers, one loaded with boron, available for such measurements. At the Fermilab Neutron Therapy Facility, these ion chambers are generally used with air as the filling gas. Since alpha particles and lithium ions from the (10)B(n,alpha)(7)Li reactions have very short ranges in air, the Bragg-Gray principle may not be satisfied for the borated TE ion chamber. A calibration method is described in this paper for the determination of boron capture dose using paired ion chambers. The two TE ion chambers were calibrated in the thermal column of the National Institute of Standards and Technology (NIST) research reactor. The borated TE ion chamber is loaded with 1,000 ppm of natural boron (184 ppm of (10)B). The NIST thermal column has a cadmium ratio of greater than 400 as determined by gold activation. The thermal neutron fluence rate during the calibration was determined using a NIST fission chamber to an accuracy of 5.1%. The chambers were calibrated at two different thermal neutron fluence rates: 5.11 x 10(6) and 4.46 x 10(7)n cm(-2) s(-1). The non-borated ion chamber reading was used to subtract collected charge not due to boron neutron capture reactions. An optically thick lithium slab was used to attenuate the thermal neutrons from the neutron beam port so the responses of the chambers could be corrected for fast neutrons and gamma rays in the beam. The calibration factor of the borated ion chamber was determined to be 1.83 x 10(9) +/- 5.5% (+/- 1sigma) n cm(-2) per nC at standard temperature and pressure condition.

Flight microangiopathy in medium-to-long distance flights: prevention of edema and microcirculation alterations with HR (Paroven, Venoruton; 0-(beta-hydroxyethyl)-rutosides): a prospective, randomized, controlled trial

This study evaluated the effects of HR (Paroven, Venoruton; 0-(beta-hydroxyethyl)-rutosides) on the prevention and control of flight microangiopathy, and particularly on edema, in subjects with varicose veins flying for more than 7 hours. Forty patients with varicose veins, edema, and initial skin alterations due to chronic venous hypertension were included. Measurements of skin laser Doppler flowmetry resting flux, Po(2) and rate of ankle swelling, were made before and after the flights (within 4 hours before the flights and within 2 hours after the flights). The length of the flights was between 7 and 9 hours; all seats were in coach class. The 2 groups were comparable for distribution. The variation of Po(2) was significant in both groups. However, in subjects treated with HR, the decrease in Po(2) was smaller (P < 0.05). The decrease in laser Doppler flowmetry resting flux was also significant in both groups, with a higher flux at the end of the control period in the treated subjects (P < 0.05). The venoarteriolar response progressively decreased at 7 and 9 hours. The decrease was less evident in the treatment group (P < 0.05). The rate of ankle swelling was progressively increased in the control group; the increase was not significant in the HR group. In long-haul flights, HR is useful for reducing the increased capillary filtration and in controlling edema in patients with venous hypertension and is effective in controlling perfusion disorders and microangiopathy, particularly swelling and edema, due to flights.

Flight microangiopathy in medium- to long-distance flights: prevention of edema and microcirculation alterations with total triterpenic fraction of Centella asiatica

The aim of this study was the evaluation of microcirculatory alterations associated with edema in passengers travelling for more than 3 hours and the study of the effects of TTFCA (total triterpenic fraction of Centella asiatica) on the development of microcirculation alterations and edema, in a prospective, randomized study. Laser Doppler flowmetry (LDF), transcutaneous PO2 and PCO2, rate of ankle swelling (RAS) were used. Subjects were randomized after informed consent into two groups: one control group (no drug or other treatment), and a treatment group (TTFCA 60 mg thrice daily for 2 days before the flight, the day of the flight, and for another day after the flight). Inclusion criteria were age range between 30 and 50, mild-moderate superficial venous disease with varicose veins. Subjects traveled in economy class. In controls there was a progressive increase in CO2, RAS, and edema score and a progressive decrease in flux (RF) and venoarteriolar response with flying time. The variations in all parameters were milder (p>0.05) in the TTFCA group. RAS and edema were significantly lower in the TTFCA-treated group (p<0.025). The progressive increase in RAS, PCO2, and the decrease in VAR and O2 were linearly associated with flight time (up to 10 hours). These results are very interesting and indicate an option for patients prone to edema and microcirculation disturbances during long flights.

[Femoral artery pseudo-aneurysms--changes in treatment, report of 7 years]

The femoral artery remains the most used peripheral site for radiological catheter access. With a greater number of both diagnostic and therapeutic procedures being performed by interventional radiologists and cardiologists, and with larger catheters being used for stenting and endovascular grafting, the incidence of iatrogenic pseudo-aneurysms reported has reached as high as 0.5-2%. Ideally, they should thrombus spontaneously. However, when this does not occur, management options include: observation, ultrasound-guided obliterative compression, direct thrombin injection, embolization, stent graft insertion, and very rarely-surgery. During a 7-year period (1992-1999) we treated 131 cases of femoral artery false aneurysms. Until 1998 ultrasound-guided compression-obliteration, with a 95% success rate, was our method of choice. Since 1998, direct thrombin injection, with 100% success in 24 cases, has become our preferred method. It is pain-free, fully successful even in anticoagulated patients, and is currently our treatment of choice.

Tissue response to an expanded polytetrafluoroethylene external valve support device: a histologic study in dogs

Expanded polytetrafluoroethylene (ePTFE) external valve support devices (EVS) have been used successfully in patients to restore valve function in leg veins with incompetent valves when incompetence is due to dilatation of the vein walls or elongation of the valve leaflet edges. To assess tissue response to these devices, the authors implanted 12 of them in dogs, wrapping the devices around veins in the head and neck. The dogs recovered from the implantation procedure uneventfully, and the veins remained patent on color flow Doppler scanning. Gross and histologic evaluations of vein segments and attached EVS devices after sacrifice of the dogs 30 days postoperatively showed that the ePTFE devices did not affect vein patency or the cellular composition or architecture of vein walls. There were no adverse tissue reactions to the EVS and no thrombus formation in the veins to which the EVS had been applied. Tissue attachment to the EVS was apparent in all specimens. These histologic results support clinical experiences indicating that the ePTFE EVS device is safe to use in external valvuloplasty for the treatment of venous incompetence.

Vascular screening in andropause: non-invasive investigations in vascular disease screening

Erectile dysfunction (ED) can be associated with atherosclerotic disease. It is therefore important to be able to evaluate the extent of arterial disease. This includes subclinical arterial disease. We have developed a score based on high-resolution-B-mode ultrasound scanning of the carotid-femoral bifurcations. This is a cost-effective screening procedure that correlates well with the risk of cardiovascular events. The penile circulation can also be investigated to assess local circulation and the level of fibrosis. During this investigation it is worthwhile evaluating the carotid-femoral arteries because the risk factors that predict ED are the same as those for atherosclerosis. Penile fibrosis contributes to the pathogenesis of ED. Whether this change is associated with hypertension needs to be established by further studies.

Microcirculatory studies in erectile disorders

Local microcirculatory disturbances and fibrosis are thought to contribute to the pathogenesis of erectile dysfunction (ED). The assessment of these disturbances is now possible using non-invasive techniques such as laser Doppler flowmetry (LDF) and measuring transcutaneous pO2 and pCO2. However, these techniques need standardisation (e.g. in terms of equipment, conditions in which the examination is carried out and duration of measurement). Nevertheless, these techniques have a qualitative value. Marked alterations are seen in smokers and hypertensive patients. LDF has also been used to monitor the effect of treatment (e.g. after intracavernosal PGE1). These techniques remain non-diagnostic in individual patients. However, in groups of patients they may produce useful information (e.g. to assess treatments for ED).

Graft dilatation following abdominal aortic aneurysm resection and grafting

BACKGROUND

It has been suggested that graft dilatation following repair of abdominal aortic aneurysm (AAA) is associated with complications such as anastomotic aneurysm and graft rupture. The purpose of the present study was to document the degree of dilatation observed in grafts after aneurysm repair and to correlate this with any graft-related complications.

METHODS

Between January 1987 and December 1992, 219 patients had elective repair of their AAA at St George Hospital. A follow-up ultrasound scan was available for 154 of these patients. The following factors were examined: age, sex, size of aneurysm, type and size of graft, time of follow-up scan, size of graft at follow-up and any graft-related complications.

RESULTS

The mean graft dilatation observed in knitted grafts (42.6%; 95% CI: 39.1-46.1%) was significantly greater than that observed for woven grafts (25.5%; 95% CI: 19.0-32.1%; P < 0.0001). There were no graft-related complications.

CONCLUSIONS

Graft dilatation is a predictable phenomenon following AAA repair. It is more pronounced in knitted than in woven grafts, but does not necessarily lead to graft-related complications or failure.

Comparison of low-molecular-weight heparin, administered primarily at home, with unfractionated heparin, administered in hospital, and subcutaneous heparin, administered at home for deep-vein thrombosis

In this study, 294 patients with acute proximal DVT (deep venous thrombosis) were randomly assigned to receive intravenous standard heparin in the hospital (98 patients) or low-molecular-weight heparin (LMWH) (nadroparin 0.1 mL [equivalent to 100 AXa IU] per kg of body weight subcutaneously twice daily) administered primarily at home (outpatients) or alternatively in hospital (97 patients) or subcutaneous calcium heparin (SCHep) (99 patients, 0.5 mL bid) administered directly at home. The study design allowed outpatients taking LMWH heparin to go home immediately and hospitalized patients taking LMWH to be discharged early. Patients treated with standard heparin or LMWH received the oral anticoagulant starting on the second day, and heparin was discontinued when the therapeutic range (INR 2-3) had been reached. Anticoagulant treatment was maintained for 3 months. Patients treated with SCHep were injected twice daily for 3 months without oral anticoagulants. Patients were evaluated for inclusion and follow-up with color duplex scanning. Venography was not used. In case of suspected pulmonary embolism (PE) a ventilatory-perfusional lung scan was performed. Endpoints of the study were recurrent or extension of DVT, bleeding, the number of days spent in hospital, and costs of treatments. Of the 325 patients included, 294 completed the study. Dropouts totaled 31 (10.5%); six of the 325 included patients (1.8%) died from the related, neoplastic illness. Recurrence or extension of DVT was observed in 6.1% of patients in the LMWH group, in 6.2% in the standard heparin group, and in 7.1% in the SCHep group. Most recurrences (11/17) were in the first month in all groups. Bleedings were all minor, mostly during hospital stay. Hospital stay in patients treated with LMWH was 1.2+/-1.4 days in comparison with 5.4+/-1.2 in those treated with standard heparin. There was no hospital stay in the SCHep group. Average treatment costs in 3 months in the standard heparin group (US $2,760) were considered to be 100%; in comparison costs in the LMWH group was 28% of the standard heparin and 8% in the SCHep group. This study indicated that LMWH and SCHep can be used safely and effectively to treat patients with proximal DVT at home at a lower cost.

Monte Carlo calculations to characterize the source for neutron therapy facilities

Modern radiation treatment planning for photons includes full 3D modeling of the adsorbed dose distribution, accurate inclusion of the patient anatomy, and consideration of significant changes in material density and composition. Such efforts are founded in an accurate description of the radiation source and the beam delivery system. Modern fast neutron therapy facilities employ highly penetrating beams and isocentric beam delivery. Treatment planning is largely based on analytic models adapted from photon codes and interaction cross sections normalized to macroscopic attenuation. However, the recent PEREGRINE initiative at Lawrence Livermore Laboratory offers the possibility of fully stochastic modeling if the neutron source can be adequately described. In this article we report neutron source modeling of three high energy facilities. Neutron production is based on the intra-nuclear cascade model of the LAHET code while neutron transport through the beam delivery system is managed by MCNP using cross section libraries extended to 100 MeV neutron energy. PEREGRINE is then used to transport the neutron beam through typical phantoms. The resulting neutron sources are in excellent agreement with the limited experimental information and the measured phantom data are well described by the PEREGRINE transport using the LAHET/MCNP determined neutron sources.

Development and evaluation of a community based, multiagency course for medical students: descriptive survey

OBJECTIVE

To develop and evaluate an effective, community based, multiagency course (involving doctors, nurses, non-health statutory workers, and voluntary organisations) for all Leicester medical students, in response to the General Medical Council's recommendation of preparing the doctors of tomorrow to handle society's medical problems.

DESIGN

Survey evaluating a task oriented, problem solving course, designed by medical students in partnership with the University of Leicester and the local community. The students, staff, and participating agencies and patients all helped in the evaluation of the first course. The students' performance on the course was also individually assessed.

SETTING

Inner city housing estate with Jarman index 64.1 in Leicester.

SUBJECTS

All third year medical students at Leicester University.

MAIN OUTCOME MEASURES

Results of the student assignments and students' responses to a questionnaire. Results of feedback questionnaires distributed to the patients and agency representatives.

RESULTS

In a two month period, 168 students completed the first course. 163 students passed the criterion referenced assignment, 50 of whom achieved an "excellent" grade. 166 completed the questionnaire, with 159 wishing to see the course continue in the present format and 149 saying that the course linked theoretical teaching with the practical experiences gained in the community.

CONCLUSIONS

The University of Leicester has a viable mechanism for providing a community based, multiagency course for all its medical students. Many of the principles applied in the development and implementation of the course could be transferred to other medical schools.

Gender in medicine: the views of first and fifth year medical students

This study of first and fifth year medical students found a general recognition among male and female students that gender affects future career choices and the ability to reach career goals. Females were seen as being disadvantaged both in terms of career choice and their ability to achieve career goals. These views are less abstract and more based upon the reality of personal experiences in clinical attachments among fifth year students. While both male and female students describe negative experiences of clinical training, female students were more likely to suffer discrimination because of their gender in certain specialties, such as surgery, and to be dissuaded from pursuing a career in that specialty. Despite the general awareness of the effects of gender in medicine this did not appear to have an effect upon personal career choice. However, some female students were considering career choices at an early stage in their career based on accommodating their future desire to have a family life. Over half of all male and female fifth year students reported that having time for their family was an important consideration in choosing a career.

Late-onset Huntington's disease: a geriatric psychiatry perspective

Late-onset Huntington's disease is more common than has been generally appreciated and is associated with a wide range of psychiatric symptoms and syndromes. Geriatric psychiatrists have an important role to play in establishing the diagnosis and providing guidance to elderly patients and their families as they struggle with difficult management decisions. An illustrative case report and selective literature review are presented that highlight the genetic and clinical aspects of the condition.

Gerstmann-Sträussler-Scheinker disease with mutation at codon 102 and methionine at codon 129 of PRNP in previously unreported patients

We present two patients with Gerstmann-Sträussler-Scheinker disease (GSS), one from a previously undescribed kindred and one from the Canadian branch of a previously reported British kindred. In both patients, GSS is caused by a substitution of thymine for cytosine at codon 102 of the prion protein gene (PRNP). In each patient, we confirmed the clinical diagnosis by neuropathologic examination. The mutation, causing a substitution of leucine for proline at residue 102 (P102L) of the prion protein, has been previously reported in at least 30 other families. In the patients described here, the mutation was in coupling with methionine at PRNP codon 129.

Molecular genetic predictive testing for Alzheimer's disease: deliberations and preliminary recommendations

Forty-one participants representing diverse professional back-grounds attended a workshop on genetic predictive testing for familial Alzheimer's disease (FAD) on January 23, 1993 at Surrey Place Centre in Toronto, Canada. Rapidly emerging molecular genetic findings in AD indicate that predictive testing is now technologically feasible for selected individuals, although defining eligibility criteria remains problematic. Legal, ethical, biomedical, and psychosocial issues related to establishing predictive testing programs for AD were discussed at the workshop. This article reflects these discussions, provides the current biomedical background for them and examines the Huntington's disease (HD) predictive testing experience. Observations concerning molecular genetic predictive testing for AD in light of its genetic heterogeneity and clinical characteristics, such as usual later age of onset than HD, are presented. It is proposed that predictive testing for AD can now be cautiously offered in a research setting primarily according to the recommendations contained within the Ethical Issues Policy Statement on Huntington's Disease Molecular Genetics Predictive Test. However, in their application to AD, some points in the statement are considered to require emphasis, modification, or currently to be of uncertain applicability. This represents an initial step in an on-going process of debate concerning AD that will be required as new advances occur in genetic and clinical research and in bioethics.

Family with 22-derived marker chromosome and late-onset dementia of the Alzheimer type: II. Further cytogenetic analysis of the marker and characterization of the high-level repeat sequences using fluorescence in situ hybridization

We have further characterized an unusual 22p+ marker chromosome with a double nucleolus organizer region (dNOR) previously identified in a family with late-onset dementia of the Alzheimer type. G-banding and morphology of the marker's q arm were typically normal. However, the p+ arm had a terminal cytological satellite and a GT-positive region at the midpoint. Standard C-banding documented 2 C-positive regions: one was associated with the primary centromere; the other, which was at the midpoint of the p arm, was not associated with a constriction. With replication-banding, there was a darkly staining region in the middle of the p+ arm that resembled the pericentromeric region of a chromosome 21 or 22. Fluorescence in situ hybridization with pXlr 101, a probe recognizing the full repeating unit of rDNA, indicated that the marker had an unusually larger rDNA region; with pU 1.2, a probe recognizing the human rDNA promoter, the signal was a doublet. The marker had 2 signals with a beta-satellite probe, and a second signal in addition to that present at the primary centromere under low stringency with alpha-satellite probes and a classic satellite probe. Immunostaining of chromosome spreads after R-banding and ultraviolet (UV) denaturation showed that the major portion of the marker's p arm was highly methylated.

Monozygotic twins concordant for late-onset probable Alzheimer disease with suspected Alzheimer disease in four sibs

Probable Alzheimer disease (AD) is described in 79-year-old male twins with monozygosity confirmed by DNA examination. The first twin to be affected began to show signs of intellectual deterioration at age 70. In the other, onset was at age 72. Four of their living sibs (current age range = 75-92) are also suspected to have AD. The possible roles of genetic and environmental factors in the development of AD in this sibship are discussed.

Failure of accelerated neutron therapy to control high grade astrocytomas

Sixty-two patients with high grade malignant astrocytoma were treated with fast neutrons using three different treatment schemes to evaluate the effect of shortening the overall time. Dose and fraction number were kept constant. The total dose was 16-18 neutron Gy delivered in six fractions, weekly for 6 weeks, twice a week over 3-4 weeks, or three times a week over 2 weeks. There were no obvious differences in survival times among the three groups. We conclude that accelerated neutron therapy does not improve survival of patients with grade 3 and 4 astrocytoma.

Normal tissue reactions and complications following high-energy neutron beam therapy: I. Crude response rates

The incidence of significant complications (fibrosis, ulceration, necrosis of bone or soft tissue or serious functional impairment) was determined in relation to neutron dosage and follow-up time for 5 anatomical sites totalling 617 patients who had survived 2 or more years following treatment. The regions studied were head and neck (268 patients), thorax (lung and esophagus, 76 patients), upper abdomen (132 patients), pelvis (prostate and bladder, 114 patients) and extremities (27 patients). Neutron doses ranged from 16 to 28 Gy. All patients were followed until death or up to 10 years after treatment. A total of 109 complications were observed yielding a crude complication rate of 18% for the whole series. Observed complication rates were 7% in the 16-20 Gy dose range, 19% between 20 and 24 Gy, and 33% in patients receiving more than 24 Gy. Probit analysis of the data indicated a median effective dose (50% complications) of 29 (+/- 0.5) Gy with an estimated standard deviation of 8 Gy. A reasonable estimate of "tolerance" may then be taken as 29 - 8 = 21 Gy. Comparing the 5 anatomical sites revealed no significant differences in estimated tolerance doses. With the available data, no effect of field-size or target volume could be demonstrated. The incidence of complications apparently increases with time in long-term survivors. Although the overall incidence is only 18%, actuarial analysis of the data suggests that the complication rate might have exceeded 50% if all treated patients had survived 10 years. It is concluded that, with the exception of the nervous system and possibly other viscera, a neutron dose of 20 Gy (in 12 fractions over 4 weeks) represents a practical tolerance limit for all sites.