The impact of COVID-19 on Australian clinicians' decision making in line with the principles of Choosing Wisely

AIM

To explore the perspectives of clinicians' decision-making processes and considerations in line with the Choosing Wisely principles during the first wave of the COVID-19 pandemic.

DESIGN

An exploratory qualitative approach was used.

METHODS

Data were collected via semi-structured interviews to encourage participants to discuss their own experience in making clinical decisions during the COVID-19 pandemic. A total of 12 clinicians from across disciplines were interviewed to reach data saturation. Interview data were analysed considering the Choosing Wisely principles.

RESULTS

Five main themes as they relate to clinician decision-making emerged and included; prioritizing care and treatment, uncertainty regarding best practice as a result of rapidly changing guidelines, organizational challenges to clinical decision-making, the use of telehealth and enabling consumer engagement with health services.

CONCLUSION

Despite the disruption caused by COVID-19, clinicians were mindful of necessary care and worked to ensure that core care was not compromised during the first wave of the pandemic. The need for clinicians to protect both their own safety and that of their colleagues arose as an additional factor that influenced clinicians' decision-making process during the COVID-19 pandemic.

Systemic Treatment-Decision Algorithms in Muscle-Invasive Bladder Cancer: Clinical Complexities and Navigating for Improved Outcomes

Muscle-invasive bladder cancer has poor prognosis. If organ confined, it is potentially curable; however, across all prognostic groups, approximately half of patients will relapse. For patients with advanced disease, the median overall survival remains under two years. Systemic treatment options are centered on the use of platinum-based combination chemotherapy, with the choice of cisplatin- or carboplatin-based regimens determined on the basis of criteria including performance status and renal function. PD-1/PD-L1 checkpoint-directed immunotherapy has been established for use in advanced disease with modest overall improvements in survival outcomes. Based on current data, optimal utilization appears to be a switch maintenance strategy on completion of chemotherapy. In the curative setting, cisplatin-based chemotherapy provides modest improvements in cure rates in those fit to receive it. Data on the use of adjuvant immunotherapy are currently contradictory, with disease-free survival demonstrated for adjuvant nivolumab, but not atezolizumab, and no overall survival benefit has yet been confirmed. The Nectin-4 directed antibody drug conjugate enfortumab vedotin is an established treatment option for patients previously treated with both chemotherapy and immunotherapy. The emerging therapeutic targets under evaluation include Trop-2 with sacituzumab govitecan, fibroblast growth factor receptors, HER2, and DNA repair deficiency in biomarker-selected patients. The development of properly validated predictive biomarkers has proven challenging for this disease and should be a central priority in the future development of treatment options. This review summarizes the available systemic treatment options in both palliative and curative disease settings, and highlights the available evidence and current limitations for making treatment recommendations.

Measurement of Direct-Photon Cross Section and Double-Helicity Asymmetry at sqrt[s]=510 GeV in p[over →]+p[over →] Collisions

We present measurements of the cross section and double-helicity asymmetry A_{LL} of direct-photon production in p[over →]+p[over →] collisions at sqrt[s]=510  GeV. The measurements have been performed at midrapidity (|η|<0.25) with the PHENIX detector at the Relativistic Heavy Ion Collider. At relativistic energies, direct photons are dominantly produced from the initial quark-gluon hard scattering and do not interact via the strong force at leading order. Therefore, at sqrt[s]=510  GeV, where leading-order-effects dominate, these measurements provide clean and direct access to the gluon helicity in the polarized proton in the gluon-momentum-fraction range 0.02<x<0.08, with direct sensitivity to the sign of the gluon contribution.

Employing the theory of planned behaviour to design an e-cigarette education resource for use in secondary schools

Background

An extended version of the theory of planned behaviour (TPB) was used to inform the design of a framework for an educational resource around e-cigarette use in young people.

Methods

A sequential exploratory design was employed. In Phase 1, elicited behavioural, normative and control beliefs, via 7 focus groups with 51 participants, aged 11–16 years, identified salient beliefs around e-cigarette use. These were used to construct a questionnaire administered to 1511 young people aged 11–16 years, which determined predictors of e-cigarette use and ever use. In Phase 2, sociodemographic variables, e-cigarette knowledge, access, use, marketing and purchasing of e-cigarettes and smoking behaviour were also gathered. The composite findings from Phase 1 and 2 informed the design of a post primary educational resource in Phase 3 around e-cigarette use.

Results

Current e-cigarette use was 4%, with almost 23% reporting ever use, suggesting current use is stable but experimentation may be increasing in this cohort. Sociodemographic variables, knowledge of e-cigarettes, smoking behaviour and TPB variables (direct and indirect measures of attitudes, subjective norm, and perceived behavioural control) accounted for 17% of the variance in current e-cigarette use, with higher intentions to use e-cigarettes within the next month, having the strongest impact on use (p < 0.001), followed by self-efficacy (p = 0.016). Sociodemographic and TPB variables accounted for 65% of the variance in intentions to use e-cigarettes in the next month; current e-cigarette use (p < 0.001), more positive attitudes (p < 0.001), stronger social influence (p < 0.001), higher self-efficacy (p < 0.001), higher control beliefs (p < 0.001) and greater motivation to use e-cigarettes (p < 0.001) were the main predictors of intentions. Phases 1 and 2 informed the mapping of key predictors of intentions and use of e-cigarettes onto the Theoretical Domains Framework, which identified appropriate intervention functions and behaviour change techniques.

Conclusions

This paper is the first to bridge the theoretical-practice gap in an area of significant public health importance through the development of a framework for a novel theory driven school-based educational resource aimed at reducing experimentation and uptake of e-cigarette use in young people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12674-3.

Engaging consumers and health professionals in collaborative decision-making to optimize care

Shared communication and collaborative decision-making between consumers and health professionals is essential in optimizing the quality of consumer care. However, the consumers' ability to ask questions and seek answers, as well as health professionals' communication skills to engage with the consumer, are necessary considerations for the collaborative decision-making process. This quality improvement initiative sought to understand the context of collaborative decision making from the perspective of consumers and health professionals adapted from the international Choosing Wisely program. Findings indicated health professionals acknowledged a problem with unnecessary and overuse of tests, treatments, and procedures. Consumers suggested they were confident asking questions about their health and care. The findings of this study highlight collaborative decision-making as a worthwhile and beneficial undertaking.

Probing Gluon Spin-Momentum Correlations in Transversely Polarized Protons through Midrapidity Isolated Direct Photons in p^{↑}+p Collisions at sqrt[s]=200 GeV

Studying spin-momentum correlations in hadronic collisions offers a glimpse into a three-dimensional picture of proton structure. The transverse single-spin asymmetry for midrapidity isolated direct photons in p^{↑}+p collisions at sqrt[s]=200  GeV is measured with the PHENIX detector at the Relativistic Heavy Ion Collider (RHIC). Because direct photons in particular are produced from the hard scattering and do not interact via the strong force, this measurement is a clean probe of initial-state spin-momentum correlations inside the proton and is in particular sensitive to gluon interference effects within the proton. This is the first time direct photons have been used as a probe of spin-momentum correlations at RHIC. The uncertainties on the results are a 50-fold improvement with respect to those of the one prior measurement for the same observable, from the Fermilab E704 experiment. These results constrain gluon spin-momentum correlations in transversely polarized protons.

The Mortality After Release from Incarceration Consortium (MARIC): Protocol for a multi-national, individual participant data meta-analysis

INTRODUCTION

More than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance.

OBJECTIVES

To comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison.

METHODS

We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology.

RESULTS

The combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up.

CONCLUSIONS

The consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population.

KEY WORDS

Mortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.

Host-specific differences in the contribution of an ESBL IncI1 plasmid to intestinal colonization by Escherichia coli O104:H4

Objectives

To assess stability and contribution of a large ESBL-encoding IncI1 plasmid to intestinal colonization by Escherichia coli O104:H4 in two different mammalian hosts.

Methods

Specific-pathogen-free 3-4-day-old New Zealand White rabbits and conventionally reared 6-week-old weaned lambs were orally infected with WT E. coli O104:H4 or the ESBL-plasmid-cured derivative, and the recovery of bacteria in intestinal homogenates and faeces monitored over time.

Results

Carriage of the ESBL plasmid had differing impacts on E. coli O104:H4 colonization of the two experimental hosts. The plasmid-cured strain was recovered at significantly higher levels than WT during late-stage colonization of rabbits, but at lower levels than WT in sheep. Regardless of the animal host, the ESBL plasmid was stably maintained in virtually all in vivo passaged bacteria that were examined.

Conclusions

These findings suggest that carriage of ESBL plasmids has distinct effects on the host bacterium depending upon the animal species it encounters and demonstrates that, as for E. coli O157:H7, ruminants could represent a potential transmission reservoir.

Modalities and accuracy of diagnosis of external ventricular drainage-related infections: a prospective multicentre observational cohort study

BACKGROUND

Device infection is a major complication of placement external ventricular drains (EVD). Diagnostic features are often masked by underlying disease or cerebrospinal fluid (CSF) contamination by blood. We aim to assess which diagnostic modalities are applied for EVD-related infection (ERI) diagnosis and evaluate their accuracy.

METHODS

This observational prospective study included 187 adult patients with an EVD. Modalities of clinical diagnosis of ERI diagnosed by treating physicians on clinical grounds and blood and CSF analysis (clinically diagnosed ERI (CD-ERI)) were assessed prospectively. Additionally, the diagnostic accuracy of clinical and laboratory parameters for the diagnosis of culture proven ERI (CP-ERI) was evaluated, using data of the study patients and including a retrospective cohort of 39 patients with CP-ERI.

RESULTS

Thirty-one CD-ERIs were diagnosed in the prospective cohort. Most physicians used CSF analysis to establish the diagnosis. ROC analysis revealed an AUC of 0.575 (p = 0.0047) for the number of positive SIRS criteria and AUC of 0.5420 (p = 0.11) for the number of pathological neurological signs for diagnosis of CP-ERI. Diagnostic accuracy of laboratory values was AUC 0.596 (p = 0.0006) for serum white blood cell count (WBCC), AUC 0.550 (p = 0.2489) for serum C-reactive protein, AUC 0.644 (p < 0.0001) for CSF WBCC and AUC 0.690 for CSF WBC/red blood cell count ratio (both p < 0.0001). Neither a temporal trend in potential predictors of CP-ERI nor a correlation between clinical diagnosis and proven CSF infection was found.

CONCLUSIONS

Clinicians base their diagnosis of ERI mostly on CSF analysis and occurrence of fever, leading to over-diagnosis. The accuracy of the clinical diagnosis is low. Commonly used clinical and laboratory diagnostic criteria have a low sensitivity and specificity for ERI.

Lifetime Measurements of Excited States in ^{172}Pt and the Variation of Quadrupole Transition Strength with Angular Momentum

Lifetimes of the first excited 2^{+} and 4^{+} states in the extremely neutron-deficient nuclide ^{172}Pt have been measured for the first time using the recoil-distance Doppler shift and recoil-decay tagging techniques. An unusually low value of the ratio B(E2:4_{1}^{+}→2_{1}^{+})/B(E2:2_{1}^{+}→0_{gs}^{+})=0.55(19) was found, similar to a handful of other such anomalous cases observed in the entire Segré chart. The observation adds to a cluster of a few extremely neutron-deficient nuclides of the heavy transition metals with neutron numbers N≈90-94 featuring the effect. No theoretical model calculations reported to date have been able to explain the anomalously low B(E2:4_{1}^{+}→2_{1}^{+})/B(E2:2_{1}^{+}→0_{gs}^{+}) ratios observed in these cases. Such low values cannot, e.g., be explained within the framework of the geometrical collective model or by algebraic approaches within the interacting boson model framework. It is proposed that the group of B(E2:4_{1}^{+}→2_{1}^{+})/B(E2:2_{1}^{+}→0_{gs}^{+}) ratios in the extremely neutron-deficient even-even W, Os, and Pt nuclei around neutron numbers N≈90-94 reveal a quantum phase transition from a seniority-conserving structure to a collective regime as a function of neutron number. Although a system governed by seniority symmetry is the only theoretical framework for which such an effect may naturally occur, the phenomenon is highly unexpected for these nuclei that are not situated near closed shells.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Delays in the presentation to stroke services of patients with transient ischaemic attack and minor stroke

BACKGROUND

The UK National Institute for Health and Care Excellence (NICE) guidelines state that carotid endarterectomy should be scheduled within 2 weeks of symptoms. The recent National Stroke Strategy has reduced the time interval to 48 h. This study aimed to review the possible delays.

METHODS

This study analysed patients with confirmed transient ischaemic attack (TIA) or minor stroke, referred to a single tertiary centre clinic and followed up 1 month after the event. A questionnaire was used to collect data on the rapid-access clinic pathway, and details of previous medication and treatment.

RESULTS

Some 150 patients presented with a confirmed TIA or minor stroke during a 5-month interval (June to October 2014). Fifty-one (34·0 per cent) had a history of TIA or stroke and 35 (23·3 per cent) had undergone an 'index' event in the 5 days before presentation. Forty-five patients (30·0 per cent) experienced a reduction or loss of vision. Of this group, 32 had a deficit in vision only, none of whom attributed these symptoms to a cerebrovascular event. Overall 92 (61·3 per cent) of the 150 patients had a delay in presentation to medical services. Forty-seven (31·3 per cent) had residual symptoms at the clinic appointment. Eighty-eight patients (58·7 per cent) did not think they were having a stroke and 54 (36·0 per cent) were unaware of the National Stroke Strategy (FAST campaign - Face, Arm, Speech, Time).

CONCLUSION

Two-thirds of patients were not aware they were having a stroke, one-third were unaware of the FAST campaign and nearly one-third presented with eye symptoms. Inclusion of eye symptoms and reaffirmation of the need to react might avoid unnecessary delays in the presentation of patients with TIA and minor stroke.

Prevalence and molecular typing of Cryptosporidium in dairy cattle in England and Wales and examination of potential on-farm transmission routes

An average of 70 samples were collected from 80 dairy farms in England and Wales, from cattle, co-grazed sheep, wildlife and farm wastes, to investigate prevalence, potential sources and transmission routes of Cryptosporidium. At least one positive sample was detected on 74 of the farms (92.5%) by IFAT microscopy. The prevalence in cattle was 10.2% (95% CI 9.4-11.1%), with greater prevalences detected in calf samples, especially from those under 1 month (45.1%). Young calves were also more likely to be shedding Cryptosporidium parvum and larger concentrations of oocysts, whereas older calves and adult cattle were more likely to be shedding Cryptosporidium bovis and Cryptosporidium andersoni, respectively. The C. parvum subtypes detected were predominantly from types commonly identified in UK cattle (67% were either IIaA15G2R1 or IIaA17G1R1). A novel subtype, IIaA17G1R2, was identified from one cattle sample. The prevalence in co-grazed sheep was low (4%). Birds and rodents may represent significant reservoirs of Cryptosporidium due to high prevalence, large oocyst concentrations, and the detection of a C. parvum subtype known to be present in human populations, identified in samples from these wildlife. Cryptosporidium were detected in dirty water and manure, and also from pasture samples where slurry had been spread. On 64% of the farms, identical Cryptosporidium species were detected (mainly C. parvum or C. bovis) from different cattle groups on the farms, although no direct or indirect contact between the groups were recorded, apart from sharing staff. The same Cryptosporidium species were found in cattle, farm wastes and bird samples on the same farms, but rarely, or not at all, present in sheep or rodent samples. The matching of species/subtypes was also related to the proximity of the different sample sources which may indicate a potential transmission route.

The significance of low-level viraemia in diverse settings: analysis of the Treat Asia HIV Observational Database (TAHOD) and the Australian HIV Observational Database (AHOD)

OBJECTIVES

The aim of the study was to assess the significance of low-level viraemia (LLV) and the timing of treatment change in low/middle-income country (L/MIC) compared with high-income country (HIC) settings.

METHODS

Patients with virological control following commencement of combination antiretroviral therapy (cART) were included in the study. LLV was defined as undetectable viral load (<50 HIV-1 RNA copies/mL) followed by confirmed detectable viral load < 1000 copies/mL. Virological failure was defined as viral load > 1000 copies/mL. Kaplan-Meier plots of time to virological failure by prior LLV and income category were generated. Regimen changes in the setting of LLV were compared between sites. Sensitivity analysis of rates of LLV and virological failure by person-years and number of tests was conducted for differing definitions of LLV and virological failure.

RESULTS

A total of 1748 patients from HICs and 823 patients from L/MICs were included in the study. One hundred and ninety-six (11.2%) HIC participants and 36 (4.4%) L/MIC participants experienced at least one episode of LLV. Of the patients who underwent regimen switch in HIC settings, the majority changed from a nucleoside reverse transcriptase inhibitor (NRTI)/protease inhibitor (PI) regimen to an NRTI/nonnucleoside reverse transcriptase inhibitor (NNRTI) regimen (26.8%). Very few switches were made in L/MIC settings. Rates of LLV were significantly higher for HICs compared with L/MICs per 1000 person-years (28.6 and 9.9 per 1000 person-years, respectively), but not in terms of the number of tests (9.4 and 7.2 per 1000 tests, respectively). Rates of virological failure per test were significantly higher for L/MICs compared with HICs (30.7 vs. 19.6 per 1000 tests, respectively; P < 0.001). LLV was a significant predictor of virological failure at 2 years in L/MICs [0.25; 95% confidence interval (CI) 0.11-0.50; P = 0.043] but not in HICs (0.13; 95% CI 0.08-0.22; P = 0.523).

CONCLUSIONS

LLV is weakly predictive of virological failure at 2 years in L/MICs but not in HICs. This suggests that interventions targeted at subjects with LLV in L/MICs would help to improve treatment outcomes.

Recommendations for the development of e-modules for the continuing professional development of European dentists

AIMS

To provide evidence-based and peer-reviewed recommendations for the development of dental continuing professional development (CPD) learning e-modules.

METHODS

The present recommendations are consensus recommendations of the DentCPD project team and were informed by a literature research, consultations from e-learning and IT expert, discussions amongst the participants attending a special interest group during the 2012 ADEE meeting, and feedback from the evaluation procedures of the exemplar e-module (as described in a companion paper within this Supplement). The main focus of these recommendations is on the courses and modules organised and offered by dental schools.

RESULTS AND DISCUSSION

E-modules for dental CPD, as well as for other health professionals' continuing education, have been implemented and evaluated for a number of years. Research shows that the development of e-modules is a team process, undertaken by academics, subject experts, pedagogists, IT and web designers, learning technologists and librarians. The e-module must have clear learning objectives (outcomes), addressing the learners' individual needs, and must be visually attractive, relevant, interactive, promoting critical thinking and providing feedback. The text, graphics and animations must support the objectives and enable the learning process by creating an attractive, easy to navigate and interactive electronic environment. Technology is usually a concern for learners and tutors; therefore, it must be kept simple and interoperable within different systems and software. The pedagogical and technological proficiency of educators is of paramount importance, yet remains a challenge in many instances.

CONCLUSIONS

The development of e-courses and modules for dental CPD is an endeavour undertaken by a group of professionals. It must be underpinned by sound pedagogical and e-learning principles and must incorporate elements for effective visual learning and visual design and a simple, consistent technology.

Guidelines for the organisation of continuing professional development activities for the European dentist

AIM

Free movement of dental professionals across the European Union calls for more uniform continuing education in dentistry to ensure up-to-date, high-quality patient care and patient safety. This article provides guidelines for the management and delivery of high-quality continuing professional development (CPD) by European dental schools and other CPD providers.

METHOD

The guidelines are based on an extensive literature inventory, a survey of existing practices (both available as separate publications), discussions during meetings of the Association for Dental Education in Europe in 2011 and 2012 and debate amongst the members of the DentCPD project team representing six dental schools.

RESULTS

On the basis of the literature review, survey and discussions, we recommend that (i) every dentist should be given the opportunity for CPD, (ii) providers should be quality-approved and impartial, (iii) educators should be approved, impartial, suitably trained, and with educational expertise, (iv) the mode of CPD delivery should suit the educational activity, with clear learning objectives or outcomes, (v) effort should be made to assess the learning, (vi) participant feedback should be collected and analysed to inform future developments and (vii) uniform use of the pan-European system of learning credit points (ECTS) should be implemented.

CONCLUSION

Implementation of these guidelines should make dental CPD more transparent to all relevant parties and facilitate the transferability of earned credits across the European Union. It will also enable better quality control within dentistry, resulting in enhanced dental care and ultimately the improvement in patient safety.

The development of an exemplar e-module for the continuing professional development of European dentists

AIM

To present the development of an exemplar e-module for dental continuing professional development (CPD) provided by dental schools and other dental educational providers.

MATERIALS AND METHODS

The exemplar e-module covered the topic of 'Sterilisation and cross-infection control in the dental practice' as this is one of the most recommended topics for dental CPD in Europe. It was developed by a group of topic experts, adult learning and distance learning experts and a technical developer. Major concerns were pedagogy, interoperability, usability and cost reduction. Open-source material was used to reduce the cost of development.

RESULTS

The e-module was pre-piloted in dental practitioners for usability and then evaluated by experts in the field and dental academics through an electronic questionnaire and an online presentation and discussion at the ADEE 2012 Special Interest Group on DentCPD-Lifelong learning. This facilitated refinement before final production. A Creative Commons License was implemented to ensure the developers' rights and facilitate wider distribution and access to CPD providers.

DISCUSSION AND CONCLUSIONS

The e-module was developed according to well-defined pedagogical and technical guidelines for developing e-learning material for adult learners. It was structured to promote self-study by directing learners through their study, promoting interaction with the material, offering explanation and providing feedback. Content validity was ensured by extensive review by experts. The next step would be to expand the evaluation to practising dentists in various countries after relevant translations, and adaptations to local policies have been made.

Continuing professional development systems and requirements for graduate dentists in the EU: survey results from the DentCPD project

INTRODUCTION

By maintaining skills and keeping dentists up-to-date, continuing professional development (CPD) supports safe clinical practice. However, CPD for dentists across Europe is not harmonised.

AIM

One aim of the 'DentCPD' project (www.dentcpd.org) was to identify and agree essential CPD requirements for EU dentists. As part of the process, data were collected on existing approaches to CPD for EU dentists. This paper reports those findings.

METHODS

Informed by a review of the literature and internet search, the CPD for Graduate Dentists questionnaire gathered data from dental educators on CPD systems, requirements, provision and accreditation in Europe. It sought opinion on mandatory CPD and e-learning.

RESULTS

Responses were received from 143 individuals from 30 EU countries. About half the countries had a compulsory CPD system which typically included mandatory core topics. Elsewhere CPD was optional or based on recommended hours. University dental schools and professional dental associations were the most common CPD providers. National regulatory bodies were the most common accrediting body. Only 41% of respondents thought they knew the criteria for successful accreditation of CPD. Eighty-one percent agreed that 'CPD should be obligatory for all dentists'.

CONCLUSION

These results present an overview of the status of CPD for EU dentists. Despite a notable trend towards regulated CPD systems, current requirements for dentists to engage in CPD show variation. The harmonisation of requirements would enhance both dentist mobility and safe clinical practice.

Core continuing professional development (CPD) topics for the European dentist

INTRODUCTION

In the context of free movement, EU-citizens need assurance that dental practitioners providing their care have a degree/license to practice that meets EU-standards and that they maintain their knowledge and skills through ongoing education.

AIM

One aim of the 'DentCPD' project (HYPERLINK 'http://www.dentcpd.org' www.dentcpd.org) was to identify and agree essential CPD requirements for EU dentists. This paper reports the consensus process and outcomes.

METHODS

Agreement on core components of CPD was achieved through a three stage process: an online survey of dental educators' (n = 143) views on compulsory topics; a paper-based questionnaire to practitioners (n = 411); leading to a proposal discussed at the Association for Dental Education (ADEE) 2011 Lifelong Learning special interest group (SIG).

RESULTS

From the online survey and practitioner questionnaire, high levels of agreement were achieved for medical emergencies (89%), infection control (79%) and the medically compromised patient (71%). The SIG (34 attendees from 16 countries) concluded that these three CPD topics plus radiation protection should be core-compulsory and three CPD topics should be core-recommended (health and safety, pain management, and safeguarding children & vulnerable adults). They also agreed that the teaching of all topics should be underpinned by evidence-based dentistry.

CONCLUSION

Building four core topics into CPD requirements and making quality-approved education and training available will ensure that all dentists have up-to-date knowledge and skills in topic areas of direct relevance to patient safety. In turn, this will contribute to patients having access to comparably high standards of oral health care across Europe.

Continuing professional development systems and requirements for graduate dentists in the EU: survey results from the DentCPD project

INTRODUCTION

By maintaining skills and keeping dentists up-to-date, continuing professional development (CPD) supports safe clinical practice. However, CPD for dentists across Europe is not harmonised.

AIM

One aim of the 'DentCPD' project (www.dentcpd.org) was to identify and agree essential CPD requirements for EU dentists. As part of the process, data were collected on existing approaches to CPD for EU dentists. This paper reports those findings.

METHODS

Informed by a review of the literature and internet search, the CPD for Graduate Dentists questionnaire gathered data from dental educators on CPD systems, requirements, provision and accreditation in Europe. It sought opinion on mandatory CPD and e-learning.

RESULTS

Responses were received from 143 individuals from 30 EU countries. About half the countries had a compulsory CPD system which typically included mandatory core topics. Elsewhere CPD was optional or based on recommended hours. University dental schools and professional dental associations were the most common CPD providers. National regulatory bodies were the most common accrediting body. Only 41% of respondents thought they knew the criteria for successful accreditation of CPD. Eighty-one percent agreed that 'CPD should be obligatory for all dentists'.

CONCLUSION

These results present an overview of the status of CPD for EU dentists. Despite a notable trend towards regulated CPD systems, current requirements for dentists to engage in CPD show variation. The harmonisation of requirements would enhance both dentist mobility and safe clinical practice.

Core continuing professional development (CPD) topics for the European dentist

INTRODUCTION

In the context of free movement, EU-citizens need assurance that dental practitioners providing their care have a degree/license to practice that meets EU-standards and that they maintain their knowledge and skills through ongoing education.

AIM

One aim of the 'DentCPD' project (HYPERLINK 'http://www.dentcpd.org' www.dentcpd.org) was to identify and agree essential CPD requirements for EU dentists. This paper reports the consensus process and outcomes.

METHODS

Agreement on core components of CPD was achieved through a three stage process: an online survey of dental educators' (n = 143) views on compulsory topics; a paper-based questionnaire to practitioners (n = 411); leading to a proposal discussed at the Association for Dental Education (ADEE) 2011 Lifelong Learning special interest group (SIG).

RESULTS

From the online survey and practitioner questionnaire, high levels of agreement were achieved for medical emergencies (89%), infection control (79%) and the medically compromised patient (71%). The SIG (34 attendees from 16 countries) concluded that these three CPD topics plus radiation protection should be core-compulsory and three CPD topics should be core-recommended (health and safety, pain management, and safeguarding children & vulnerable adults). They also agreed that the teaching of all topics should be underpinned by evidence-based dentistry.

CONCLUSION

Building four core topics into CPD requirements and making quality-approved education and training available will ensure that all dentists have up-to-date knowledge and skills in topic areas of direct relevance to patient safety. In turn, this will contribute to patients having access to comparably high standards of oral health care across Europe.

Zoonotic cryptosporidiosis in the UK - challenges for control

The protozoan parasite Cryptosporidium infects all classes of vertebrates. Of the major human pathogenic species, Cryptosporidium parvum and Cryptosporidium hominis predominate in the UK. Cryptosporidium hominis is a human-adapted species, while C. parvum has many animal hosts and is particularly common in preweaned farmed ruminants. Evaluation of zoonotic risks has been provided mainly by descriptive and analytical epidemiological studies and enhanced recently by genetic typing of isolates. The robust nature of the transmissive oocyst stage, multiple transmission routes, lack of antiparasitic treatment options and vaccines, and resistance to chlorine disinfection present challenges for control. Subtyping C. parvum isolates has been used to link human cases and suspected sources of infection in sporadic cases and outbreaks. Although it is possible that all C. parvum isolates are potentially zoonotic, populations with and without farm animal linkage have been identified. New zoonotic risks have emerged in at least one outbreak, caused by the Cryptosporidium sp. rabbit genotype. This re-enforces the need to characterize infecting and contaminating isolates to ensure appropriate interventions. This study describes the risks of zoonotic cryptosporidiosis by detailing the hosts providing a potential reservoir, the risks of transmission to humans, outbreaks in animal-associated settings and guidance for control with special emphasis on the UK.

A team approach: implementing a model of care for preventing osteoporosis related fractures

The implementation of a multidisciplinary team-based model of care has led to significant increases in identification of patients with osteoporosis who are at risk of refracture, together with improved treatment uptake and ongoing management.

INTRODUCTION

Osteoporosis-related fractures and consequent hospital admissions are largely preventable; however, little attention has been paid to how to achieve this, in particular, through improved models of care. Presentation to emergency departments (ED) with minimal trauma fracture (MTF) provides opportunity for patients at risk to be identified, referred and managed through a systematic process ensuring prompt intervention and continuing follow-up. This study is aimed to design and implement a care model for people over 50 years of age, presenting to ED with an MTF.

METHOD

Established a multidisciplinary fracture prevention team to identify and capture at-risk patients for referral and management. Clinical data revealed the extent of lost opportunities. An electronic flagging system and data acquisition tool were developed and piloted. Established a referral pathway to detect, manage and follow-up patients, coordinated by a fracture prevention nurse.

RESULTS

Increased awareness of osteoporosis as a cause of MTF, better identification of at-risk patients across departments and services and development of a flagging and referral protocol has resulted in 100% capture of at-risk patients presented to ED. As a result there has been a significant increase in patients attending the fracture prevention clinic (FPC) (p < 0.001) from 11% in 2007 to 29% in 2008 and a significantly reduced time between fracture and when patients are seen in the FPC (p < 0.001).

CONCLUSION

A multipronged systematic team approach to identifying and capturing patients with a high risk of refracture and a dedicated nurse coordinator role has created efficiencies in the detection and management of osteoporosis.

High Performance Organic Field-Effect Transistors and Integrated Inverters

Integrated plastic circuits (IPCs) will become an integral component of future low cost electronics. For low cost processes IPCs have to be made of all-polymer Transistors. We present our recent results on fabrication of Organic Field-Effect Transistors (OFETs) and integrated inverters. Top-gate transistors were fabricated using polymer semiconductors and insulators. The source-drain structures were defined by standard lithography of Au on a flexible plastic film, and on top of these electrodes, poly(3-alkylthiophene) (P3AT) as semiconductor, and poly(4-hydroxystyrene) (PHS) as insulator were homogeneously deposited by spin-coating. The gate electrodes consist of metal contacts. With this simple set-up, the transistors exhibit excellent electric performance with a high source-drain current at source - drain and gate voltages below 30V. The characteristics show very good saturation behaviour for low biases and are comparable to results published for precursor pentacene. With this setup we obtain a mobility of 0.2cm2/Vs for P3AT. Furthermore, we discuss organic integrated inverters exhibiting logic capability. All devices show shelf-lives of several months without encapsulation.

Subclinical thyroid dysfunction does not affect one-year mortality in elderly patients after hip fracture: a prospective longitudinal study

Mortality after hip fractures in the elderly is one of the most important patient outcome measures. Subclinical thyroid dysfunction is common in the elderly population. This is a prospective study of 131 elderly patients with a mean (SD) age of 82.0 (8.9) years (range: 61-94) admitted consecutively to our trauma unit. The aim of the study was to determine the prevalence of subclinical thyroid dysfunction in an elderly cohort of patients with hip fracture and to determine if this affects the one-year mortality. There were three times more women (n=100) than men (n=31) in this cohort. All patients underwent surgical treatment for the hip fracture. The prevalence of subclinical hypothyroidism (TSH>5.5 mU/L) was 15% (n=20) and of subclinical hyperthyroidism (TSH<0.35 mU/L) was 3% (n=4). Overall 18% (n=24) of patients had a subclinical thyroid dysfunction. The twelve-month mortality was 27% (n=36). Age, gender, heart rate at admission, pre-existing coronary heart disease, ASA grade and presence of overt or subclinical thyroid dysfunction were analysed for association with twelve-month mortality using a forward stepwise logistic regression analysis. Only ASA grade was found to significantly affect mortality at twelve months (chi(2)=3.98, df=1, p=0.046). Independently the presence of subclinical hypo- or hyperthyroidism was not associated with a higher mortality (p=0.477). We conclude that subclinical thyroid dysfunction does not affect the one-year mortality in elderly patients treated surgically for hip fracture.

Cryptosporidiosis in two alpaca (Lama pacos) holdings in the South-West of England

Cryptosporidiosis was investigated on two alpaca (Lama pacos) holdings in the South-West of England. Diagnosis was initially confirmed in a cria with diarrhoea from each holding. Cohort faeces samples were subsequently collected and examined for presence of Cryptosporidium oocysts by immunofluorescence microscopy. On the first holding, 30 samples (24 adults, 6 crias) were tested, and oocysts were detected in three of the cria samples but in none of the adults. On the second holding, 14 floor faeces samples representing apparently healthy crias and one faeces sample from a cria with diarrhoea were collected. Oocysts were detected in four of the "healthy" faeces samples and the sample of diarrhoeic faeces. All isolates were confirmed as Cryptosporidium parvum using polymerase chain reaction restriction fragment length polymorphism of the cryptosporidium oocyst wall protein (COWP) and ssu rRNA genes. Sequence analysis of a 741bp region of ssu rDNA was carried out on nine of these and revealed high sequence homology with previously reported C. parvum isolates. This investigation highlights the possibility of alpaca crias subclinically shedding oocysts, which has implications for epidemiology and transmission in animals as well as raising zoonotic concerns for human contacts. Gene sequencing of UK isolates from South American camelids is also described for the first time.