The meaning of preparedness for informal caregivers of older adults: A concept analysis

AIM

To examine the concept of preparedness over time in research with informal caregivers of older adults.

DESIGN

Concept analysis.

METHODS

Rodgers' evolutionary method of concept analysis was used to guide this theoretical paper due to the dynamic nature of preparedness, which is influenced by both context and time. Using Rodgers' inductive approach, concept elements were derived from a content analysis of included studies. In the final step, to generate hypotheses and implications regarding the concept, the conceptual structure of preparedness of informal caregivers of older adults was connected to a theoretical problem in the nursing discipline using the Caregiving Stress Process Framework.

DATA SOURCES

Four databases (EBSCO CINAHL, Ovid MEDLINE, Ovid PsycINFO and Scopus) were searched in November 2022 and updated in September 2023. No date limits were set for searching, as the intent was to analyse possible variations of the concept over time.

RESULTS

The attributes of preparedness include self-confidence, having knowledge, skills and abilities to perform daily tasks, handling emotions and developed over time. These attributes can be compared with the stressors outlined in the Caregiving Stress Process Framework (i.e., the moment the caregiver identifies some 'stressor'; something that prevents them from feeling confident in their preparedness).

CONCLUSION

The concept of preparedness of informal caregivers of older adults is defined as caregiver's self-confidence about their current competence related to the knowledge, skills and abilities to perform daily tasks, and to handle emotions over time. To link the concept to a theoretical perspective, we propose adaptations to a well-known theory, the Caregiving Stress Process Framework. Future research on caregiving preparedness needs to avoid circular definitions and work with the attributes of preparedness to support caregivers.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This paper contributes to the development of interventions that focus on the health and preparedness of informal caregivers of older adults. Clarifying the concept of preparedness helps nurses to support caregivers since it is then known which aspects are included in the preparedness of caregivers (e.g., daily tasks and handling emotions). A more fulsome understanding of preparedness supports us to see beyond stressors of caregiving.

IMPACT

This study addresses informal caregivers of older adults' preparedness to provide care. We synthesized existing definitions that have been used in research with this population to propose a robust conceptualization of the concept of preparedness, which contributes to better understanding of how preparedness can be supported.

REPORTING METHOD

We were unable to locate a reporting method related to this kind of work (concept analysis).

PATIENT OR PUBLIC CONTRIBUTION

Not applicable as no new data generated.

Nursing Students' Perceptions on a Pain Management E- Learning Module: An Exploratory Quantitative Study

BACKGROUND

Nursing students are graduating ill-prepared to assess and manage pain in older adults. To address this gap, we developed an e-learning module on the topic.

AIM

To examine nursing students' perceptions on a pain management e-learning module focused on older adults.

METHODS

Utilizing an exploratory quantitative design, we assessed nursing students' perceptions of the e-learning module. We used a feedback survey (four 5-point, Likert-type items) and one open-ended question to assess students' perceptions. Descriptive statistics were used to summarize students' perceptions and demographic characteristics. Responses to the open-ended question were content analyzed.

RESULTS

A total of 181 of 249 students completed the module, of whom two-thirds were female. Students perceived that the module enhanced their knowledge, confidence, and perception in working with older people. Students also found the method of instruction interactive and enjoyable.

CONCLUSIONS

The e-learning module on pain management was viewed by nursing students to be helpful and its interactive method of learning improved their knowledge, confidence, and perceptions of working with older adults in pain.

Leave events among Aboriginal and Torres Strait Islander people: a systematic review

BACKGROUND

Leave events are a public health concern resulting in poorer health outcomes. In Australia, leave events disproportionally impact Aboriginal and Torres Strait Islander people. A systematic review was conducted to explore the causes of leave events among Aboriginal and Torres Strait Islander people and strategies to reduce them.

METHODS

A systematic review was conducted using Medline, Web of Science, Embase and Informit, a database with a strong focus on relevant Australian content. Additionally, we examined the references of the records included, and performed a manual search using Google, Google scholar and the Australia's National Institute for Aboriginal and Torres Strait Islander Health Research. Two independent reviewers screened the records. One author extracted the data and a second author reviewed it. To appraise the quality of the studies the Mixed Methods Appraisal Tool was used as well as the Aboriginal and Torres Strait Islander Quality Appraisal Tool. A narrative synthesis was used to report quantitative findings and an inductive thematic analysis for qualitative studies and reports.

RESULTS

We located 421 records. Ten records met eligibility criteria and were included in the systematic review. From those, four were quantitative studies, three were qualitative studies and three reports. Five records studied data from the Northern Territory, two from Western Australia, two from New South Whales and one from Queensland. The quantitative studies focused on the characteristics of the patients and found associations between leave events and male gender, age younger than 45 years and town camp residency. Qualitative findings yielded more in depth causes of leave events evidencing that they are associated with health care quality gaps. There were multiple strategies suggested to reduce leave events through adapting health care service delivery. Aboriginal and Torres Strait Islander representation is needed in a variety of roles within health care provision and during decision-making.

CONCLUSION

This systematic review found that multiple gaps within Australian health care delivery are associated with leave events among Aboriginal and Torres Strait Islander people. The findings suggest that reducing leave events requires better representation of Aboriginal and Torres Strait Islander people within the health workforce. In addition, partnership with Aboriginal and Torres Strait Islander people is needed during the decision-making process in providing health services that meet Aboriginal and Torres Strait Islander cultural needs.

Non-fatal injuries among boys and girls presenting to Red Cross War Memorial Children's Hospital, Cape Town, South Africa

BACKGROUND

In South Africa (SA), road traffic injuries, homicides and burns are the leading causes of injury-related deaths among children. Injury-related deaths are well documented for SA, but this is not the case for non-fatal injuries.

OBJECTIVES

To describe the non-fatal injuries sustained among children aged 0 - 13 years, to identify any significant sex differences by age group, cause of injury, admission status and injury severity.

METHODS

The trauma unit database from 1997 to 2016 at Red Cross War Memorial Children's Hospital, Cape Town, was utilised for this analysis. The prevalence of injuries and the boy/girl ratios with 95% confidence intervals (CIs) were reported.

RESULTS

Analysis indicated significant differences by sex for individual injury causes (transport, assault, burns, falls and other injuries), age group, injury severity and admission status. Moderately severe injuries were largely caused by burns, while severe injuries were mostly transport related. Boys had significantly higher proportions of all injury causes. The boy/girl ratio was lowest for assault (1:18), where significantly more girls aged 1 - 3 and 4 - 6 years were injured. Rape/sexual assault was 5.5 times higher for girls, with a significantly higher proportion of moderate-severity injuries (87%; 95% CI 84.7 - 89.4).

CONCLUSION

The study findings call for a more targeted prevention response for boy and girl children. Interventions should be targeted at the prevention of burns, traffic collisions and interpersonal violence, in particular sexual assaults against girls.

Direct and Indirect Mechanisms of Chemotherapy-Induced Bone Loss in Adjuvant Breast Cancer: An Integrative Review

OBJECTIVE

Breast cancer survivors are at increased risk of bone complications, indicating the need to better understand the effects of necessary treatments on bone health. The role of chemotherapy in bone loss is unclear, and its influence over time is not understood. This integrative review examined the existing literature on chemotherapy-induced bone loss in patients with early-stage, curative breast cancer focusing on long-term outcomes. Evaluating the mechanisms of chemotherapy-induced bone loss in humans along with preclinical (animal) models may elucidate pathways and improve care by providing targets for bone health-related interventions.

DATA SOURCES

A review of retrieved articles dated January 2010 to December 2020 from MEDLINE and EMBASE databases were searched. A total of six clinical (human) and three preclinical (animal) studies were included.

CONCLUSION

The findings identified two main themes (1) indirect and direct cellular mechanisms of chemotherapy-induced bone loss and (2) long-term bone complications and symptoms in breast cancer survivors. Implications for pre- and postmenopausal women are presented.

IMPLICATIONS FOR NURSING PRACTICE

Enhanced bone surveillance performed by the specialized oncology nurse can improve long-term bone health outcomes. Prospective analyses evaluating short- and long-term chemotherapy-induced bone loss are recommended for future clinical trials to inform practice and evidence-informed interventions and treatments.

A modified Dabestani-Mahan formula estimates a normal pulmonary artery systolic pressure: a single-center retrospective study

Background

Pulmonary artery systolic pressure (PASP) is increasingly used as an important datapoint in clinical decision-making and prognostication even in specialties outside of cardiology. Estimation of PASP by Doppler quantification using tricuspid regurgitation (TR) peak velocity is commonly used and correlates well with invasive measurement by right heart catheterization. Further study of transthoracic echocardiogram (TTE) techniques to estimate PASP is needed to provide this datapoint in the absence of sufficient Doppler data for the TR peak velocity method. One technique using right ventricular outflow tract acceleration time (AT) to estimate mean pulmonary artery pressure (MPAP) has been proposed by Dabestani Et al. by the equation MPAP=90-(0.62x AT). Assuming a linear relationship between MPAP and PASP, as suggested by Chemla Et al. by MPAP=(0.61xPASP)+2, a modified formula PASP=145-AT could possibly estimate a normal PASP ≤25 mmHg.

Purpose

To examine if a modified Dabestani-Mahan formula PASP=145-AT can estimate a normal PASP ≤25 mmHg as calculated by the TR peak velocity method.

Methods

We queried the electronic medical record at our institution for a sample of 300 patients who had a TTE performed between 2017 and 2020. Each TTE was reviewed and PASP was estimated for each using the TR peak velocity method. A right atrial pressure of 3 mmHg, 8 mmHg, or 15 mmHg was used in the estimation based on inferior vena cava diameter and collapsibility in keeping with the 2015 American Society of Echocardiography guidelines. A short axis view of pulmonary flow using the pulse-waved Doppler sample volume over the transpulmonary valve jet was then reviewed. The time from onset of ejection to peak flow velocity was measured manually as AT in milliseconds using Change Healthcare Cardiology Web Software Package 14.1.1. The measured AT was averaged over three cardiac cycles. Patients with a heart rate between 60 and 100 beats per minute at time of TTE and with sufficient Doppler data to estimate PASP by TR peak velocity and to measure AT were included in a logistic regression analysis.

Results

154 patients were included in the statistical analysis. Patients who had a right ventricular outflow tract acceleration time greater than 120 milliseconds, giving a PASP ≤25 mmHg by the modified formula PASP=145-AT, had a 36 times greater odds of having a PASP ≤25 mmHg by the TR peak velocity method (OR=36.0, 95% CI=10.36–125.12, p<0.001).

Conclusion(s)

Based on a single-center sample, a right ventricular outflow tract acceleration time greater than 120 milliseconds could be used to estimate a normal pulmonary artery systolic pressure less than or equal to 25 mmHg in the absence of sufficient Doppler data for the commonly used TR peak velocity method.

Funding Acknowledgement

Type of funding sources: None.

Urinary urgency acts as a source of divided attention leading to changes in gait in older adults with overactive bladder

AIMS

There is a well-recognised but unexplained association between lower urinary tract symptoms including urgency and urgency incontinence and falls in older people. It has been hypothesised that urinary urgency acts as a source of divided attention, leading to gait changes which increase falls risk. This study aimed to assess whether urinary urgency acts as a source of divided attention in older adults with overactive bladder (OAB).

METHODS

27 community-dwelling adults aged 65 years and over with a clinical diagnosis of OAB underwent 3-Dimensional Instrumented Gait Analysis under three conditions; bladder empty, when experiencing urgency, and when being distracted by the n-back test. Temporal-spatial gait and kinematic gait data were compared between each condition using repeated measures ANOVA.

RESULTS

Gait velocity decreased from 1.1ms-1 in the bladder empty condition to 1.0ms-1 with urgency and 0.9ms-1 with distraction (p = 0.008 and p<0.001 respectively). Stride length also decreased, from 1.2m to 1.1m with urgency and 1.0m with distraction (p<0.001 for both). The presence of detrusor overactivity did not influence these results (p = 0.77).

CONCLUSIONS

In older adults with OAB, urinary urgency induced similar changes in gait to those caused by a distracting task. These gait changes are associated with increased fall risk. This may be part of the explanation for the association between falls and lower urinary tract symptoms in older people. Future research should examine the effect of pharmacological treatment of OAB on gait and on the effect of dual-task training on gait when experiencing urgency.

Massive Perivillous Fibrin Deposition and Chronic Histiocytic Intervillositis a Complication of SARS-CoV-2 Infection

An emerging complication of COVID-19 (SARS-CoV-2) infection is reported. A 23-year-old patient presented with high temperature and reduced fetal movements at 25 + 5/40 weeks of gestation. RT-PCR proved maternal COVID-19 infection. Ultrasound examination confirmed intrauterine death. Placenta histology showed necrosis of the villous trophoblast, associated with Chronic Histiocytic Intervillositis (CHI) and Massive Perivillous Fibrin Deposition (MPFD) with up to 90% - of the intervillous spaces being involved. Immunohistochemistry showed CD68 positive histiocytes in the intervillous spaces and the villous trophoblast was positive for the COVID-19 spike protein. RNA scope signal was indicative of the presence of the viral genome and active viral replication in the villous trophoblastic cells, respectively. MPFD is a gradually developing end-stage disease with various etiology, including autoimmune and alloimmune maternal response to antigens expressed at the feto-maternal interface and frequently accompanies chronic alloimmune villitis or histiocytic intervillositis. Covid-19 infection is associated with similar pattern of histological changes of the placenta leading to placental insufficiency and fetal death. This case report supports maternal- fetal vertical transmission of SARS-CoV-2 virus leading to placental insufficiency and fetal demise. MPFD and CHI appear to be the typical placental histology for SARS-CoV-2 virus infection associated fetal demise.

Increased right ventricular uptake on (99m Tc)-sestamibi SPECT myocardial perfusion imaging as a marker of elevated pulmonary artery systolic pressure measured by Doppler echocardiography

Funding Acknowledgements

Type of funding sources: None.

Background

Though prior work has been done, the significance of the not uncommon finding of increased right ventricular (RV) tracer uptake in patients undergoing (99m Tc)-sestamibi SPECT myocardial perfusion imaging remains poorly defined and this finding not been systemically integrated into the interpretation of the study, despite likely carrying both diagnostic and prognostic relevance for the patient.

Purpose

To examine if the presence of increased RV tracer uptake in patients undergoing myocardial perfusion imaging with same-day protocol (99m Tc)-sestamibi SPECT is associated with a higher pulmonary artery systolic pressure (PASP) measured non-invasively with transthoracic Doppler echocardiography 

Methods

Patients who underwent myocardial perfusion imaging with same-day protocol (99m Tc)-sestamibi SPECT at a single academic health system between 2017-2020 were retrospectively enrolled. Those patients who had a transthoracic echocardiogram performed within 60 days of the nuclear study with sufficient Doppler data to estimate pulmonary artery systolic pressure(PASP) using the tricuspid regurgitation peak velocity method were included. A right atrial pressure of either 3 mmHg, 8 mmHg, or 15 mmHg was used in the calculation of PASP in keeping with the 2015 American Society of Echocardiography guidelines. The rest images for each nuclear study were reviewed and analyzed for the presence of RV tracer uptake. RV uptake was graded as either 0 or "no RV uptake", 1+ or "partial RV uptake", or  2+ or "complete RV uptake".  The nuclear studies were grouped accordingly and the mean PASP for each group was computed.  The mean PASP was also computed for a combined group of patients who demonstrated either 1+ or 2+ RV uptake. Statistical analysis using a t-test was performed to compare the mean PASP of each patient group. 

Results

193 patients were included in the analysis. Of those, 123(63%) demonstrated "no RV uptake",  58(31%) demonstrated 1+ or "partial RV uptake", and 12(6%) demonstrated 2+ or "complete RV uptake". 70 patients(36%) had either 1+ or 2 + RV uptake. The mean PASP was 27.2 ± 7 mmHg for the "no RV uptake" group, 28.3 ± 9 mmHg for the 1+ RV uptake group and 41. 6 ± 14 mmHg for the 2+ RV uptake group. When combined, patients demonstrating 1+ or 2+ RV uptake had a mean PASP of 30.6 ± 11 mmHg. There was no statistical difference in the mean PASP of the "no RV uptake" group and the 1+ or "partial RV uptake group" (p = 0.434). The difference in mean PASP between the "no RV uptake" group and the combined 1+ or 2+ RV uptake group was statistically significant(p = 0.028). 

Conclusion

In a small single health system sample, patients undergoing (99m Tc)-sestamibi SPECT myocardial perfusion imaging who have either partial or complete RV uptake on rest images have an increased pulmonary artery systolic pressure compared to patients who do not exhibit this finding.

Unplanned readmission for older persons: A concept analysis

AIM

The purpose of this concept analysis is to define and analyse the concept of unplanned readmission to hospital for older persons.

DESIGN

Review the literature and analyse the concept of unplanned readmission.

METHOD

Guided by Walker and Avant's eight-stage method of concept analysis, four databases (Ovid MEDLINE, Scopus, CINAHL, and Embase) were searched between 1946 and 2020 for empirical studies focused on older persons with multiple chronic conditions, experiences or perspectives and unplanned readmission. A total of 34 articles (10 quantitative, 17 qualitative, three mixed methods), one concept analysis and three historical articles were included.

RESULTS

An unplanned readmission is an experience, process and event. The proposed definition of unplanned readmission is an older person's need for acute care treatment for an urgent or emergent health crisis that has occurred after a previous hospitalization(s). Unplanned readmission is characterized by the attributes of older persons' previous hospitalization(s), the urgent or emergent nature of the older persons' health and the older persons' need for acute care hospital services to resolve their health crisis.

CONCLUSION

Unplanned readmission is a complex concept that is different from planned and emergency visits/admissions and readiness for discharge. These findings provide a link for understanding unplanned readmission as a consequence of discharge readiness. Analysing this concept supports the need for older persons to seek unplanned readmission for acute care treatment of urgent and emergent health crisis, reduces the blame that older persons may feel from questions related to preventability, and stresses the need to include older persons' experiences in the development and expansion of nursing theory, interventions and current understandings of unplanned readmission.

Radiologists are increasingly recommending follow-up of chest radiographs: a 10-year review

PURPOSE

To assess for changes in trends of GP chest radiograph reporting over a 10-year period and to assess if there has been a change in recommendations for follow-up.

METHODS

Retrospective study of an Irish tertiary referral center. The total number of GP-referred chest x-rays performed per year from 2007 to 2017 are recorded. One-hundred male/100 female GP-referred chest x-rays are chosen at random from NIMIS data for each of 2007, 2010, 2013, and 2017. Reports are analyzed with regard to abnormal findings, recommendation for follow-up, and yield of follow-up imaging.

RESULTS

There were 4917 GP CXRs performed in 2007, 4856 in 2010, 5561 in 2013, and 6492 in 2017. Follow-up was recommended in 17 studies(8.5%) in 2007, 19 studies(9.5%) in 2010, 22 studies(11%) in 2013, and 27 studies(13.5%) in 2017. Indications for follow-up recommendation were largely to ensure resolution of infection (52%) or for nodule surveillance (43%). There has been a notable increase in lung nodule follow-up, with suggested follow-ups increasing from 6 in 2007, to 7 in 2010, 9 in 2013, and 14 in 2017, an increase of 58%.

CONCLUSION

Along with the increase in the quantity of GP-referred chest radiographs over the past 10 years, suggestions for follow-up have increased, particularly for nodule surveillance. Reasons for this increase may include lack of availability of CT to GPs for lung cancer screening, insensitivity of plain radiographs to early cancer detection, and possible fear of litigation for missing lesions, making radiologists more cautious.

Beyond HOSPEX: what is the additional training value of military hospital exercises (HOSPEX)?

BACKGROUND

The use of simulation in clinical environments is a frequently used adjunct to training individuals and teams. The military uses clinical simulation to train large numbers of personnel, standardise patient pathways and sustain specific skills to ensure medical personnel are prepared to deploy in their clinical roles.

METHODS

As part of a North Atlantic Treaty Organization (NATO) exercise, 256 Field Hospital (Reserves) deployed a team of clinicians to simulate a role 2 basic field hospital. This hospital exercise (HOSPEX) involved training, and a 4-day real-time exercise with casualty simulation. A retrospective survey of all clinical personnel was conducted to analyse the utility of the exercise on their understanding of their job role, the workings of the field hospital and their confidence in deploying on operations.

RESULTS

39 personnel were surveyed, with questions graded on a modified Likert scale. 41% had previous operational experience in their current job role. A significantly higher proportion of respondents graded their understanding of their job role, and the field hospital overall, as good or excellent having completed the exercise (p<0.01), and 90% felt more confident in fulfilling their operational role postexercise. 90% of respondents had previous experience of simulation, and 94% of these rated the military simulation as being more beneficial than civilian equivalents.

DISCUSSION

With a shift towards simulation in medical training, opportunities have arisen within HOSPEX to develop additional skills for teams and individuals. Simulation is especially important in personnel who have not had previous operational experience, who may deploy on first time operations in senior clinical and leadership roles.

CONCLUSION

HOSPEXs are perceived as being extremely useful by clinical personnel preparing for future operational deployment. HOSPEX simulation has prepared the military for varied operations since its inception, and the paradigm has potential for extension into civilian training for high intensity medical responses.

Sustaining Primary Health Care Programs and Services: A Scoping Review Informing the Nurse Practitioner Role in Canada

Sustainability is a key concept in the politics and local policy of health care delivery, particularly during discussions on the principles of primary health care (PHC) and health care reform. In Canada, previous reforms in PHC were implemented with the goal of achieving long-term sustainable change in health systems across the country. However, insufficient resources and a changing environment have impeded the sustainability of many PHC programs and services. An example is the nurse practitioner (NP) role, which was introduced in Canada in 1967 but failed to be sustained. In the mid-1990s, in response to a call for PHC reform, the role was reimplemented with the support of government legislation, regulation, and remuneration mechanisms. However, despite evidentiary success of NP role effectiveness and efficiency in Canada's health system, many barriers toward full implementation of the role continue to exist and sustainability remains at risk. This scoping review was undertaken to inform a research project exploring the closure of an NP clinic in a western Canadian province. The review searched relevant peer-reviewed and gray literature from Canada, United Kingdom, and Australia, to better understand and describe the factors influencing sustainability of the NP role and other PHC programs and services.

Efficacy and cultural appropriateness of psychosocial interventions for paediatric burn patients and caregivers: a systematic review

Background

Paediatric burns are highly painful and traumatising injuries that are overrepresented among Aboriginal and Torres Strait Islander people. Paediatric burn patients’ pain remains poorly managed by pharmacological interventions, leading to increased anxiety, distress, and trauma in patients and their caregivers. Non-pharmacological psychosocial interventions have been suggested as effective in reducing pain and psychological morbidities among paediatric burn patients and their caregivers; however, their degree of effectiveness and appropriateness for Aboriginal and Torres Strait Islander people is unclear.

Methods

A non-date restricted systematic review was conducted through four databases. Studies published in English assessing psychosocial interventions on paediatric burn patients’ physical pain along with theirs and/or their caregiver’s anxiety, distress, or trauma symptoms were identified and included in this review. Included studies were assessed for their ability to reduce one of the outcomes of interests and for their reflection of Aboriginal and Torres Strait Islander peoples’ perspectives of health.

Results

Of the 3178 identified references, 17 were eligible. These include distraction based techniques (n = 8), hypnosis/familiar imagery (n = 2), therapeutic approaches (n = 4), and patient preparation/procedural control (n = 3). Distraction techniques incorporating procedural preparation reduced pain, while discharge preparation and increased ‘patient control’ reduced patient and caregiver anxiety; and internet based Cognitive Behaviour Therapy reduced short-term but not long-term post-traumatic stress symptoms. No interventions reflected Aboriginal and Torres Strait Islander peoples’ perspectives of health; and few targeted caregivers or focused on reducing their symptoms.

Conclusions

The development and assessment of psychosocial interventions to appropriately meet the needs of Aboriginal and Torres Strait Islander paediatric burn patients is required.

Preferences for Continence Care Experienced at End of Life: A Qualitative Study

CONTEXT

Functional dependence at end of life often leaves individuals requiring help for personal care, including maintaining continence. Current continence guidelines offer little direction for end of life continence care, and little is known of the perspectives of people receiving palliative care.

OBJECTIVES

The aim of the study was to examine the continence care preferences of people receiving palliative care to understand what approaches to care and what goals of care are important to them.

METHODS

This is a qualitative descriptive exploratory study with data gathered in individual interviews using a semi-structured interview guide. Participants were receiving bladder and/or bowel care on either tertiary or hospice palliative care units.

RESULTS

Fourteen Canadian patients (seven female, seven male), six from tertiary and eight from hospice palliative care units, were recruited. From the analysis, three themes were identified: loss of control, finding a way to manage, and caregivers can help and can hinder. Dignity was often lost as a result of having to receive continence care, with most participants following staff recommendations for management approaches as the easiest way. Patients did not recall being asked about their bladder and bowel preferences.

CONCLUSIONS

As patients approached end of life they were willing to give up dignity if it was required to address symptoms causing them more distress, like pain. Health care professionals and family have an important role in social interactions around continence care. Health care professionals should incorporate patient preferences as best they can and explain the options when treating incontinence at end of life.

Are we Over-Imaging the Obese Patient with Suspected Pulmonary Embolus in Ireland

Aims To assess if there was a significant difference in the number of positive studies for pulmonary embolism between obese and non obese patients. Methods A retrospective analysis of all CTPAs performed in our institution over one year in patients aged 18-50 was performed. Data regarding the diagnosis of pulmonary embolism, the presence of airways disease, other significant chest findings, D dimer values and demographic data including a BMI surrogate was obtained. Results Two hundred and thirty CTPAs were performed in our institution over 12 months. Two hundred and twenty-one were included for analysis, of which 129 were male and 92 were female. Sixty-nine (31%) patients were classified as obese. Eleven (16%) of these had positive studies. One hundred and fifty-two patients were in the non obese category, of which 24 (15%) had positive studies. Conclusions We are not over imaging the obese patient, but are over imaging patients in general with suspected PE, but are exposing a significant number overall, to unnecessary radiation.

The role of microbiota and inflammation in self-judgement and empathy: implications for understanding the brain-gut-microbiome axis in depression

RATIONALE

The gut-brain axis includes bidirectional communication between intestinal microbiota and the central nervous system. Bifidobacterium and Lactobacillus spp. have been implicated in psychological health, such as depression, through various pathways (e.g. inflammation). Research needs a better understanding of direct and indirect effects through examination of psychological factors that make people susceptible to, or offer protection against, depression.

OBJECTIVE

This study investigated the relationships between gut microbiota, inflammation and psychological risk and resilience factors for depression.

METHODS

Forty participants (13 m/27 f) recruited from the general population completed self-report questionnaires for depression, self-judgement, over-identification and affective and cognitive empathy. Faecal and blood samples were taken to assay microbiota (Bifidobacterium; Lactobacillus spp.) and pro-inflammatory molecules (C-reactive protein, CRP and interleukin-6, IL-6), respectively.

RESULTS

Hierarchical regression analyses (controlling for sex, age and the shared variance of risk and resilience factors) showed that (i) cognitive depression was significantly predicted by negative self-judgement and reduced cognitive empathy; (ii) abundance of Lactobacillus spp. was directly related to positive self-judgement but only indirectly to cognitive depression and lower affective empathy (both through self-judgement); and (iii) CRP was the strongest predictor of reduced cognitive empathy, with suppression effects seen for age (negative) and IL-6 (positive) after controlling for CRP.

CONCLUSIONS

Findings suggest that lactobacilli and inflammation may be differentially associated with mood disorder via brain mechanisms underpinning self-judgement and cognitive empathy, respectively. Further trials investigating interventions to increase Lactobacillus spp. in depression would benefit from direct measures of self-judgement and affective empathic distress, whilst those that aim to reduce inflammation should investigate cognitive empathy.

Human papillomavirus and oral and oropharyngeal carcinoma: the essentials

There is a global increase in the prevalence of human papillomavirus (HPV)-driven oropharyngeal squamous cell carcinoma (OPSCC) in Australia and New Zealand. Risk factors for HPV-positive OPSCC are male gender, white race, age older than 40 but younger than 59 years old, having multiple lifetime sex partners, having oro-genital and oro-anal sex. High-risk HPV subtypes play a major role in the pathogenesis of OPSCC, however, they play a much lesser role in oral squamous cell carcinoma (OSCC). Among the laboratory tests used to detect oncogenic HPV infection, polymerase chain reaction is a sensitive method but does not reflect the role of HPV in oncogenesis. While widely used, p16 immunohistochemistry is both a sensitive and a specific surrogate marker for oncogenic HPV infection in OPSCC, but not in OSCC. However, it is a useful prognostic marker in OPSCC. The current gold standard to accurately detect oncogenic HPV infection is E6/E7 mRNAin situ hybridization. Because both HPV-positive and p16-positive OPSCC have better short-term prognoses there is current debate and trials on treatment de-escalation in HPV-positive OPSCC. Dental practitioners can play an important role in early diagnosis of HPV-positive OPSCC.

Combined impairments in vision, hearing and cognition are associated with greater levels of functional and communication difficulties than cognitive impairment alone: Analysis of interRAI data for home care and long-term care recipients in Ontario

OBJECTIVES

The objective of the current study was to understand the added effects of having a sensory impairment (vision and/or hearing impairment) in combination with cognitive impairment with respect to health-related outcomes among older adults (65+ years old) receiving home care or residing in a long-term care (LTC) facility in Ontario, Canada.

METHODS

Cross-sectional analyses were conducted using existing data collected with one of two interRAI assessments, one for home care (n = 291,824) and one for LTC (n = 110,578). Items in the assessments were used to identify clients with single sensory impairments (e.g., vision only [VI], hearing only [HI]), dual sensory impairment (DSI; i.e., vision and hearing) and those with cognitive impairment (CI). We defined seven mutually exclusive groups based on the presence of single or combined impairments.

RESULTS

The rate of people having all three impairments (i.e., CI+DSI) was 21.3% in home care and 29.2% in LTC. Across the seven groups, individuals with all three impairments were the most likely to report loneliness, to have a reduction in social engagement, and to experience reduced independence in their activities of daily living (ADLs) and instrumental ADLs (IADLs). Communication challenges were highly prevalent in this group, at 38.0% in home care and 49.2% in LTC. In both care settings, communication difficulties were more common in the CI+DSI group versus the CI-alone group.

CONCLUSIONS

The presence of combined sensory and cognitive impairments is high among older adults in these two care settings and having all three impairments is associated with higher rates of negative outcomes than the rates for those having CI alone. There is a rising imperative for all health care professionals to recognize the potential presence of hearing, vision and cognitive impairments in those for whom they provide care, to ensure that basic screening occurs and to use those results to inform care plans.

How Valid are Patient Reports of Family History of Illness?

The recall rate of patients’ family medical histories was studied in 200 cancer and non-cancer patients. Data on age and cause of death for parents and grandparents were collected. Although most patients knew the age and cause of death of parents, less than half knew for grandparents. Cancer patients had significantly greater recall for maternally related relatives. A subsample of patients’ family medical histories was compared to death certificate data. Patients’ reports were found to be highly inaccurate. Since only a small subgroup could provide medical history data for grandparents, the generaliz-ability for history of family illness is questioned.

Errors in interpretation of neck levels in postoperative pathological specimens

Accurate orientation of pathological specimens is of fundamental importance, and specimens that are divided postoperatively may be misinterpreted. We asked surgeons and pathologists to identify boundaries between nodal levels on a clinical photograph of a neck dissection specimen. Few participants were able to identify the boundaries between levels accurately, with several important errors where a marked level contained none of the relevant anatomical tissue. Most errors were in level I, and the number decreased towards level IV. Errors were made by both pathologists and surgeons. The boundaries of level IIA were consistently overestimated, which may have implications for previous studies that evaluated patterns of nodal spread.

Hearing in school-aged children with trisomy 21 - results of a longitudinal cohort study in children identified at birth

OBJECTIVES

To report the prevalence of hearing problems and the hearing sequelae in school-aged children with trisomy 21 in a longitudinal study.

DESIGN

All children with trisomy 21 were identified via schools, community-based child development centres, general practitioners, or the universal newborn hearing screen. Audiological data and otorhinolaryngological problems were prospectively entered in to the Audiological Surveillance Programme database from each visit.

SETTING

Retrospective review of the Audiological Surveillance Programme database in the Glasgow area (United Kingdom) of all children reviewed between 2004 and 2012.

PARTICIPANTS

All pre-teenaged children with trisomy 21 of school age (aged 5-12 years old).

MAIN OUTCOME MEASURES

Hearing thresholds, aetiology of hearing loss and management of hearing loss was determined for the cohort of children.

RESULTS

A total of 102 children were included. Fifty-four had normal hearing. Twenty-six had fluctuating otitis media with effusion; five had hearing in normal limits, six were managed with hearing aids, fourteen were managed conservatively, and one had ventilation tube insertion. Fifteen had persistent otitis media with effusion; four had ventilation tube insertion; and nine were managed with hearing aids. Seven had mixed hearing loss with four required hearing aids.

CONCLUSIONS

Otitis media with effusion was the commonest cause of hearing impairment; effusions may fluctuate through the pre-teenaged years, and thus, hearing aids are beneficial. Ventilation tube insertion and bone-conducting hearing aids were useful when ear-level hearing aids were not tolerated. Mixed hearing loss occurred in later years as sensorineural hearing loss developed on a background of otitis media with effusion.

Investigating the effects of an oral fructose challenge on hepatic ATP reserves in healthy volunteers: A (31)P MRS study

BACKGROUND

Impaired homeostasis of hepatic ATP has been associated with NAFLD. An intravenous fructose infusion has been shown to be an effective challenge to monitor the depletion and subsequent recovery of hepatic ATP reserves using (31)P MRS.

AIMS

The purpose of this study was to evaluate the effects of an oral rather than intravenous fructose challenge on hepatic ATP reserves in healthy subjects.

METHODS

Self-reported healthy males were recruited. Following an overnight fast, baseline liver glycogen and lipid levels were measured using Magnetic Resonance Spectroscopy (MRS). Immediately after consuming a 500 ml 75 g fructose drink (1275 kJ) subjects were scanned continuously for 90 min to acquire dynamic (31)P MRS measurements of liver ATP reserves.

RESULTS

A significant effect on ATP reserves was observed across the time course (P < 0.05). Mean ATP levels reached a minimum at 50 min which was markedly lower than baseline (80 ± 17% baseline, P < 0.05). Subsequently, mean values tended to rise but did not reach statistical significance above minimum. The time to minimum ATP levels across subjects was negatively correlated with BMI (R(2) = 0.74, P < 0.005). Rates of ATP recovery were not significantly correlated with BMI or liver fat levels, but were negatively correlated with baseline glycogen levels (R(2) = 0.7, P < 0.05).

CONCLUSIONS

Depletion of ATP reserves can be measured non-invasively following an oral fructose challenge using (31)P MRS. BMI is the best predictor of postprandial ATP homeostasis following fructose consumption.

Serum levels of the progesterone induced blocking factor do not precipitously rise in women with gynecologic cancer in contrast to women exposed to progesterone

PURPOSE

To determine if an immunomodulatory protein (progesterone induced blocking factor [PIBF]) that is progesterone induced and found in higher concentration during pregnancy is similarly found with increased levels in women with gynecologic cancers.

MATERIALS AND METHODS

A newly developed enzyme linked immunoabsorbent assay (ELISA) assay was used to measure PIBF in the sera of six women with various gynecologic cancers and compare them to five controls (three with benign tumors and two having gynecologic procedures for non-tumors.

RESULTS

The PIBF levels in women with gynecologic cancer did not rise precipitously as historical controls of women or men exposed to progesterone. The two highest PIBF levels of the 11 subjects were in women with gynecologic cancer.

CONCLUSIONS

The data suggest that if PIBF helps cancer cells to evade immune surveillance, it probably operates through an intracytoplasmic presence. If an increase in sera PIBF could have been detected in women with gynecologic cancer, then this ELISA test could have been used to detect tumor recurrence. Future studies may concentrate on evaluating intracytoplasmic PIBF to possibly help determine which tumors may respond to progesterone antagonist receptors.

Efficacy and side-effect profiles of lactulose, docusate sodium, and sennosides compared to PEG in opioid-induced constipation: a systematic review

Opioid-induced constipation (OIC) is a side effect of opioid therapy that can affect quality of life, adherence to treatment, and morbidity and possibly mortality.

OBJECTIVES

To investigate whether docusate sodium, sennosides, and lactulose have equal efficacy and side effect profiles compared to PEG in the management of OIC in adults.

METHODS

A systematic review was undertaken. Randomized controlled trials of adults taking opioids for cancer or non-cancer pain were considered if they met inclusion criteria.

CONCLUSIONS

Statistical pooling was not possible as no studies met inclusion criteria. Large, well-powered, randomized controlled trials are feasible. Standard definitions of OIC would assist with the execution of these studies and contribute to their internal and external validity. Further research is strongly encouraged.

A low calorie morning meal prevents the decline of hepatic glycogen stores: a pilot in vivo13C magnetic resonance study

A low dose oral glucose challenge following an overnight fast inhibits further reduction in hepatic glycogen reserves without raising levels above baseline.