DAF-16/FOXO and HLH-30/TFEB comprise a cooperative regulatory axis controlling tubular lysosome induction in C. elegans

Although life expectancy has increased, longer lifespans do not always align with prolonged healthspans and, as a result, the occurrence of age-related degenerative diseases continues to increase. Thus, biomedical research has been shifting focus to strategies that enhance both lifespan and healthspan concurrently. Two major transcription factors that have been heavily studied in the context of aging and longevity are DAF-16/FOXO and HLH-30/TFEB; however, how these two factors coordinate to promote longevity is still not fully understood. In this study, we reveal a new facet of their cooperation that supports healthier aging in C. elegans. Namely, we demonstrate that the combinatorial effect of daf-16 and hlh-30 is required to trigger robust lysosomal tubulation, which contributes to systemic health benefits in late age by enhancing cross-tissue proteostasis mechanisms. Remarkably, this change in lysosomal morphology can be artificially induced via overexpression of SVIP, a previously characterized tubular lysosome stimulator, even when one of the key transcription factors, DAF-16, is absent. This adds to growing evidence that SVIP could be utilized to employ tubular lysosome activity in adverse conditions or disease states. Mechanistically, intestinal overexpression of SVIP leads to nuclear accumulation of HLH-30 in gut and non-gut tissues and triggers global gene expression changes that promotes systemic health benefits. Collectively, our work reveals a new cellular process that is under the control of DAF-16 and HLH-30 and provides further insight into how these two transcription factors may be exerting their pro-health effects.

Robotic trials in arthroplasty surgery

Total hip and knee arthroplasty (THA, TKA) are largely successful procedures; however, both have variable outcomes, resulting in some patients being dissatisfied with the outcome. Surgeons are turning to technologies such as robotic-assisted surgery in an attempt to improve outcomes. Robust studies are needed to find out if these innovations are really benefitting patients. The Robotic Arthroplasty Clinical and Cost Effectiveness Randomised Controlled Trials (RACER) trials are multicentre, patient-blinded randomized controlled trials. The patients have primary osteoarthritis of the hip or knee. The operation is Mako-assisted THA or TKA and the control groups have operations using conventional instruments. The primary clinical outcome is the Forgotten Joint Score at 12 months, and there is a built-in analysis of cost-effectiveness. Secondary outcomes include early pain, the alignment of the components, and medium- to long-term outcomes. This annotation outlines the need to assess these technologies and discusses the design and challenges when conducting such trials, including surgical workflows, isolating the effect of the operation, blinding, and assessing the learning curve. Finally, the future of robotic surgery is discussed, including the need to contemporaneously introduce and evaluate such technologies.

Birmingham Royal Orthopaedic Hospital (BROH) Femoral Offset-An Ancillary Measure of Adult Dysplasia of the Hip

Introduction  Adult dysplasia of the hip (ADH) is a disorder of abnormal development of the hip joint resulting in a shallow acetabulum and uncovering of the femoral head. Several radiological measurements such as the Tönnis angle (acetabular index), lateral center edge angle of Wiberg, and cross-sectional imaging parameters exist to calculate hip dysplasia. Aims  The aim of this article was to describe a new ancillary linear measure of ADH on cross-sectional imaging, the Birmingham Royal Orthopaedic Hospital (BROH) Femoral offset. Patients and Methods  Anteroposterior radiographs of the pelvis and computed tomography imaging of 100 consecutive patients with suspected hip dysplasia were reviewed. Demographic details and clinical indications were recorded. Tönnis angle was utilized to measure hip slope on radiographs and the BROH femoral offset was calculated for each patient. Student's t -test and one-way analysis of variance (ANOVA) were performed. Intraclass correlation coefficient analysis was evaluated to assess the reliability between observers. Results  There was a total of 100 patients (128 hips) included in the study (60 with normal Tönnis angle, 53 had dysplasia, and 15 had decreased Tönnis angle). The average BROH femoral offset in the dysplastic cohort was increased in comparison to the normal cohort with a statistically significant p -Value of 0.0001. The p -value was 0.00031 on ANOVA. The BROH femoral offset calculation revealed good intra- and interobserver reliability of 0.9 and 0.9, respectively. Conclusion  The BROH femoral offset can be an additional index for measuring ADH that is easier to calculate, and reproducible with good intra- and inter-observer reliability on cross-sectional imaging.

Public beliefs about the consequences of living with obesity in the Republic of Ireland and Northern Ireland

Background

This study aimed to capture public beliefs about living with obesity, examine how these beliefs have changed over time and to explore whether certain characteristics were associated with them in a nationally representative sample of adults from the Republic of Ireland (RoI) and Northern Ireland (NI).

Methods

A cross-sectional survey employed a random quota sampling approach to recruit a nationally representative sample of 1046 adults across NI and RoI. Telephone interviews captured information on demographics; health behaviours & attitudes; and beliefs about the consequences of obesity (measured using the Obesity Beliefs Scale). Univariable analyses compared beliefs about the consequences of living with obesity between participants with a self-reported healthy weight and those living with overweight or obesity, and non-responders (those for whom weight status could not be ascertained due to missing data). Multiple linear regression examined associations between obesity-related beliefs and socio-demographics, self-rated health and perceived ability to change health behaviours. Multiple linear regression also compared changes in obesity-related beliefs between 2013 and 2020 in the RoI.

Results

Higher endorsement of the negative outcomes of obesity was significantly associated with living with a healthy weight, higher self-rated health, dietary quality and perceived ability to improve diet and physical activity. Those who lived with overweight, with obesity and non-responders were less likely to endorse the negative consequences of obesity. Those living with obesity and non-responders were also more likely to support there is an increased cost and effort in maintaining a healthy weight. Comparison with survey data from 2013 showed that currently, there is a greater endorsement of the health benefits of maintaining a healthy weight (p < 0001), but also of the increased costs associated with it (p < 0001).

Conclusion

Beliefs about the consequences of maintaining a healthy body weight are associated with individuals’ weight, self-rated health, diet and perceived ease of adoption of dietary and exercise-related improvements. Beliefs about the health risks of obesity and perceived greater costs associated with maintaining a healthy weight appear to have strengthened over time. Present findings are pertinent to researchers and policy makers involved in the design and framing of interventions to address obesity.

Supplementary information

The online version contains supplementary material available at 10.1186/s12889-022-14280-9.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Development and psychometric testing of the gender misconceptions of men in nursing (GEMINI) scale among nursing students

BACKGROUND

Misconceptions about men in nursing may influence recruitment and retention, further perpetuating the gender diversity imbalance in the nursing workforce. Identifying misconceptions and implementing early intervention strategies to address these deep-rooted stereotypes remain challenging but is considered critical to support students who are commencing a nursing career.

OBJECTIVE

To develop and evaluate the psychometric properties of the 'Gender Misconceptions of meN in nursIng (GEMINI) Scale.

DESIGN

Cross-sectional survey.

METHODS

Pre-registration nursing students enrolled in undergraduate nursing programs across 16 nursing institutions in Australia were surveyed from July to September 2021. The 17-item self-report GEMINI Scale measured the gender misconceptions of men in nursing.

RESULTS

Of the 1410 completed surveys, data from 683 (45%) women were used for exploratory factor analysis showing a one factor structure, while data from 727 men (47%) were used for confirmatory factor analysis of the 17-item GEMINI Scale, which showed a good model fit. The scale demonstrated high internal consistency (Cronbach's alpha of 0.892). Men were found to have higher gender misconceptions (p < 0.001) while respondents who: a) identified nursing as their first career choice (p = 0.002); b) were in their final year of program enrolment (p = 0.016); and c) engaged in health-related paid work (p = 0.002) had lower gender misconceptions.

CONCLUSION

The GEMINI Scale is a robust, valid, reliable, and easy to administer tool to assess misconceptions about men in nursing, which may potentially influence academic performance and retention. Identifying and addressing specific elements of misconceptions could inform targeted strategies to support retention and decrease attrition among these students.

IMPACT STATEMENT

Genderism harms nursing, as well as the men and women working in the profession. Recruitment and retention of men into nursing is needed to cultivate male role models and diversify the workforce, however this is impeded by negative portrayals in popular culture and misconceptions entrenched in society.

Exploring Nursing Students' Experiences With Different Teaching Pedagogies: A Mixed-Methods Study

BACKGROUND

Educational methods continue to evolve to meet the challenge of teaching undergraduate nursing students. Innovative teaching pedagogies require nursing students to be actively involved in their own learning compared with traditional didactical styles.

METHOD

Students were exposed to three distinct teaching pedagogies: inquiry-based, online, and educator-led during their second year of study. Students' learning preferences were explored using a mixed-methods approach. Quantitative data were collected using an online questionnaire, followed by a focus group interview.

RESULTS

The quantitative data revealed students preferred being taught directly from educators rather than through self-directed and online study. Manifest content analysis of qualitative data revealed four categories that supported student learning and five categories that hindered student learning.

CONCLUSION

Students struggled when required to be self-directed in their learning. Students reported feeling uncertain and overwhelmed initially, which highlighted the importance of strong social and academic support to facilitate effective learning. [J Nurs Educ. 2022;61(3):147-152.].

Quantifying the impact of regional variations in COVID-19 infections and hospitalisations across Ireland

Background

As most COVID-19 transmission occurs locally, targeted measures where the likelihood of infection and hospitalization is highest may be a prudent risk management strategy. To date, in the Republic of Ireland, a regional comparison of COVID-19 cases and hospitalizations has not been completed. Here, we investigate (i) the variation in rates of confirmed infection and hospital admissions within geographical units of the Republic of Ireland and (ii) frequency of deviations in risk of infection or risk of hospitalization.

Methods

We analyzed routinely collected, publicly available data available from the National Health Protection and Surveillance Centre and Health Service Executive from nine geographical units, known as Community Health Organization areas. The observational period included 206 14-day periods (1 September 2020–15 April 2021).

Results

A total of 206 844 laboratory-confirmed cases and 7721 hospitalizations were reported. The national incidence of confirmed infections was 4508 [95% confidence interval (CI) 4489–4528] per 100 000 people. The risk of hospital admission among confirmed cases was 3.7% (95% CI 3.5–3.9). Across geographical units, the likelihood that rolling 14-day risk of infection or hospitalization exceeded national levels was 9–86% and 0–88%, respectively. In the most affected regions, we estimate this resulted in an excess of 15 180 infections and 1920 hospitalizations.

Conclusions

Responses to future COVID-19 outbreaks should consider the risk and harm of infection posed to people living in specific regions. Given the recent surges of COVID-19 cases in Europe, every effort should be made to strengthen local surveillance and to tailor community-centred measures to control transmission.

The negative impact of smartphone usage on nursing students: An integrative literature review

BACKGROUND

Smartphones are ubiquitous, and for some, an indispensable companion. In nursing education curricula and clinical healthcare settings, smartphones have the potential to augment student learning. Nursing students report significant benefits to smartphone use, which extend beyond learning, to include enhanced communication, clinical decision making and evidence-based practice. Despite these benefits, little is known about the negative impact of smartphones on student learning.

OBJECTIVES

This integrative review aimed to synthesise findings from published research that referred to the detrimental direct or indirect effect of smartphone usage on nursing students.

DESIGN

The integrative review was guided by the five-stage approach as conceptualised by Whittemore and Knafl (2005).

METHODS

Seven electronic databases were systematically searched in consultation with a university librarian (CINAHL Plus, Ovid Medline ALL, Nursing and Allied Health Database, PsycINFO, PubMed, Scopus and ERIC) using a combination of key search terms and medical subject headings. A total of 646 articles were retrieved, and following removal of duplicates, screening of titles and abstracts, a final 27 articles met the inclusion criteria for this review.

RESULTS

Studies in the review originated from Korea (n = 7), Turkey (n = 6), India (n = 4), Spain (n = 3), USA (n = 2), Spain/Portugal (n = 1), Iran (n = 1), France (n = 1), Canada (n = 1) and Egypt (n = 1). Personal smartphone use was reported to be a distraction within clinical and classroom learning, and considered as uncivil, and compromised professionalism. Frequently, smartphones were used for entertainment (e.g. social networking) rather than professional purposes. The studies identified a concerning level of nomophobia and smartphone addiction among nursing students that caused stress and anxiety, and adversely affected sleep, learning and academic performance. Recommendations were proposed for smartphone policies.

CONCLUSIONS

Excessive smartphones use among nursing students may adversely affect physical and mental health and potentially impact on student learning within the classroom and clinical environment. Educators should consider the implementation of policies or guidance for the responsible use of smartphones by nursing students whilst in the classroom setting and during clinical placement, to mitigate the potential negative impact on health and academic performance.

Impact of COVID-19 on clinical outcomes for patients with fractured hip: a multicentre observational cohort study

Aims

There are reports of a marked increase in perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in the UK, USA, Spain, and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic.

Methods

We completed a multicentre cohort study across ten hospitals in England. Data were collected from 1 March 2020 to 6 April 2020, during which period the World Health Organization (WHO) declared COVID-19 to be a pandemic. Patients ≥ 60 years of age admitted with hip fracture and a minimum follow-up of 30 days were included for analysis. Primary outcome of interest was mortality at 30 days post-surgery or postadmission in nonoperative patients. Secondary outcomes included length of hospital stay and discharge destination.

Results

In total, 404 patients were included for final analysis with a COVID-19 diagnosis being made in 114 (28.2%) patients. Overall, 30-day mortality stood at 14.4% (n = 58). The COVID-19 cohort experienced a mortality rate of 32.5% (37/114) compared to 7.2% (21/290) in the non-COVID cohort (p < 0.001). In adjusted analysis, 30-day mortality was greatest in patients who were confirmed to have COVID-19 (odds ratio (OR) 5.64, 95% confidence interval (CI) 2.95 to 10.80; p < 0.001) with an adjusted excess risk of 20%, male sex (OR 2.69, 95% CI 1.37 to 5.29; p = 0.004) and in patients with ≥ two comorbidities (OR 4.68, CI 1.5 to 14.61; p = 0.008). Length of stay was also extended in the COVID-19 cohort, on average spending 17.6 days as an inpatient versus 12.04 days in the non-COVID-19 group (p < 0.001).

Conclusion

This study demonstrates that patients who sustain a neck of femur fracture in combination with COVID-19 diagnosis have a significantly higher risk of mortality than would be normally expected.Cite this article: Bone Joint Open 2020;1-11:697-705.

First year nursing students' perceptions of learning interpersonal communication skills in their paid work: A multi-site Australasian study

Nursing students are increasingly undertaking paid work while studying and most choose paid work in health care or hospitality. This paper is drawn from a larger sequential exploratory mixed-method study which examined the relationship between students working while studying nursing and the impact on academic performance. In this paper, we explored first year nursing students' perceptions of communication skills gained through paid work. Using a qualitative exploratory design, 50 first year commencing nursing students from four nursing schools (3 Australia; 1 New Zealand) were interviewed. Inductive thematic analysis was used which identified two themes: (i) recognising the value of learning interpersonal communication skills and; (ii)opportunities to develop effective interpersonal communication skills. Paid work provides interpersonal communication skills; active listening, being present and interacting while multi-tasking and emotion management. Undergraduate education providers need to recognise the benefits of paid work for students, including enhancing interpersonal skills.

On farm interventions to minimise Campylobacter spp. contamination in chicken

1. This review explores current and proposed on-farm interventions and assess the potential of these interventions against Campylobacter spp. 2. Interventions such as vaccination, feed/water-additives and, most importantly, consistent biosecurity, exhibit potential for the effective control of this pathogen and its dissemination within the food chain. 3. Due to the extensive diversity in the Campylobacter spp. genome and surface-expressed proteins, vaccination of poultry is not yet regarded as a completely effective strategy. 4. The acidification of drinking water through the addition of organic acids has been reported to decrease the risk of Campylobacter spp. colonisation in broiler flocks. Whilst this treatment alone will not completely protect birds, use of water acidification in combination with in-feed measures to further reduce the level of Campylobacter spp. colonisation in poultry may be an option meriting further exploration. 5. The use of varied types of feed supplements to reduce the intestinal population and shedding rate of Campylobacter spp. in poultry is an area of growing interest in the poultry industry. Such supplements include pro - and pre-biotics, organic acids, bacteriocins and bacteriophage, which may be added to feed and water. 6. From the literature, it is clear that a distinct, albeit not unexpected, difference between the performance of in-feed interventions exists when examined in vitro compared to those determined in in vivo studies. It is much more likely that pooling some of the discussed approaches in the in-feed tool kit will provide an answer. 7. Whilst on-farm biosecurity is essential to maintain a healthy flock and reduce disease transmission, even the most stringent biosecurity measures may not have sufficient, consistent and predictable effects in controlling Campylobacter spp. Furthermore, the combination of varied dietary approaches and improved biosecurity measures may synergistically improve control.

Safe management of surgical smoke in the age of COVID-19

Background

The COVID-19 global pandemic has resulted in a plethora of guidance and opinion from surgical societies. A controversial area concerns the safety of surgically created smoke and the perceived potential higher risk in laparoscopic surgery.

Methods

The limited published evidence was analysed in combination with expert opinion. A review was undertaken of the novel coronavirus with regards to its hazards within surgical smoke and the procedures that could mitigate the potential risks to healthcare staff.

Results

Using existing knowledge of surgical smoke, a theoretical risk of virus transmission exists. Best practice should consider the operating room set-up, patient movement and operating theatre equipment when producing a COVID-19 operating protocol. The choice of energy device can affect the smoke produced, and surgeons should manage the pneumoperitoneum meticulously during laparoscopic surgery. Devices to remove surgical smoke, including extractors, filters and non-filter devices, are discussed in detail.

Conclusion

There is not enough evidence to quantify the risks of COVID-19 transmission in surgical smoke. However, steps can be undertaken to manage the potential hazards. The advantages of minimally invasive surgery may not need to be sacrificed in the current crisis.

The type and amount of paid work while studying influence academic performance of first year nursing students: An inception cohort study

BACKGROUND

Working while engaging in tertiary studies can have potential benefits for students in developing their repertoire of employability skills, including teamwork, time management, customer service and interpersonal communication. Not unexpectedly engaging in excessive hours of work can have a detrimental effect on students' grades. Yet little is known about the impact of engaging in different types of paid work (nursing or non-nursing), and the amounts, on first year nursing students' academic performance across different nursing programs.

OBJECTIVES

The aim of this study was to examine the association between: a) amount; and b) type of term-time weekly paid work, particularly its effect on academic performance, among commencing undergraduate students in the first semester of nursing studies across different nursing programs.

DESIGN

Inception cohort study.

SETTINGS

Four tertiary institutes across Australia and New Zealand.

PARTICIPANTS

All commencing Bachelor of Nursing students attending Orientation sessions at their respective institutes were invited to participate in the study. The median age of participants was 23 years, the majority (87.5%) were female and nearly two-thirds were non-school leavers. Among those in paid work, the median hours worked was 20 h.

METHODS

A baseline survey, completed by consenting students at the start of their Orientation session included items related to respondents' demographic data, self-reported paid work engagement (type and hours); we also requested their permission to link grade point average (academic performance data) at the end of first semester. Data were analysed using SPSS Version 25.

RESULTS

A total of 1314 students completed the survey and 89% of survey respondents agreed for their survey to be linked to academic grades at the end of the semester. There was an inverse relationship between time spent in weekly paid work and academic performance. Additionally, three predictors emerged as statistically significant for high grade point average: (i) engaging in non-nursing related work (AOR: 1.64, 95% CI: 1.19-2.26); (ii) not being first in family to attend university (AOR: 1.57, 95% CI: 1.20-2.07) and; (iii) being a school-leaver (AOR: 1.49, 95% CI: 1.12-1.98).

CONCLUSIONS

Despite the diversity among undergraduate nursing students studying across Australasia, it is evident that the amount and type of paid work engagement can impact on students' academic performance while studying. This underscores the importance for tertiary institutes to not only support students in their learning but also understand the need to achieve the right balance, in working while studying, to support students' academic success.

"Juggling many balls": Working and studying among first-year nursing students

AIMS AND OBJECTIVES

To explore the experiences of first-year nursing students, their motivations for working and how they juggled study and other commitments while engaging in paid work.

BACKGROUND

There has been a global rise in the number of students balancing full-time study, paid work and other commitments, with the main antecedent financial reasons.

DESIGN

Qualitative exploratory study.

METHODS

Drawn from a larger Australasian sequential exploratory mixed-method study, this qualitative study was conducted with fifty first-year undergraduate nursing and midwifery students who commenced their nursing studies in 2017. Telephone or face-to-face interviews were conducted with purposively selected students engaged in either nursing or non-nursing fields of work. Interviews were conducted from April-July 2017. Interviews lasted from 15-40 min. Results were thematically analysed. EQUATOR guidelines for qualitative research (COREQ) applied.

FINDINGS

Two main themes and accompanying subthemes were identified. The first theme explored students' motivation behind combining work and study and identified the need for financial security and "me time". The second theme "Juggling many balls" provided insights into the benefits students perceived, how they kept the "balls" in the air and at times dropped "balls" while balancing work, study and other commitments.

CONCLUSIONS

The motivation behind paid work was mainly financial; however, students also reported work allowed an escape and time for self which had social and health benefits. Working provided a range of positive benefits, including a sense of achievement, improved self-esteem and financial independence.

RELEVANCE TO CLINICAL PRACTICE

Being able to juggle and multi-task improved skills such as organisation and the ability to prioritise, all skills that have applicability for the role as registered nurse.

The association between obstructive sleep apnea and metabolic abnormalities in women with polycystic ovary syndrome: a systematic review and meta-analysis

Study Objectives

In this systematic review and meta-analysis, we aimed to examine the relationship between obstructive sleep apnea (OSA) and metabolic abnormalities in women with polycystic ovary syndrome (PCOS).

Methods

Electronic databases (Medline, Embase, Cinahl, PsycInfo, Scopus, Web of Science, Opengrey, and CENTRAL), conference abstracts, and reference lists of relevant articles were searched. No restriction was applied for language or publication status.

Results

Six studies involving 252 participants were included. Women with PCOS and OSA had significantly higher body mass index (mean difference [MD]: 6.01 kg/m2, 95% confidence intervals [CI]: 4.69-7.33), waist circumference (MD: 10.93 cm, 95% CI: 8.03-13.83), insulin resistance, systolic and diastolic blood pressure, and worse lipids' profile and impaired glucose regulation compared with women with PCOS without OSA. Most studies did not adjust for weight in their between-groups analysis. Total and free testosterone levels were not significantly different between the two groups. The majority of studies were found to be at high risk of selection bias, did not account for important confounders, were conducted in one country (United States), and used different methodologies to assess testosterone levels (preventing a meta-analysis for this specific outcome).

Conclusions

OSA is associated with obesity and worse metabolic profiles in women with PCOS. However, whether the effects of OSA are independent of obesity remain unclear. As OSA is a treatable condition, research focused on the independent effects of OSA on key clinical outcomes in women with PCOS, including fertility, psychological health, type 2 diabetes, and cardiovascular risk, is lacking and needed. PROSPERO registration number: CRD42016048587.

Understanding the enrolled nurse to registered nurse journey through a model adapted from Schlossberg's transition theory

BACKGROUND

Substantial numbers of Enrolled Nurses (ENs) enrol in higher education programs to undergo the transition to Registered Nurse (RN) with the experience described as containing numerous challenges.

OBJECTIVES

This paper reports on a synthesis of the literature that explores the experiences of ENs undertaking a program of study to convert to RN. Consequently, a model is developed to identify educational interventions and resources to enable a successful transition for these students.

DESIGN

A narrative review was completed with thematic synthesis of the literature guided by Schlossberg's Transition Theory, and Thomas and Harden's framework for systematic analysis of qualitative studies.

DATA SOURCES

CINAHL, Scopus, ProQuest Central and Health Collection were searched.

REVIEW METHODS

The databases were searched for English language journal articles, theses and grey literature published from 1987 to 2016 from Australia, New Zealand, the United Kingdom, Canada and the USA. The key search words included truncations of: "enrolled nurse", 'licensed practical nurse', "transition", "conversion" and "experience". This resulted in the identification of 33 related articles for review.

RESULTS

Themes and sub-themes developed from the literature synthesis were integrated into an 'EN to RN Transition model.' The four stages of the model reflect the experiences of the ENs as they overcame the various challenges they encountered during their transition to RN. The model was used to develop recommendations that may improve their transition experience and decrease attrition.

CONCLUSION

This paper reports on a synthesis of the literature, and presents a four stage model, that reflects the experiences of ENs in their transition to RN. Recognising the elements within each stage can assist educators develop strategies and provide educational resources to enhance the EN journey.

Understanding perceptions of nursing professional identity in students entering an Australian undergraduate nursing degree

Developing a professional identity is an essential transition for nursing students as they move through their undergraduate degree. Professional identity is described as a person's perception of themselves within a profession or the collective identity of the profession. The formation of a professional identity is an evolving process, shaped by the media, educational experiences and role modelling. The aim of this study was to develop a greater understanding of the perceptions that students, about to embark on their undergraduate nursing degree, had of the nursing profession. A drawing and mind mapping exercise was conducted with a convenience sample of commencing nursing students to explore how they viewed their future profession. The data underwent thematic analysis and then grouped into sub-themes and themes. Four key themes were identified, 'To be a nurse, I have to look the part', 'To be a nurse, I have to perform in a variety of roles', 'To be a nurse, I have to connect with others', and 'To be a nurse, I have to care for myself.' The formation of a strong pre-professional identity is important for nursing students due to the link between future job satisfaction and the development of a robust nursing workforce.

UK FASHIoN: feasibility study of a randomised controlled trial of arthroscopic surgery for hip impingement compared with best conservative care

BACKGROUND

Femoroacetabular impingement (FAI) is a syndrome of hip or groin pain associated with shape abnormalities of the hip joint. Treatments include arthroscopic surgery and conservative care. This study explored the feasibility of a randomised controlled trial to compare these treatments.

OBJECTIVES

The objectives of this study were to estimate the number of patients available for a full randomised controlled trial (RCT); to explore clinician and patient willingness to participate in such a RCT; to develop consensus on eligibility criteria, surgical and best conservative care protocols; to examine possible outcome measures and estimate the sample size for a full RCT; and to develop trial procedures and estimate recruitment and follow-up rates.

METHODS

Pre-pilot work: we surveyed all UK NHS hospital trusts (n = 197) to identify all FAI surgeons and to estimate how much arthroscopic FAI surgery they performed. We interviewed a purposive sample of 18 patients, 36 physiotherapists, 18 surgeons and two sports physicians to explore attitudes towards a RCT and used consensus-building methods among them to develop treatment protocols and patient information. Pilot RCT: we performed a pilot RCT in 10 hospital trusts. Patients were randomised to receive either hip arthroscopy or best conservative care and then followed up at 3, 6 and 12 months using patient-reported questionnaires for hip pain and function, activity level, quality of life, and a resource-use questionnaire. Qualitative recruitment intervention: we performed semistructured interviews with all researchers and clinicians involved in the pilot RCT in eight hospital trusts and recorded and analysed diagnostic and recruitment consultations with eligible patients.

RESULTS

We identified 120 surgeons who reported treating at least 1908 patients with FAI by hip arthroscopy in the NHS in the financial year 2011/12. There were 34 hospital trusts that performed ≥ 20 arthroscopic FAI operations in the year. We found that clinicians were positive about a RCT: only half reported equipoise, but most said that they would be prepared to randomise patients. Patients strongly supported a RCT, but expressed concerns about its design; these were used to develop patient information for the pilot RCT. We developed a surgical protocol and showed that this could be used in a RCT. We developed a physiotherapy-led exercise-based package of best conservative care called 'personalised hip therapy' and showed that this was practicable. In the pilot RCT, we recruited 42 out of 60 eligible patients (70%) across nine sites. The mean duration and recruitment rate across all sites were 4.5 months and one patient per site per month, respectively. The lead site recruited for the longest period (9.3 months) and accrued the largest number of patients (2.1 patients per month). We recorded and analysed 84 diagnostic and recruitment consultations in 60 patients and used these to develop a model for an optimal recruitment consultation. We identified the International Hip Outcome Tool at 12 months as an appropriate outcome measure and estimated the sample size for a full trial as 344 participants: a number that could be recruited in 25 centres over 18 months.

CONCLUSION

We have demonstrated that it is feasible to perform a RCT to establish the clinical effectiveness of hip arthroscopy compared with best conservative care for FAI. We have designed a full trial and developed and tested procedures for it, including an innovative approach to recruitment. We propose that a full trial be implemented.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

On compressible and piezo-viscous flow in thin porous media

In this paper, we study flow through thin porous media as in, e.g. seals or fractures. It is often useful to know the permeability of such systems. In the context of incompressible and iso-viscous fluids, the permeability is the constant of proportionality relating the total flow through the media to the pressure drop. In this work, we show that it is also relevant to define a constant permeability when compressible and/or piezo-viscous fluids are considered. More precisely, we show that the corresponding nonlinear equation describing the flow of any compressible and piezo-viscous fluid can be transformed into a single linear equation. Indeed, this linear equation is the same as the one describing the flow of an incompressible and iso-viscous fluid. By this transformation, the total flow can be expressed as the product of the permeability and a nonlinear function of pressure, which represents a generalized pressure drop.

A stochastic two-scale model for pressure-driven flow between rough surfaces

Seal surface topography typically consists of global-scale geometric features as well as local-scale roughness details and homogenization-based approaches are, therefore, readily applied. These provide for resolving the global scale (large domain) with a relatively coarse mesh, while resolving the local scale (small domain) in high detail. As the total flow decreases, however, the flow pattern becomes tortuous and this requires a larger local-scale domain to obtain a converged solution. Therefore, a classical homogenization-based approach might not be feasible for simulation of very small flows. In order to study small flows, a model allowing feasibly-sized local domains, for really small flow rates, is developed. Realization was made possible by coupling the two scales with a stochastic element. Results from numerical experiments, show that the present model is in better agreement with the direct deterministic one than the conventional homogenization type of model, both quantitatively in terms of flow rate and qualitatively in reflecting the flow pattern.

A new simple six-step model to promote recruitment to RCTs was developed and successfully implemented

OBJECTIVES

How a randomized controlled trial (RCT) is explained to patients is a key determinant of recruitment to that trial. This study developed and implemented a simple six-step model to fully inform patients and to support them in deciding whether to take part or not.

STUDY DESIGN AND SETTING

Ninety-two consultations with 60 new patients were recorded and analyzed during a pilot RCT comparing surgical and nonsurgical interventions for hip impingement. Recordings were analyzed using techniques of thematic analysis and focused conversation analysis.

RESULTS

Early findings supported the development of a simple six-step model to provide a framework for good recruitment practice. Model steps are as follows: (1) explain the condition, (2) reassure patients about receiving treatment, (3) establish uncertainty, (4) explain the study purpose, (5) give a balanced view of treatments, and (6) Explain study procedures. There are also two elements throughout the consultation: (1) responding to patients' concerns and (2) showing confidence. The pilot study was successful, with 70% (n = 60) of patients approached across nine centers agreeing to take part in the RCT, so that the full-scale trial was funded.

CONCLUSION

The six-step model provides a promising framework for successful recruitment to RCTs. Further testing of the model is now required.

Poor mental health in severely obese patients is not explained by the presence of comorbidities

The prevalence of obesity, especially severe obesity where body mass index (BMI) exceeds 40 kg m(-2) and where the physical risks are greatest, is increasing. However, little is known about the impact of severe obesity on psychological well-being and self-rated health (SRH). We aimed to investigate this relationship in patients attending an Irish weight management clinic. SRH was measured with a single-item inventory (excellent = 1, poor = 5). Well-being was measured with the validated World Health Organization-Five Well-being Index (WHO-5), in which scores <13 indicate poor well-being. Previous studies of the Irish population have reported mean SRH = 2.56 (males) and 2.53 (females) and mean well-being = 16.96. One hundred eighty-two (46.8%) completed questionnaires were returned. The sample was representative of the clinic population with a mean age of 47.1, mean baseline BMI of 51.9 kg m(-2) and 64.3% females. Mean SRH was 3.73 in males and 3.30 in females; mean well-being was 10.27 in males and 10.52 in females. In the final multivariable models, number of medications, depression and obstructive sleep apnoea, WHO-5 and current BMI were significant predictors of SRH, and secondary level education, social support and mindfulness scores were significant predictors of psychological well-being. Number of medications was not significant. The results suggest that the poor psychological well-being seen is not explained by the presence of comorbidities and that social support and mindfulness may be important targets for improving psychological well-being. Improving psychological well-being in addition to weight loss and effective management of comorbidities may be important for improving SRH.

Asymptotic behaviour of Stokes flow in a thin domain with a moving rough boundary

We consider a problem that models fluid flow in a thin domain bounded by two surfaces. One of the surfaces is rough and moving, whereas the other is flat and stationary. The problem involves two small parameters ϵ and μ that describe film thickness and roughness wavelength, respectively. Depending on the ratio λ=ϵ/μ, three different flow regimes are obtained in the limit as both of them tend to zero. Time-dependent equations of Reynolds type are obtained in all three cases (Stokes roughness, Reynolds roughness and high-frequency roughness regime). The derivations of the limiting equations are based on formal expansions in the parameters ϵ and μ.

Hip pain in young adults

BACKGROUND

Traditionally, the management of hip pain has been well defined by age groups such as the limping child and older patients with symptomatic osteoarthritis (OA). However, young adults (typically aged 16-50 years) with persistent hip pain who do not have OA or a childhood hip disorder have presented a diagnostic challenge and their management less well defined.

OBJECTIVE

We present a clinical review intended as a guide for general practitioners to aid the identification of such patients through focused history taking and examination. We outline the primary care management and provide guidance on when to refer.

DISCUSSION

Our understanding of the causes of hip pain in young adults has increased significantly over the last decade. This has led to the recognition that subtle hip shape abnormalities, termed femoroacetabular impingement, can cause symptomatic soft tissue damage and may initiate OA. This is important as it now raises the possibility of identifying and treating young adults with pre-arthritic symptoms (the 'at-risk' hip).

High concordance between expert anaesthetists' actions and advice of decision support system in achieving oxygen delivery targets in high-risk surgery patients

BACKGROUND

Goal-directed therapy has a secure place in perioperative care. Algorithms are based on Starling's law of the heart, notwithstanding that this does not numerically define volume or heart performance variables. These have been developed based on a Guytonian view of the circulation and are implemented in a computerized decision support system (Navigator™). We studied the feasibility and performance of the graphical display of the system in an intervention and a control group of patients undergoing major abdominal surgery.

METHODS

Patients were randomized to either graphically (intervention) or numerically (control) guided administration of therapy. Goals were set and treatments and concordance with guidance noted, where applicable. Anaesthesia was provided by one of three experienced anaesthetists well acquainted with Navigator™. The primary objective was to determine whether the use of graphical display decision support more efficiently enables the achievement of oxygen delivery targets. This was quantitated as percentage time in the target zone and averaged standardized distance from the target centre.

RESULTS

The mean percentage time in the target zone was 36.7% for control and 36.5% for intervention. The averaged standardized difference was 1.5 in control and 1.6 in intervention. There was no significant difference in fluid balances. There was a high level of concordance between decision support recommendation and anaesthetist action (84.3%).

CONCLUSIONS

In experienced hands, the addition of a graphical display for haemodynamic guidance resulted in a similar time in target and averaged standardized difference. The haemodynamic guidance system should be explored in a comparative study to anaesthesia management without guidance.

Is a fracture of the transverse process of L5 a predictor of pelvic fracture instability?

In the management of a pelvic fracture prompt recognition of an unstable fracture pattern is important in reducing mortality and morbidity. It is believed that a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. However, there is little evidence in the literature to support this view. The aim of this study was to determine whether a fracture of the transverse process of L5 is a reliable predictor of pelvic fracture instability. We reviewed our hospital trauma database and identified 80 patients who sustained a pelvic fracture between 2006 and 2010. There were 32 women and 48 men with a mean age of 40 years (10 to 96). Most patients were injured in a road traffic accident or as a result of a fall from a height. A total of 41 patients (51%) had associated injuries. The pelvic fractures were categorised according to the Burgess and Young classification. There were 45 stable and 35 unstable fractures. An associated fracture of the transverse process of L5 was present in 17 patients; 14 (40%) of whom had an unstable fracture pattern. The odds ratio for an unstable fracture of the pelvis in the presence of a fracture of the transverse process of L5 was 9.3 and the relative risk was 2.5. A fracture of the transverse process of L5 in the presence of a pelvic fracture is associated with an increased risk of instability of the pelvic fracture. Its presence should alert the attending staff to this possibility.

Social capital and self-rated health in the Republic of Ireland: evidence from the European Social survey

This paper analyses the determinants of self-reported health in Ireland, conditioning self-reported health on a set of socio-economic, labour market and social capital variables. Ireland has the highest self-reported health rate in Europe, a finding backed-up by other studies. Data were derived from the 2002 and 2005 European Social survey. The full 87,915 observations from both rounds were pooled and used to estimate mean self-rated health across Europe. The Irish data were isolated, totalling 2,049 individuals for 2002 and 2,286 individuals for 2005. The 2002 data were used to analyse the determinants of subjective health state, as it had a richer array of social capital variables. The results demonstrate statistically significant effects of income on self-reported health that are robust to different statistical specifications and statistically significant though modest effects of social capital variables such as associational membership and frequency of social meeting and labour market variables such as being on a limited as opposed to permanent contract.

Proof of concept percutaneous treatment system to enable fast and finely controlled ablation of biological tissue

A prototype system has been developed for producing controllable ablation of spherical lesions with a diameter of up to 2 cm. The system is based on a solid-state energy source operating in the super high frequency (SHF is defined as being a frequency of between 3 and 30 GHz) region of the electromagnetic spectrum. Results obtained from preliminary tissue testing, performed on morbid tissue samples prepared in a laboratory environment, show repeatability in terms of shape and size of ablation, and demonstrate the ability to produce controlled ablation in morbid liver and kidney models.

Sensitization to the neuroendocrine, central monoamine and behavioural effects of murine tumor necrosis factor-alpha: peripheral and central mechanisms

Systemic administration of murine tumour necrosis factor-alpha (mTNF-alpha; 0.1-2.0 microg, i.p.) dose-dependently increased plasma corticosterone and augmented monoamine utilization within the paraventricular nucleus of the hypothalamus (PVN), locus coeruleus, medial prefrontal cortex (PFC), central and medial amygdala. A time-dependent sensitization was induced in mice, wherein reexposure to mTNF-alpha 28 days (but not 1 day) following the initial cytokine treatment provoked marked signs of illness (diminished activity, ptosis, piloerection) and increased plasma corticosterone levels. Serotonin (5-HT) activity was augmented upon mTNF-alpha reexposure at the 1- or 28-day intervals in the PFC and medial amygdala, respectively. Intracerebroventricular (i.c.v.; 1-500 ng) mTNF-alpha did not promote illness, but modestly increased plasma corticosterone levels. Neither the illness nor the corticosterone changes were subject to a sensitization upon i.c.v. cytokine reexposure. Acute i.c.v. mTNF-alpha increased norepinephrine (NE), 5-HT and dopamine (DA) activity within the PVN and median eminence/arcuate nucleus complex (ME/ARC), and NE utilization within the central amygdala. Subsequent i.c.v. mTNF-alpha further enhanced the hypothalamic monoamine variations. Finally, systemic (i.p.) mTNF-alpha pretreatment did not proactively influence sickness or corticosterone responses upon later i.c.v. cytokine challenge, but augmented locus coeruleus NE activity and 5-HT and DA utilization within the ME/ARC. It is suggested that the sensitization with respect to sickness and corticosterone activity in response to mTNF-alpha reflect the involvement of peripheral mechanisms. Moreover, it appears that mTNF-alpha promotes central neurochemical plasticity through independent central and peripheral mechanisms.

Analysis of outbreaks of infectious intestinal disease in Ireland: 1998 and 1999

Surveillance of general outbreaks of infectious gastroenteritis was introduced in 1998 by the Food Safety Authority of Ireland (FSAI), in co-operation with the eight health boards. A total of 67 general outbreaks of gastroenteritis in Ireland were reported to the FSAI in 1998 and 1999. Over 1900 people were ill as a result of these outbreaks. Four percent required hospitalisation and there were two deaths. The duration of the outbreaks varied between one day and 38 days. Salmonellae (44%) and small round structured viruses (SRSV) (12%) were the most commonly reported pathogens. In 25% of the outbreaks the aetiology was unknown. The commonest settings were restaurants, hotels and take-aways, which accounted for 45% (30/67) of all outbreaks. Sixteen percent of all outbreaks occurred in hospitals and residential institutions. Over half of the outbreaks were reported to be foodborne, 63% of which were due to various serotypes of Salmonella enterica. Eggs were implicated as the vehicle of infection in 13% of all outbreaks. An infected food handler was identified in almost one third of outbreaks, although it could not be established if this had contributed directly to the outbreak.

Monitoring gastrointestinal intraluminal PCO2: problems with airflow methods

Gastrointestinal intraluminal PCO2 (PiCO2) information is used to assess the adequacy of trauma patient resuscitation and to assist in choosing resuscitative interventions. Therefore, determining the limitations and potential caveats of different PiCO2 monitoring systems is clinically important. This study compared two PCO2 monitoring systems. The airflow device adds and then removes air samples to quantitate PCO2, whereas the fiber-optic device does not.

METHODS

Airflow (TRIP Tonometer/Tonocap) and fiber-optic (Neotrend) systems were used. In vitro they were compared with each other and to two end-tidal CO2 monitors measuring the PCO2 of humidified air containing 5% and then 10% CO2. In vivo the two systems' catheters were surgically juxtaposed in 15 dogs' stomachs; paired PiCO2 readings were taken throughout hemorrhage and resuscitation.

RESULTS

In vitro, paired PCO2 values from the airflow and fiber-optic devices correlated with each other (r = 0.99) and with end-tidal values (r = 0.99 with airflow, r = 0.95 with fiber-optic). In vivo, paired values differed significantly (P < 0.0001), correlating poorly for two devices simultaneously measuring the same variable (r = 0.61). Fiber-optic PiCO2 values were higher than airflow values (mmHg +/- SEM): 69.3 +/- 4.8 vs. 61.3 +/- 5.6 at the start of hemorrhage, 141.3 +/- 12.9 vs. 87.7 +/- 7.9 by end of hemorrhage, and 104.3 +/- 9.6 vs. 82.8 +/- 7.0 by end of resuscitation for fiber-optic and airflow, respectively.

CONCLUSIONS

Despite agreement in vitro, airflow methods can influence PiCO2 values obtained in vivo. Passive sensing methods used to monitor PiCO2, such as fiber-optic methods, are preferable because they neither deliver O2 to, nor remove CO2 from the local microenvironment.

An international outbreak of Vero cytotoxin-producing Escherichia coli O157 infection amongst tourists; a challenge for the European infectious disease surveillance network

In March 1997, an outbreak of Vero cytotoxin-producing Escherichia coli O157 (VTEC) infection occurred amongst holidaymakers returning from Fuerteventura, Canary Islands. For the investigation, a confirmed case was an individual staying in Fuerteventura during March 1997, with either E. coli O157 VTEC isolated in stool, HUS or serological evidence of recent infection; a probable case was an individual with bloody diarrhoea without laboratory confirmation. Local and Europe-wide active case finding was undertaken through national centres, Salm-Net and the European Programme of Intervention Epidemiology, followed by a case-control study. Fourteen confirmed and one probable case were identified from England (7), Finland (5), Wales (1), Sweden (1) and Denmark (1) staying in four hotels. Three of the four hotels were supplied with water from a private well which appeared to be the probable vehicle of transmission. The case-control study showed illness was associated with consumption of raw vegetables (OR 8.4, 95% CI 1-5-48.2) which may have been washed in well water. This investigation shows the importance of international collaboration in the detection and investigation of clusters of enteric infection.

Cerebral near infrared spectroscopy: emitter-detector separation must be increased

We have compared the effect of increasing optode separation (range 0.7-5.5 cm) on the sensitivity of near infrared spectroscopy (NIRS) to discrete reductions in scalp and cerebral oxygenation in 10 healthy men (mean age 32, range 26-39 yr) using multichannel NIRS. During cerebral oligaemia (a mean reduction in middle cerebral artery flow velocity of 47%) induced by a mean reduction in end-tidal PCO2 of 2.4 kPa, the decrease in oxyhaemoglobin detected by NIRS became significantly greater with increasing optode separation (P < 0.0001). In response to scalp hyperaemia induced by inflation and release of a pneumatic scalp tourniquet, increases in oxyhaemoglobin became significantly smaller with increasing optode separation (P < 0.0002). These results are consistent with theoretical models of the behaviour of NIR light in the adult head and support the concept of using multi-detector NIRS to separate intra- and extracranial NIR signal changes. However, the emitter-detector separation used by currently available cerebral oximeters is not large enough to provide optimal spatial resolution.

An estimate of the proportion of diarrhoeal disease episodes seen by general practitioners attributable to rotavirus in children under 5 y of age in England and Wales

Mean weekly incidence rates for a 4-week period of new episodes of infectious intestinal disease (IID) and laboratory reports of faecal isolations in children under 5 y of age presenting in general practice were used to estimate the incidence of IID due to rotavirus infection in England and Wales. Between January 1992 and December 1996, a total of 92452 new episodes of IID were seen at sentinel general practices and reported to the Royal College of General Practitioners (RCGP) Research Unit in Birmingham, UK. Of these 32% (29592) were in children under 5 y of age. During the same period the Communicable Disease Surveillance Centre (CDSC) in London, UK received 159532 reports of faecal identifications in children under 5 y of age; 69219 (43%) of these were due to rotavirus. By modelling RCGP data and laboratory reports, the proportion of episodes attributable to rotavirus infection was estimated to be 29% (95% CI: 24% to 34%). By extrapolation of RCGP data it was estimated that rotavirus accounted for 762000 of new episodes of IID nationally in children under 5 y of age between January 1992 and December 1996. Implementation of a rotavirus vaccination programme could substantially reduce the incidence of childhood diarrhoea.

Sensitivity of near infrared spectroscopy to cerebral and extra-cerebral oxygenation changes is determined by emitter-detector separation

OBJECTIVE

To examine the effect of two emitter-detector separations (2.7 and 5.5 cm) on the detection of changes in cerebral and extra-cerebral tissue oxygenation using near infrared spectroscopy (NIRS).

METHODS

Two NIR detectors were placed on the scalp 2.7 and 5.5 cm from a single NIR emitter. Changes in deoxyhaemoglobin (HHb), oxyhaemoglobin (O2Hb),oxidised cytochrome C oxidase (Cyt) and total haemoglobin (tHb) were recorded from each detector during the induction of cerebral oligaemia (transition from hypercapnia to hypocapnia) and scalp hyperaemia (following release of a scalp tourniquet).

RESULTS

Cerebral oligaemia (mean decrease in middle cerebral artery blood flow velocity of 44%) induced by a mean reduction in end tidal CO2 of 18 mmHg was accompanied by a significant increase in the spectroscopic signal for HHb and a decrease in the O2Hb signal. The signal change per unit photon path length detected at 5.5 cm was significantly greater for HHb (p = 0.007) than that detected at 2.7 cm. In contrast, the increase in all chromophores detected at 5.5 cm during scalp hyperaemia was significantly less than that detected at 2.7 cm (p<0.001).

CONCLUSIONS

The differing sensitivity of the proximal and distal channels to changes in cerebral and extracerebral oxygenation is compatible with theoretical models of NIR light transmission in the adult head and may provide a basis for spatially resolving these changes. The optimal emitter-detector separation for adult NIRS requires further investigation and may differ between individuals.

Diagnostic delay in breast disease: a system analysis of a public urban hospital

OBJECTIVE

To analyze the diagnostic process in 146 women referred to a breast clinic in an urban setting between January 1, 1994, and December 31, 1996.

DESIGN

We devised the "diagnostic delay index (DDI)," defined as the time between the medical system's awareness of a diagnostic need and the completion of the diagnostic process. The time awaiting breast clinic consultation and the diagnostic events experienced--including clinic visits, imaging studies, and biopsies--were recorded. We stratified patients in 2 pathways (palpable masses and mammogram-identified lesions) and by benign or malignant outcome.

RESULTS

Patients in pathways 1 (n = 85) and 2 (n=61) had a mean (+/-SD) DDI of 68.4 (+/-46.9) days and 71.9 (+/-35.2) days, respectively. Patients in both pathways who had a malignant outcome had a significantly lower DDI than those who had a benign outcome (47.5+/-30.9 days vs 78.6+/-42.6) (P<.001); this advantage was most pronounced in patients with palpable lumps. The average patient waited more than 3 weeks for both an initial clinic consultation and operating room access. Quartile analysis of the DDI revealed statistically significant differences in clinic access time, number of visits, diagnostic events per visit, and operating room access time. Regression analysis demonstrates the relationship between DDI and measured process variables: DDI= -21.11+0.09 age+1.86 pathway-12.18 outcome+1.08 clinic access+11.91 visits+0.94 operating room access (R2=61.5%).

CONCLUSIONS

In a public hospital, diagnostic delay is related to inadequate access to surgical consultation and a delay in operating room access. Regression analysis demonstrates the relationships between these components of system diagnostic delay and suggests strategies for reducing the DDI.

Changes in tissue oxyhaemoglobin concentration measured using multichannel near infrared spectroscopy during internal carotid angiography

OBJECTIVE

To develop an in vivo model for testing spatially resolved spectroscopy and quantified near infrared spectroscopy (NIRS) cerebral blood flow measurements.

METHOD

Multiple detector NIRS has been used to study changes in tissue oxyhaemoglobin (O2Hb) concentration during selective internal carotid angiography. A significant reduction in O2Hb occurred in tissue interrogated by detectors situated between 0.7 and 4.1 cm from the NIRS light source.

RESULTS

The time course of O2Hb concentration change was consistent with displacement of oxygenated blood by the radiocontrast medium from vascular beds of differing flow and NIR light attenuation. Increasing changes in O2Hb concentration per unit photon path length--predicted to occur at greater emitter-detector separations if those changes had occurred predominantly in cerebral tissue--were found in the first four seconds after injection of radiocontrast medium. However, later changes (6-10 s) were larger and were not proportional to emitter-detector separation.

CONCLUSION

The findings indicate that simple assumptions regarding the distribution of the internal carotid artery blood supply to cerebral and extracerebral tissues, the photon path length through those tissues, and their relative contributions to attenuation of NIR light may not be justified.