bluuebunny/crossref_metadata_2025 huggingface dataset:
Lithotripter shock waves are capable of damage at sub-cellular dimensions in the absence of cavitation
Authors: Williams James C. , Rietjens Drew L. , Zarse Chad A. , McAteer James A.
Published: February 2014

Lithotripter shock waves (SW’s) cause tissue damage, but the size dimension of the SW-tissue interaction is not known. Unilamellar membrane vesicles were used as a model for subcellular organelles, and SW-induced damage was quantitated with and without cavitation. Membrane vesicles (≊100 nm diameter) were made by extrusion from egg phosphatidylcholine, and exposed to SW’s (1 Hz and 20 kV) in a research lithotripter that yields output similar to an unmodified Dornier HM3. SW-dependent vesicle lysis was linearly dependent on SW number (p<0.001), with a mean lysis of 0.12±0.02% at 400 SW’s (n=49 vials). This lysis value is >100 times less than that seen in red blood cells exposed to a similar SW dose. Vesicle lysis was independent of kV in the range tested (17–23 kV, p>0.9, n=14 vials). When vesicles were exposed to SW’s in the presence of high overpressure (>130 atm) to eliminate cavitation effects, SW’s still induced lysis not different from that at atmospheric pressure, 0.10±0.02% (n=10). This implies that lithotripter shock waves may be capable of causing intracellular damage to tissue even in regions where cavitation does not occur. [Work supported by NIH Grants P01 DK43881 and R01 DK55674.]
Combined shock wave and immunotherapy of mouse melanoma tumors
Authors: Miller Douglas , Song Jianming , Li Lang , Taylor Jeremy , Bao Shiping , Tata Darrell
Published: February 2014

The effect of lithotripter shock waves (SWs) and interleukin-12 (IL12) treatment on the growth of B16 melanoma was investigated. Tumor cells were implanted and grown for 10 days on the hind legs of C57/Bl mice. Prior to treatment, mice were anesthetized, the tumor region was shaved, and air and phosphate buffered saline (PBS) were injected into the tumor at 10% of tumor volume each. Shock-wave treatment consisted of 500 shock waves (7.4-MPa peak negative pressure) from a spark-gap lithotripter. IL12 treatment consisted of 500 ng in the initial PBS injection, and additional injections 2 days and 4 days later. Tumor volume was measured every other day and tumor growth was statistically modeled. After 10 days, modeled volume increases, relative to the initial volumes in groups of six mice, were a factor of 17.8 for sham treatment, 7.8 for SWs, 3.6 for IL12, and 1.0 for combined SWs and IL12 (P<0.0001 relative to shams). The combined treatment significantly prolonged survival (0.09 relative risk of death versus sham) and one mouse had complete tumor remission. These results are encouraging for combined SW and immunotherapy treatment of tumors. [Work supported by NIH CA83904.]
Instability of a vortex sheet leaving a right-angled corner
Authors: Davis Anthony M. J. , Kerschen Edward J.
Published: February 2014

David Crighton had a long-standing interest in how the results of Orszag and Crow [Stud. Appl. Math. 49, 167–181 (1970)], for the instability of a vortex sheet leaving a zero-thickness trailing edge which separates a uniform stream from a fliud at rest, would be modified by creating a solid right-angled corner that restricts the stationary unperturbed flow to a quadrant. The Wiener–Hopf technique cannot be applied to this problem which, having wedge-shaped regions, is amenable to Mellin transforms. The matching conditions at the vortex sheet yield a pair of functional difference equations whose solution in terms of the Barnes double gamma function is achieved after doubling their order. Then, local series expansions valid near and far from the corner enable the appropriate pole structure to be identified and the arbitrary periodic functions to be determined. The results are applied to instability wave excitation by an acoustic wave incident on the trailing edge region.
Q-factor limit of nonlinear systems
Authors: Hedberg Claes M. , Rudenko Oleg V.
Published: February 2014

The Q factor of a resonator is a constant, which gives an estimation of its ‘‘quality.’’ A system with a high Q can accumulate high energy and provide markedly nonlinear phenomena even in the case of weak power sources. At small amplitudes Q is limited by linear absorption caused by both the medium inside the resonator and its boundaries. As the amplitude increases, nonlinear absorption and frequency response distortion come into play, and Q is determined by both system design and the acoustic field strength. In general, nonlinearity leads a to significant decrease in Q. One can enhance Q in different ways using impedance boundaries whose frequency-dependent response destroys shock fronts, a medium containing selective absorbers suppressing shock formation, resonators of special shape, or special types of excitation to counter the distortion. Data on nonlinear Q-factors and response taking into account dissipative and frequency-dependent properties of systems are presented.
Speech perception among good and poor readers
Authors: Eckhouse Erin , Wayland Ratree
Published: February 2014

A relationship between phonological awareness and reading ability among children has been suggested by some researchers. Several studies also suggested that phonological deficits among children are related to impairments in speech perception. The goal of this study is to examine the ability to discriminate and categorize various speech sounds by school-aged good and poor readers. Subjects were 30 third and fourth graders recruited from a local elementary school in Gainesville, Florida. Based on the school’s, as well as, the State of Florida’s standardized test, half of these subjects will be classified as good readers and the other half as poor readers. All subjects are native speakers of English. They were asked to perform five speech perception tasks. The first task ‘‘tug-dug,’’ examined subjects’ categorization of a VOT continuum ranging from 10–80 ms long. The second task, ‘‘spy-sky’’ was designed to test subjects’ ability to detect onset frequency of formant transitions. The last three tasks, ‘‘shop-chop,’’ examined the combined effect of a gap and fricative noise duration in the categorization of fricative–affricate continuum. A relationship between subjects’ speech perception and their reading ability as measured by several standardized tests will be explored and discussed.
Discrimination and identification of vowels in hearing-impaired and masked normal-hearing listeners
Authors: Davis Carrie , Kewley-Port Diane , Coughlin Maureen
Published: February 2014

This study examined the effects of mild-to-moderate sloping sensorineural hearing loss on vowel discrimination and identification. Five young, hearing-impaired (YHI) adults listened to vowel stimuli in three conditions: (a) at a conversational level with flat frequency response; and in two gain conditions, (b) at a high-sound level with flat frequency response; and (c) with frequency shaped gain according to the subject’s hearing loss. Listeners discriminated changes in the synthetic vowels /I ε e æ ʌ/ when F1 or F2 varied, and later identified the five vowels in a closed-set task. The results indicated that neither gain condition restored performance to that of young, normal-hearing listeners and that the potential upward spread of masking in condition (b) did not affect performance. Young, normal-hearing (YNH) listeners were age matched to YHI subjects. Hearing thresholds for the YNH listener of each YHI–YNH pair were precisely matched to those of the YHI listener by masking with spectrally shaped noise. YNH listeners with ‘‘simulated-hearing loss’’ were tested on the same discrimination and identification tasks. This design yields performance comparisons between YHI–YNH pairs when conditions of audibility are similar. The results will explain whether differences in performance between YHI–YNH pairs may be due to audibility or pathology. [Supported by NIHDCD–02229.]
Effect of spectrally and temporally altered auditory feedback on the speech of hard of hearing persons
Authors: Barac-Cikoja Dragana , Tamaki Chizuko , O’Brien Maureen , McIntosh Nancy
Published: February 2014

Nine participants with severe to profound hearing loss read a six-sentence passage under different auditory feedback conditions that included spectrally altered and/or delayed speech. Spectral smearing was implemented by filtering the speech signal into either one, two, or four frequency bands, extracting respective amplitude envelope(s), and amplitude-modulating the corresponding noise band(s). As the number of the filter bands decreased, the spectral information, and therefore the intelligibility of the resulting noise replicas of the speech signal, diminished. The three noise conditions and the unaltered speech were each tested under the simultaneous and four delayed (25, 50, 100, and 200 ms) feedback conditions. Auditory feedback was presented via insert earphones at the participant’s most comfortable listening level. Different measures of duration, intensity, and fundamental frequency (f0) were computed on individual sentences, and subjected to statistical analyses. Results indicate a differential effect of the two feedback manipulations on different acoustic parameters. Although speech delays affected duration and intensity measures the most, spectral smearing showed the most robust effect on f0 variability. Individual differences were significant. Auditory self-monitoring will be discussed as a function of hearing loss.
Acoustic analysis of the speech of adults with cochlear implants: A case study
Authors: Lowenstein Joanna H.
Published: February 2014

Most investigations that use post-lingually deafened adults with cochlear implants as their subjects focus on post-implant changes in perception. The primary acoustic research on the speech production of adult CI users consists of seven papers by Joseph Perkell’s research group at MIT (1992–1997). The authors argue that the Ineraid analog cochlear implant provides a sufficient degree of auditory feedback to affect vowel placement and duration, sibilant contrast, VOT and syllable duration, and fundamental frequency. Currently, most adults are implanted with multichannel digital implants, which provide a more complex signal and utilize more advanced speech processors. The greater frequency range and increased spectral detail should particularly affect vowel placement, stops, and intonation. This paper presents acoustic analysis of the speech of a post-lingually deafened adult with a Nucleus cochlear implant (pre-implant, 1-, 3-, and 6-month post-activation recordings). Articulatory changes that follow experience with a CI are characterized via acoustic analysis of vowel formants and duration; stop VOT, duration, and burst spectra; and F0 peaks and contours for sentences. Subject’s data are analyzed for individual longitudinal trends and implant effects. Subject trends are compared to those found in the MIT studies.
Use of partial stimulus information in spoken word recognition without auditory stimulation
Authors: Lachs Lorin , Pisoni David B.
Published: February 2014

The identification of isolated words in speech-reading environments is extremely prone to error. Many of these errors are due to the impoverished nature of spoken stimuli when the only perceptual information available is visual; some estimates place the number of visually discriminable segments at just over 25% of the number discriminable in auditory-only environments. Previous research has shown that the confusion of lipreaders is patterned with respect to the perceptual discriminability of phonetic segments in visual-only environments. In addition, other sources of information such as phonotactic, lexical, and semantic constraints can play a role in speech-reading performance. The current study examined the speech-reading responses generated by 200 normal hearing participants observing 300 isolated English words spoken by 10 talkers each. The responses were analyzed to determine if errors were random or patterned in a way that belies the use of partial information and lexical constraints during the process of visual-only spoken word recognition.
Demystifying Disease, Democratizing Health Care
Authors: Hood Leroy , Price Nathan D.
Published: February 2014

The health care community must join forces with patients to quantify wellness, define disease transitions, and reduce the cost of health care.
Swimming Against the Tide: Drugs Drive Neutrophil Reverse Migration
Authors: Lucas Christopher D. , Hoodless Laura J. , Rossi Adriano G.
Published: February 2014

Unbiased screens in transgenic zebrafish reveal drugs that resolve inflammation by driving reverse migration of neutrophils.
Carotid Stenting: What Have You Done for Me Lately?
Authors: Mack William J.
Published: February 2014

Patient outcomes after carotid stenting are associated with the number of recent procedures a surgeon has performed.
Growing Bigger in Kindergarten
Authors: Tirosh Amir
Published: February 2014

The highest incidence rate of childhood obesity occurs during kindergarten.
Cell-Type-Specific Effects of RNase L on Viral Induction of Beta Interferon
Authors: Banerjee Shuvojit , Chakrabarti Arindam , Jha Babal Kant , Weiss Susan R. , Silverman Robert H.
Published: February 2014

The interferon (IFN)-inducible antiviral state is mediated in part by the 2′,5′-oligoadenylate (2-5A) synthetase (OAS)/RNase L system. 2-5A, produced from ATP by OAS proteins in response to viral double-stranded RNA, binds to and activates RNase L. RNase L restricts viral infections by degrading viral and cellular RNA, inducing autophagy and apoptosis, and producing RNA degradation products that amplify production of type I interferons (IFNs) through RIG-I-like receptors. However, the effects of the OAS/RNase L pathway on IFN induction in different cell types that vary in basal levels of these proteins have not been previously reported. Here we report higher basal expression of both RNase L and OAS in mouse macrophages in comparison to mouse embryonic fibroblasts (MEFs). In MEFs, RNase L gene knockout decreased induction of IFN-β by encephalomyocarditis virus infection or poly(rI):poly(rC) (pIC) transfection. In contrast, in macrophages, RNase L deletion increased (rather than decreased) induction of IFN-β by virus or pIC. RNA damage from RNase L in virus-infected macrophages is likely responsible for reducing IFN-β production. Similarly, direct activation of RNase L by transfection with 2-5A induced IFN-β in MEFs but not in macrophages. Also, viral infection or pIC transfection caused RNase L-dependent apoptosis of macrophages but not of MEFs. Our results suggest that cell-type-specific differences in basal levels of OAS and RNase L are determinants of IFN-β induction that could affect tissue protection and survival during viral infections.

IMPORTANCE
Type I interferons (IFNs) such as IFN-β are essential antiviral cytokines that are often required for animal survival following infections by highly pathogenic viruses. Therefore, host factors that regulate type I IFN production are critically important for animal and human health. Previously we reported that the OAS/RNase L pathway amplifies antiviral innate immunity by enhancing IFN-β production in mouse embryonic fibroblasts and in virus-infected mice. Here we report that high basal levels of OAS/RNase L in macrophages reduce, rather than increase, virus induction of IFN-β. RNA damage and apoptosis caused by RNase L were the likely reasons for the decreased IFN-β production in virus-infected macrophages. Our studies suggest that during viral infections, the OAS/RNase L pathway can either enhance or suppress IFN production, depending on the cell type. IFN regulation by RNase L is suggested to contribute to tissue protection and survival during viral infections.
Single Clinical Isolates from Acute Uncomplicated Urinary Tract Infections Are Representative of Dominant
In Situ
Populations
Authors: Willner Dana , Low Serene , Steen Jason A. , George Narelle , Nimmo Graeme R. , Schembri Mark A. , Hugenholtz Philip
Published: February 2014

Urinary tract infections (UTIs) are one of the most commonly acquired bacterial infections in humans, and uropathogenic
Escherichia coli
strains are responsible for over 80% of all cases. The standard method for identification of uropathogens in clinical laboratories is cultivation, primarily using solid growth media under aerobic conditions, coupled with morphological and biochemical tests of typically a single isolate colony. However, these methods detect only culturable microorganisms, and characterization is phenotypic in nature. Here, we explored the genotypic identity of communities in acute uncomplicated UTIs from 50 individuals by using culture-independent amplicon pyrosequencing and whole-genome and metagenomic shotgun sequencing. Genus-level characterization of the UTI communities was achieved using the 16S rRNA gene (V8 region). Overall UTI community richness was very low in comparison to other human microbiomes. We strain-typed
Escherichia
-dominated UTIs using amplicon pyrosequencing of the fimbrial adhesin gene,
fimH
. There were nine highly abundant
fimH
types, and each UTI sample was dominated by a single type. Molecular analysis of the corresponding clinical isolates revealed that in the majority of cases the isolate was representative of the dominant taxon in the community at both the genus and the strain level. Shotgun sequencing was performed on a subset of eight
E. coli
urine UTI and isolate pairs. The majority of UTI microbial metagenomic sequences mapped to isolate genomes, confirming the results obtained using phylogenetic markers. We conclude that for the majority of acute uncomplicated
E. coli
-mediated UTIs, single cultured isolates are diagnostic of the infection.

IMPORTANCE
In clinical practice, the diagnosis and treatment of acute uncomplicated urinary tract infection (UTI) are based on analysis of a single bacterial isolate cultured from urine, and it is assumed that this isolate represents the dominant UTI pathogen. However, these methods detect only culturable bacteria, and the existence of multiple pathogens as well as strain diversity within a single infection is not examined. Here, we explored bacteria present in acute uncomplicated UTIs using culture-independent sequence-based methods.
Escherichia coli
was the most common organism identified, and analysis of
E. coli
dominant UTI samples and their paired clinical isolates revealed that in the majority of infections the cultured isolate was representative of the dominant taxon at both the genus and the strain level. Our data demonstrate that in most cases single cultured isolates are diagnostic of UTI and are consistent with the notion of bottlenecks that limit strain diversity during UTI pathogenesis.
Efficacy and Safety of Auriculopressure for Primary Care Patients with Chronic Non-Specific Spinal Pain: A Multicentre Randomised Controlled Trial
Authors: Vas Jorge , Modesto Manuela , Aguilar Inmaculada , Gonçalo Camila da Silva , Rivas-Ruiz Francisco
Published: February 2014

Background

Chronic uncomplicated musculoskeletal pain in the spine (cervical, thoracic or lumbar) is highly prevalent and may severely limit the daily activities of those affected by it.

Objective

To evaluate the efficacy and safety of treatment with auriculopressure applied to patients with non-specific spinal pain.

Methods

A multicentre randomised controlled trial with two parallel arms (true auriculopressure (TAP) and placebo auriculopressure (PAP)) was performed. The intervention phase lasted 8 weeks and outcomes were measured 1 week after the last intervention (T1) and 6 months after baseline (T2). The primary outcome measure was change in pain intensity according to a 100 mm visual analogue scale (pain VAS) at T1. Secondary outcome measures were the Lattinen index, the McGill Pain Questionnaire and the SF-12 health-related quality of life scale (Spanish version in every case).

Results

There were 265 participants (TAP group, n=130; PAP group, n=135). Pain was most frequently located in the upper back (55.1%, n=146), followed by the lower back (25.3%, n=67) and the dorsal area (12.5%, n=33). Nineteen patients (7.2%) reported pain affecting the entire spine. There were statistically significant differences between TAP and PAP in the change in the pain VAS at T1 of 10 mm (95% CI 2.8 to 17.3, p=0.007) and in the change in the pain VAS at T2 of 7.2 mm (95% CI 0.02 to 14.3, p=0.049) in favour of TAP. We also observed a statistically significant difference of 3.4 points in the physical component of the SF-12 in favour of TAP at T2 (95% CI 0.45 to 6.3, p=0.024). No severe adverse effects were detected or reported during treatment.

Conclusions

The application of auriculopressure in patients with non-specific spinal pain in primary healthcare is effective and safe, and therefore should be considered for inclusion in the portfolio of primary healthcare services.

Trial Registration Number

ISRCTN01897462.
Rehabilitation of maxillary arch with attachment-retained mesh-reinforced single complete denture
Authors: Vamsi Krishna C H , Rao A Kaleshwar , Sekhar N Chandra , Shastry Y Mahadev
Published: February 2014

Fabrication of conventional complete dentures was one of the most commonly advised treatment options to mange edentulous patients since many years. One of the commonly encountered challenging tasks in prosthodontics is a clinical situation in which patients have maxillary completely edentulous arches opposing mandibular natural dentition. This situation can be effectively managed by retaining some of the natural teeth as overdenture abutments. Tooth supported overdenture retained by attachments will improve retention, support and stability, and reduces rate of ridge resorption along with psychological benefits to the patients by providing tactile sensation. The present case report describes management of patients with edentulous maxillary arch opposing natural mandibular dentition-rehabilitated attachment-retained mesh-reinforced overdenture.
Men's and women's experiences of violence and traumatic events in rural Côte d'Ivoire before, during and after a period of armed conflict
Authors: Hossain Mazeda , Zimmerman Cathy , Kiss Ligia , Kone Drissa , Bakayoko-Topolska Monika , Manan K A David , Lehmann Heidi , Watts Charlotte
Published: February 2014

Objective

We assessed men's and women's experiences of gender based violence and other traumatic events in Côte d'Ivoire, a West African conflict-affected setting, before, during and after a period of active armed conflict (2000–2007).

Design

Cross-sectional, household survey.

Setting

12 rural communities directly impacted by the Crisis in Côte d'Ivoire, spanning regions controlled by government forces, rebels and UN peacekeepers in 2008.

Participants

2678 men and women aged 15–49 years.

Primary outcome measures

Violence exposures measured since age 15. Questions included intimate partner physical and sexual violence; physical and sexual violence by others (including combatants) and exposure to traumatic events before, during and after the Crisis period (2000–2007).

Results

Physical and/or sexual violence since age 15 was reported by 57.1% women and 40.2% men (p=0.01); 29.9% women and 12.3% men reported exposure to any violence in the past year. Nearly 1 in 10 women (9.9%) and 5.9% men (p=0.03) were forced to have sex by a non-partner since age 15, and 14.8% women and 3.3% men (p=0.00) reported their first sexual experience was forced. Combatants were rarely reported as sexual violence perpetrators (0.3% women). After the Crisis, intimate partner physical violence was the most frequently reported form of violence and highest among women (20.9% women, 9.9% men, p=0.00). Fearing for their life was reported by men and women before, during and after the Crisis.

Conclusions

Sexual violence in conflict remains a critical international policy concern. However, men and women experience different types of violence before, during and after conflict. In many conflict settings, other forms of violence, including intimate partner violence, may be more widespread than conflict-related sexual violence. Alongside service provision for rape survivors, our findings underscore the need for postconflict reconstruction efforts to invest in programmes to prevent and respond to intimate partner violence and trauma.
Methodological characteristics and treatment effect sizes in oral health randomised controlled trials: Is there a relationship? Protocol for a meta-epidemiological study
Authors: Saltaji Humam , Armijo-Olivo Susan , Cummings Greta G , Amin Maryam , Flores-Mir Carlos
Published: February 2014

Introduction

It is fundamental that randomised controlled trials (RCTs) are properly conducted in order to reach well-supported conclusions. However, there is emerging evidence that RCTs are subject to biases which can overestimate or underestimate the true treatment effect, due to flaws in the study design characteristics of such trials. The extent to which this holds true in oral health RCTs, which have some unique design characteristics compared to RCTs in other health fields, is unclear. As such, we aim to examine the empirical evidence quantifying the extent of bias associated with methodological and non-methodological characteristics in oral health RCTs.

Methods and analysis

We plan to perform a meta-epidemiological study, where a sample size of 60 meta-analyses (MAs) including approximately 600 RCTs will be selected. The MAs will be randomly obtained from the Oral Health Database of Systematic Reviews using a random number table; and will be considered for inclusion if they include a minimum of five RCTs, and examine a therapeutic intervention related to one of the recognised dental specialties. RCTs identified in selected MAs will be subsequently included if their study design includes a comparison between an intervention group and a placebo group or another intervention group. Data will be extracted from selected trials included in MAs based on a number of methodological and non-methodological characteristics. Moreover, the risk of bias will be assessed using the Cochrane Risk of Bias tool. Effect size estimates and measures of variability for the main outcome will be extracted from each RCT included in selected MAs, and a two-level analysis will be conducted using a meta-meta-analytic approach with a random effects model to allow for intra-MA and inter-MA heterogeneity.

Ethics and dissemination

The intended audiences of the findings will include dental clinicians, oral health researchers, policymakers and graduate students. The aforementioned will be introduced to the findings through workshops, seminars, round table discussions and targeted individual meetings. Other opportunities for knowledge transfer will be pursued such as key dental conferences. Finally, the results will be published as a scientific report in a dental peer-reviewed journal.
THE DEVELOPMENT AND INITIAL VALIDATION OF A QUESTIONNAIRE TO MEASURE THE KEY ATTRIBUTES OF THE CLINICAL NURSE SPECIALIST IN PALLIATIVE CARE
Authors: Cameron Dee , Johnston Bridget
Published: February 2014

Background

The Scottish Government recognises the importance of quality, person-centred healthcare, and current worldwide events have forced an examination of the nursing contribution to this agenda. This increasing requirement to demonstrate quality, person-centred care has resulted in the use of patient reported outcome measurement (PROMs) becoming essential, especially in palliative care.

Aim

The aim of this study was to develop a questionnaire (PROM), the Palliative Nursing Quality Measure (PNQM), and undertake initial validation. The PNQM aims to measure the quality of care provided by palliative care Clinical Nurse Specialists (CNSs), from the patient's perspective.

Method

Humanistic Nursing Theory provided a theoretical foundation to this study. In addition, Johnston's Expert Palliative Nurse Model provided an evidence-based framework on which to develop the questionnaire. The process of questionnaire development had six phases; including systematic literature review; questionnaire formation, advisory group of patients, expert panel review and initial testing with patients; which contributed to the questionnaire's face and content validity.

Results

The development phases identified that input from CNSs contributes significantly to the quality of care given to palliative patients. Patients benefit from the personal and professional interaction with the CNS. This includes the provision of emotional support, the CNSs expert knowledge, practical help and advice, together with on-going review of their condition and symptom management. The personal qualities of the CNS, their ability to communicate effectively and spend time with patients were deemed most important and valuable to patients.

Conclusion

The PNQM will be presented with recommendations for further testing to establish reliability and concurrent validity. In addition, recommendations for use of this questionnaire will be discussed.
DEVELOPMENT, IMPLEMENTATION AND EVALUATION OF A THEORY BASED GOAL SETTING FRAMEWORK FOR USE IN PALLIATIVE CARE (G-AP-PC)
Authors: Boa Sally , Duncan Edward , Haraldsdottir Erna , Letford Anne , Brabin Elinor , Wyke Sally
Published: February 2014

Background

Rehabilitation and goal setting can support one of the key principles of palliative care, to help people live actively until they die. However no theory based practice framework exists. A framework for goal setting in palliative care (G-AP-PC) was developed and implemented systematically in a hospice through 4 phases.

Aims

Develop and implement Goal setting and Action planning for Palliative Care [G-AP PC],) to guide and support patient-centred goal setting in practice.

Methods

Phase 1: Gathering Information about goal setting practice through a structured literature review and observation of practice in one hospice.

Phase 2: Identifying and applying theories which could underpin a goal setting framework and support patient-centred goal setting.

Phase 3: Use of a participatory approach, based on Normalization Process Theory (NPT) to develop and implement a framework for goal setting.

Phase 4 Evaluation of the impact of implementing GAP-PC, using interviews (patients/ professionals), a questionnaire (professionals) and case note analysis.

Results

G-AP PC was successfully implemented. It helped professionals to work as a team; shift their attention fromsymptoms/problems/riskto patient'sgoals; act on what patients wanted to achieve, within short timescales and provide written evidence that patients were working towards goals. Patients reported that use of G-AP PC allowed them to focus on goals that were important to them. There was also evidence that goal setting helped increase their motivation and self-efficacy.

Conclusions

Use of an explicit, theory based goal setting framework provides a mechanism for ensuring that individual based and patient centred goals are established, documented and reviewed, thus making the goal setting and the work towards achieving and adjusting (as appropriate and necessary) patients goals more focused and explicit. Implementation of this type of framework is not without its challenges, but use of NPT provides a structure to anticipate potential difficulties.
WHAT DOES PALLIATIVE CARE MEAN TO YOU? AN INTERPRETATIVE PHENOMENOLOGICAL ANALYSIS OF THE UNDERSTANDING, EXPERIENCE AND PERCEPTIONS OF PALLIATIVE CARE IN THE GYNAECOLOGY SETTING
Authors: Stewart Claire , Archer Stephanie , Bali Anish , Hay Daniel
Published: February 2014

Background

Significant deficiencies in care for patients approaching the end of life have been reported nationwide, particularly for patients managed in the non-specialist settings. Specialist palliative care teams are known to improve patient and family satisfaction but due to limited resources, they cannot care for every patient, and therefore most patients dying in hospitals are under the care of generalist teams, including surgeons and gynaecologists. Gynaecologists may play an important role in 'breaking bad news' and treatment planning for patients with advanced or incurable gynaecological cancer and it is therefore essential that they are competent and confident in the recognition and management of palliative needs.

Aims

Previous quantitative research has shown differences in how healthcare professionals understand and perceive palliative care, but they do not help explainwhythese differences exist. This study therefore aims to bridge this gap by using qualitative methods to obtain rich, detailed data on the understanding, experiences and perceptions of palliative care amongst gynaecology healthcare professionals.

Methods

Individual interviews were carried out with 10 healthcare professionals from the gynaecology department of a large tertiary hospital, including consultants, registrars and nursing staff. The data was analysed using Interpretative Phenomenological Analysis to identity relevant themes.

Results and Conclusions

Three main themes were identified including Difficult Terminology, Emotional Aspects and “I'm not sure I 'm the right person for the job” These significant human factors must be addressed when planning further education and training in palliative care.
HOW MEDICAL STUDENTS LEARN TO CARE FOR THE DYING: RESULTS FROM A QUESTIONNAIRE STUDY
Authors: Rayment Clare , O'Rourke Rebecca
Published: February 2014

Aims

To explore the exposure medical students have across clinical placements in learning to care for dying patients, with a particular focus on whether there are perceived differences relating to learning in different settings.

Methods

All 4th and 5th year medical students at one UK medical school were invited to complete a short online questionnaire. Data was analysed with descriptive statistics and thematic analysis.

Results

Response rate was 4%. 22 students responded, 15 from fourth and 7 from fifth year. 18 perceived they had been involved in the care of a dying patient and 15 had completed a module including palliative care during medical school. Students described many varied experiences across a broad range of specialities of caring for patients dying but many also had prior experience outside their medical training. Students described learning through role modelling from both perceived positive and negative encounters. Students identified similarities in underlying principles across care settings but described differences related to staff attitudes and priorities. The Liverpool Care Pathway was often mentioned as a framework for understanding how to care for the dying. Many students described the considerable impact of being involved, even on the periphery, of caring for a dying patient. Despite 4 students stating they had not been involved in the care of a dying patient, in subsequent questions they described these experiences; they were all final year medical students.

Conclusion

Across undergraduate training students have exposure to a broad range of experiences in which care of the dying is demonstrated. However, students may not always recognise when they are witnessing care of the dying. Different settings provide different experiences but consolidate common principles. These experiences have considerable impact and students expressed a need for further support. Our low response rate may affect our findings.
HOW DO SURGEONS AND ANAESTHETISTS MAKE DECISIONS ABOUT SURGERY FOR PATIENTS WHO ARE FRAIL, AND WHAT FACTORS INFLUENCE THESE DECISIONS?
Authors: Kitchen Richard , Patel Rakesh , French Gordon , Faull Christina
Published: February 2014

Background

Frailty is a concept that describes decreased physiological reserve. Evidence shows that frailty is a risk factor for post-operative complications including sepsis and delirium, increased length of stay and the inability to be discharged home after surgery. Frailty is also a risk factor for increased mortality in the setting of cardiac surgery. Little is known about how decisions are made about surgery in frail patients.

Aims

To explore how surgeons and anaesthetists make decisions about surgery in patients who are frail.

To identify what training surgeons and anaesthetists would find useful in helping them to make decisions about surgery in patients who are frail.

Methods of Data Collection

Individual interviews were conducted with three surgical consultants, three anaesthetic consultants, three surgical trainees and three anaesthetic trainees. A paired interview was also carried out to gauge the thoughts of a surgeon and an anaesthetist together about these issues.

Methods of Data Analysis

Interview transcripts were coded and codes collapsed progressively using a constant comparative approach allowing themes to emerge, with subsequent mapping to a decision-making framework.

Results Key findings

▸

Most participants preferred a shared decision making approach.

▸

Communication challenges and issues around capacity presented problems with decision making.

▸

There was a lack of understanding of the term ‘advance care planning’.

A theoretical decision making model was developed from the interview data and a preceding literature review.

Conclusions

Surgeons and anaesthetists accepted that working with frail patients was a common but challenging scenario. Specific education in this area was thought to be lacking. A tailored learning intervention for core surgical and anaesthetic trainees is subsequently being designed.
DEVELOPING SKILLS IN COMMUNICATION IN END OF LIFE CARE: EVALUATION OF A 3 DAY PILOT COURSE FOR CORE MEDICAL TRAINING
Authors: Feathers Luke , DeCaestecker Sharon , Norrie Peter , Fowler John , Faull Christina
Published: February 2014

Background

Effective communication is a core skill for professionals. Skilled communication is also regarded as one of the key domains of leadership that doctors should develop. Postgraduate training in communication skills is not embedded within training programmes other than GPs. This pilot study examines the feasibility and outcomes of communications skills training for doctors in their Core Medical Training.

Methods

Doctors completed a pre and post training questionnaire at three months to rank, knowledge and understanding of palliative care issues and their confidence in the ‘talking and supporting’ aspects of end of life care.

Results

Dealing with anger & confrontation was the training need identified most. Although some identified the general need to develop skills in ‘breaking bad news’ or ‘discuss sensitive topics’, many cited needs in specific scenarios:

“Dealing with patients who don't understand the prognosis/or who don't want to know”

“Increase in confidence discussing death with patients”

“Discussing sensitive topics like DNR(sic)in terminally ill patients”

“How to discuss end of life issues without being bogged down by clichés”

There was an increase in confidence and knowledge in all areas evaluated in the questionnaire and 86% evaluated the course as very useful and 14% as useful. Trainees valued the way the simulation exercises broke down difficult aspects of communication and the ability to try diverse communication strategies. Rehearsal of a listening approach rather than a defensive approach with ‘difficult’ patients allowed trainees to feel they had new ideas to utilise within their practice.

Conclusion

This blended method course was found to be useful and increased confidence in a range of end of life care communication tasks. It may also have promoted an increase in knowledge in other areas of end of life care.
EMPATHY AGAINST DISGUST: AN INTERPRETIVE PHENOMENOLOGICAL ANALYSIS OF HEALTHCARE PROFESSIONALS' EXPERIENCES OF CARING FOR PALLIATIVE PATIENTS WITH DISGUSTING SYMPTOMS
Authors: Muggleton Joshua , Guy Helen , Howard Ruth
Published: February 2014

Background

Disgusting symptoms are common in healthcare settings. Previous research has identified that healthcare professionals systematically avoid contact with patients with disgusting symptoms (Kray, 2004) potentially compromising patient care. Furthermore, Whitby and Gracias (2013) highlighted disgust in healthcare professionals as a possible contributory factor to dehumanization, and the abuses documented in the recent Francis report (Francis, 2013).

Disgust may also have a detrimental effect on the wellbeing of healthcare professionals. Given that showing disgust is thought to be unprofessional (Holmes, Perron and O'Byrne, 2006) healthcare professionals may feel unable to express or process disgust in their work. The suppression of emotions, such as disgust, has been associated with poorer emotional health (Gross and Oliver, 2003). Therefore, healthcare professionals may be at risk of developing long-term emotional difficulties, or burning out.

Aim

Given the ubiquity of disgust in palliative care (MacLeod, 2011), we investigated how palliative healthcare professionals' experience and cope with disgust in their work, and how they are supported in doing so.

Methods

We interviewed six palliative healthcare professionals and analysed their transcripts using Interpretive Phenomenological Analysis (Smith, 1996)

Analysis

Fifteen themes were identified and explored. These includedthe importance of being an empathetic professional, thatdisgust damages relationships with patients, and that stafftalk about ‘difficulties’, not disgust.

Conclusions

Three key findings emerged. Firstly, participants were uncomfortable talking about disgust at work, and were unable to access support for disgust. Secondly, in focusing on their patient's needs, participants often neglected their own emotional needs. As a result, it appeared that some participants projected their own emotions onto their patients, or else linked their own emotional wellbeing to the wellbeing of their patients. Finally, participants were at risk of reducing vital socio-emotional support for patients with disgusting symptoms. Based on our analysis, we suggest interventions to counteract these effects.
PALLIATIVE CARE RESEARCH ON THE ISLAND OF IRELAND OVER THE LAST DECADE: A SYSTEMATIC REVIEW
Authors: McIlfatrick Sonja , Murphy Tara
Published: February 2014

Background

As palliative care research continues to expand across Europe, and the world, questions exist about the nature and type of research undertaken in addition to the research priorities for the future. This systematic review examined palliative care research conducted on the island over the last decade.

Methods

A comprehensive search strategy was implemented and strict eligibility criteria were applied in order to identify relevant peer-reviewed journal articles. Inclusion criteria were all of the palliative care studies undertaken on the island of Ireland and published between January 2002 and May 2012. These were assessed in relation to year, setting, sample size, research methodology, and relevant findings.

Results

412 publications were identified for screening and their abstracts obtained. After eliminating articles that did not meet the inclusion criteria, 151 remained for further analysis. A thematic analysis of 128 studies published between 2006 and 2012 revealed eight core themes: (1) specific groups/ populations; (2) services and settings; (3) management of symptoms (physical, psychological, social); (4) bereavement; (5) communication and education; (6) death and dying; (7) spirituality; and (8) complementary and alternative medicine/intervention (CAM). There was an upward trend in the number of publications in palliative care research over the last ten years with over 72% of studies being published within the previous four years. A slightly higher number of studies were quantitative in nature followed by qualitative, mixed methods, and systematic reviews.

Conclusion

Whilst there has been a welcome growth in palliative care research across Ireland, this has largely been needs-based and small scale studies. In contrast, international researchers and decision makers recommend the need for more outcomes focused multidisciplinary research. An examination of palliative care research is an essential first step in seeking to develop future priority areas for further research, highlighting opportunities for future collaboration both nationally and internationally.
PATIENT AND PUBLIC INVOLVEMENT IN SCOPE DEVELOPMENT FOR A PALLIATIVE CARE HEALTH TECHNOLOGY ASSESSMENT IN EUROPE
Authors: Brereton Louise , Goyder Elizabeth , Ingleton Christine , Gardiner Clare , Chilcott Jim , van der Wilt Gert Jan , Oortwijn Wija , Mozygemba Kati , Lysdahl Kristin B , Sacchini Dario , Lepper Wojciech
Published: February 2014

Background

Patient and Public Involvement (PPI) helps to ensure that study findings are useful to end users but is under-developed in Health Technology Assessment (HTA). "INTEGRATE-HTA, (a co-funded European Union project -grant agreement 30614) is developing new methods to assess complex health technologies and applying these in a palliative care case study. Having experienced the intended and unintended consequences of palliative care services, which vary widely across Europe, patients in six countries (England, Germany, Italy, Netherlands, Norway and Poland) provided valuable insights and advice for scope development.

Aims

To establish PPI in a palliative care HTA.

Methods

As PPI to assist early scope development in HTA is novel, each country implemented PPI methods as appropriate locally. One of two advocated methods was used, either a qualitative research approach or seeking the views of patients, relatives, carers or patient representatives as research partners. Using a qualitative approach, 21 individual, face-face patient interviews were conducted and analysed thematically. When patients were research partners, an adapted version of the EUnetHTA core model guided 30 face-face discussions. Thematic analysis and conceptual mapping identified key issues.

Findings

PPI in palliative care requires researchers to have cultural awareness of the acceptability of engaging in discussions around dying in each country. Ensuring positive PPI experiences and effective participation by acknowledging patient knowledge and experience whilst establishing a two-way flow of information in the HTA process is essential. Partnership working between researchers and patients, stakeholder evaluation and remuneration when involved as partners is important.

Conclusions

PPI was successfully implemented in each country, assisting patient-centred scope development and identification of important issues related to palliative care. Although there is much to be gained from PPI, methods of PPI engagement require further development. All PPI methods have advantages and limitations which must be considered in light of local needs, resources and culture.