bluuebunny/crossref_metadata_2025 huggingface dataset:
The effects of symmetrical and asymmetrical sensorineural hearing loss on speech perception in noise
Authors: Ostler Dale A. , Crandell Carl C.
Published: February 2014

The effect of symmetrical and asymmetrical sensorineural hearing loss (SNHL) on the speech reception threshold (SRT) in speech-spectrum-shaped noise was assessed with the hearing in noise test (HINT) using an adaptive procedure. Subjects consisted of 16 listeners with symmetrical SNHL and 16 listeners with asymmetrical SNHL. Speech and noise were presented in a sound field from spatially separated loudspeakers at various azimuths (speech at 0/noise at 180, speech at 45/noise at 225, speech at 315/noise at 135). Results suggest that individuals with mild to moderately sloping asymmetrical SNHL (defined as a 15 dB or greater difference in hearing thresholds between ears at two or more frequencies) have speech-perception ability equivalent to that of individuals with an equal amount of symmetrical SNHL as long as the speech signal is presented to the better ear (BE) or from directly in front of the listener. Individuals with asymmetrical SNHL, however, exhibited more difficulty understanding speech in noise than did individuals with symmetrical SNHL if the speech signal was presented toward the poorer ear (PE). Implications are discussed as well as limitations and future directions of research.
Word recognition and phonetic perception by adult cochlear implant users: An examination of /d/–/t/
Authors: Iverson Paul
Published: February 2014

Speech perception by cochlear implant users is marked by large individual differences in word recognition accuracy. The aim of the present study was to examine whether these individual differences in speech understanding are correlated with measures of phonetic sensitivity and categorization. Thirty adult post-lingually deafened cochlear implant patients, who were heterogeneous in terms of their implants and processing strategies, were tested in four experiments. Experiments 1 and 2 tested open-set word recognition and forced-choice consonant recognition for words and syllables spoken by ten different talkers. Experiments 3 and 4 tested forced-choice phoneme identification and discrimination along a synthetic /d/–/t/ continuum. The results demonstrated that open-set word recognition accuracy was highly correlated with the location of sensitivity peaks along the /d/–/t/ continuum; word recognition accuracy was higher for cochlear implant users who had sensitivity peaks near the typical /d/–/t/ category boundary location of normal-hearing individuals. In contrast, word recognition accuracy was unrelated to mean levels of discrimination performance or to measures of phoneme identification. The results suggest that at least some aspects of the common phonetic perceptual phenomena found in normal-hearing listeners have a functional role in speech understanding via cochlear implants.
On recognizing spectrally reduced speech by multiple talkers: A cochlear implant simulation study
Authors: Fishbeck Kristen , Chiu C.-Y. Peter
Published: February 2014

In a previous study [Loizou et al., J. Acoust. Soc. Am. 106, 2097–2103 (1999)], normal-hearing listeners identified sentences from the multitalker sentence set TIMIT that were spectrally reduced using the CIS processing strategy [Shannon et al., J. Acoust. Soc. Am. 104, 2467–2476 (1998)]. It was reported that listeners could achieve open-set sentence recognition (90%) with as few as five channels, with asymptotic performance achieved with eight channels. Such results were compared with another study [Dorman et al., J. Acoust. Soc. Am. 102, 2403–2411 (1997)] using different sentences from the single-talker HINT set, where asymptotic performance was achieved with four channels. The present study directly compares identification for spectrally reduced TIMIT sentences spoken by a male talker, by a female talker, and by multiple talkers. Separate groups of subjects with normal hearing served in these three conditions. The design therefore controlled potential differences in the lexical, syntactic, and semantic aspects of the materials in TIMIT versus HINT that could have accounted for the above findings. Results will be discussed in terms of theories of auditory memory and speech perception.
Final consonant discrimination in children with phonological disorders
Authors: Edwards Jan , Fox Robert A. , Isermann Bridgett
Published: February 2014

A number of researchers have shown that children with phonological disorders, relative to typically developing age peers, have difficulty discriminating the particular contrasts that they do not produce correctly. It is less clear whether children with phonological disorders, as a group, have greater difficulty with more general measures of speech perception than their peers. In this study, 35 preschool-aged children with phonological disorders and a group of 35 typically developing controls (matched for age, gender, and nonverbal IQ) were asked to discriminate between two CVC words which differed only in the identity of the final consonant. The stimuli were digitized natural speech including both whole word and backward-gated versions. The children with phonological disorders performed significantly more poorly than their age peers. Significant correlations (with age partialed out) were observed between discrimination scores (d-primes) and raw scores on both the Goldman–Fristoe test of articulation and the PPVT-III. Since the cues to final consonants in CVC words (VC transition and release burst) are not integrated in time and the burst is not reliably present, it is not surprising that representations of final consonants for children with phonological disorders are particularly vulnerable to diminished redundancy in the acoustic signal. [Work supported by NIDCD.]
A Zebrafish Compound Screen Reveals Modulation of Neutrophil Reverse Migration as an Anti-Inflammatory Mechanism
Authors: Robertson Anne L. , Holmes Geoffrey R. , Bojarczuk Aleksandra N. , Burgon Joseph , Loynes Catherine A. , Chimen Myriam , Sawtell Amy K. , Hamza Bashar , Willson Joseph , Walmsley Sarah R. , Anderson Sean R. , Coles Mark C. , Farrow Stuart N. , Solari Roberto , Jones Simon , Prince Lynne R. , Irimia Daniel , Rainger G. Ed , Kadirkamanathan Visakan , Whyte Moira K. B. , Renshaw Stephen A.
Published: February 2014

The proresolution therapeutic tanshinone IIA drives inflammation resolution by reverse migration.
Targeting
miR-21
to Treat Psoriasis
Authors: Guinea-Viniegra Juan , Jiménez María , Schonthaler Helia B. , Navarro Raquel , Delgado Yolanda , José Concha-Garzón María , Tschachler Erwin , Obad Susanna , Daudén Esteban , Wagner Erwin F.
Published: February 2014

Targeting
miR-21
may be a new way to treat psoriasis.
Bosom Buddies: Close Connections Between Breast and Bladder Cancer
Authors: Oliver Trudy G.
Published: February 2014

Gene expression profiling of advanced bladder cancer identifies molecular subtypes highly reminiscent of subtypes found in breast cancer.
You Have Your Father’s Nose
Authors: Sohal Vikaas S.
Published: February 2014

After a male mouse has an aversive experience with a particular odor, its sperm transmit an increased sensitivity for that odor to subsequent generations.
Acetic Acid, the Active Component of Vinegar, Is an Effective Tuberculocidal Disinfectant
Authors: Cortesia Claudia , Vilchèze Catherine , Bernut Audrey , Contreras Whendy , Gómez Keyla , de Waard Jacobus , Jacobs William R. , Kremer Laurent , Takiff Howard
Published: February 2014

Effective and economical mycobactericidal disinfectants are needed to kill both
Mycobacterium tuberculosis
and non-
M. tuberculosis
mycobacteria. We found that acetic acid (vinegar) efficiently kills
M. tuberculosis
after 30 min of exposure to a 6% acetic acid solution. The activity is not due to pH alone, and propionic acid also appears to be bactericidal.
M. bolletii
and
M. massiliense
nontuberculous mycobacteria were more resistant, although a 30-min exposure to 10% acetic acid resulted in at least a 6-log
10
reduction of viable bacteria. Acetic acid (vinegar) is an effective mycobactericidal disinfectant that should also be active against most other bacteria. These findings are consistent with and extend the results of studies performed in the early and mid-20th century on the disinfectant capacity of organic acids.

IMPORTANCE
Mycobacteria are best known for causing tuberculosis and leprosy, but infections with nontuberculous mycobacteria are an increasing problem after surgical or cosmetic procedures or in the lungs of cystic fibrosis and immunosuppressed patients. Killing mycobacteria is important because
Mycobacterium tuberculosis
strains can be multidrug resistant and therefore potentially fatal biohazards, and environmental mycobacteria must be thoroughly eliminated from surgical implements and respiratory equipment. Currently used mycobactericidal disinfectants can be toxic, unstable, and expensive. We fortuitously found that acetic acid kills mycobacteria and then showed that it is an effective mycobactericidal agent, even against the very resistant, clinically important
Mycobacterium abscessus
complex. Vinegar has been used for thousands of years as a common disinfectant, and if it can kill mycobacteria, the most disinfectant-resistant bacteria, it may prove to be a broadly effective, economical biocide with potential usefulness in health care settings and laboratories, especially in resource-poor countries.
Generation of Unique Poliovirus RNA Replication Organelles
Authors: Richards Alexsia L. , Soares-Martins Jamária A. P. , Riddell Geoffrey T. , Jackson William T.
Published: February 2014

Poliovirus (PV), a model for interactions of picornaviruses with host cells, replicates its genomic RNA in association with cellular membranes. The origin of PV replication membranes has not been determined. Hypotheses about the origin of replication membranes, based largely on localization of viral proteins, include modification of coat protein complex I (COPI) and/or COPII secretory pathway vesicles and subversion of autophagic membranes. Here, we use an antibody against double-stranded RNA (dsRNA) to identify replication complexes by detection of dsRNA replication intermediates. dsRNA signal is dependent on virus genome replication and colocalizes with the viral integral membrane protein 3A, which is part of the RNA replication complex. We show that early in infection, dsRNA does not colocalize with a marker for autophagic vesicles, making it unlikely that autophagosomes contribute to the generation of PV RNA replication membranes. We also find that dsRNA does not colocalize with a marker of the COPII coat, Sec31, and, in fact, we demonstrate proteasome-dependent loss of full-length Sec31 during PV infection. These data indicate that COPII vesicles are an unlikely source of PV replication membranes. We show that the Golgi resident G-protein Arf1 and its associated guanine nucleotide exchange factor (GEF), GBF1, transiently colocalize with dsRNA early in infection. In uninfected cells, Arf1 nucleates COPI coat formation, although during infection the COPI coat itself does not colocalize with dsRNA. Phosphatidylinositol-4-phosphate, which is associated with enterovirus-induced vesicles, tightly colocalizes with Arf1/GBF1 throughout infection. Our data point to a noncanonical role for some of the COPI-generating machinery in producing unique replication surfaces for PV RNA replication.

IMPORTANCE
Picornaviruses are a diverse and major cause of human disease, and their genomes replicate in association with intracellular membranes. There are multiple hypotheses to explain the nature and origin of these membranes, and a complete understanding of the host requirements for membrane rearrangement would provide novel drug targets essential for viral genome replication. Here, we study the model picornavirus, poliovirus, and show that some, but not all, components of the cellular machinery required for retrograde traffic from the Golgi apparatus to the endoplasmic reticulum are transiently present at the sites of viral RNA replication. We also show that the full-length Sec31 protein, which has been suggested to be present on PV RNA replication membranes, is lost during infection in a proteasome-dependent manner. This study helps to reconcile multiple hypotheses about the origin of poliovirus replication membranes and points to known host cell protein complexes that would make likely drug targets to inhibit picornavirus infections.
Honey Bee-Infecting Plant Virus with Implications on Honey Bee Colony Health
Authors: Flenniken Michelle L.
Published: February 2014

Honey bees are eusocial insects that are commercially managed to provide pollination services for agricultural crops. Recent increased losses of honey bee colonies (averaging 32% annually since 2006) are associated with the incidence and abundance of pathogens. In their study in
mBio
, J. L. Li et al. [mBio 5(1):e00898-13, 2014, doi:10.1128/mBio.00898-13] share their discovery that a plant virus, tobacco ring spot virus (TRSV), replicates in honey bees and that the prevalence of this virus was high in weak colonies. Their findings increase our understanding of the role of viruses in honey bee colony losses and underscore the importance of surveying for new and/or emerging viruses in honey bees. Furthermore, their findings will pique the interest of virologists and biologists across all disciplines. The discovery that a plant virus (TRSV) replicates, spreads, and negatively affects the health of an insect host will lead to additional studies on the mechanisms of host-specific adaptation and the role of cross-kingdom infections in the transmission of this virus.
Middle East Respiratory Syndrome Coronavirus Infection in Dromedary Camels in Saudi Arabia
Authors: Alagaili Abdulaziz N. , Briese Thomas , Mishra Nischay , Kapoor Vishal , Sameroff Stephen C. , de Wit Emmie , Munster Vincent J. , Hensley Lisa E. , Zalmout Iyad S. , Kapoor Amit , Epstein Jonathan H. , Karesh William B. , Daszak Peter , Mohammed Osama B. , Lipkin W. Ian
Published: February 2014

The Middle East respiratory syndrome (MERS) is proposed to be a zoonotic disease; however, the reservoir and mechanism for transmission of the causative agent, the MERS coronavirus, are unknown. Dromedary camels have been implicated through reports that some victims have been exposed to camels, camels in areas where the disease has emerged have antibodies to the virus, and viral sequences have been recovered from camels in association with outbreaks of the disease among humans. Nonetheless, whether camels mediate transmission to humans is unresolved. Here we provide evidence from a geographic and temporal survey of camels in the Kingdom of Saudi Arabia that MERS coronaviruses have been circulating in camels since at least 1992, are distributed countrywide, and can be phylogenetically classified into clades that correlate with outbreaks of the disease among humans. We found no evidence of infection in domestic sheep or domestic goats.

IMPORTANCE
This study was undertaken to determine the historical and current prevalence of Middle East respiratory syndrome (MERS) coronavirus infection in dromedary camels and other livestock in the Kingdom of Saudi Arabia, where the index case and the majority of cases of MERS have been reported.
Job stress and burnout in hospital employees: comparisons of different medical professions in a regional hospital in Taiwan
Authors: Chou Li-Ping , Li Chung-Yi , Hu Susan C
Published: February 2014

Objectives

To explore the prevalence and associated factors of burnout among five different medical professions in a regional teaching hospital.

Design

Cross-sectional study.

Setting

Hospital-based survey.

Participants

A total of 1329 medical professionals were recruited in a regional hospital with a response rate of 89%. These voluntary participants included 101 physicians, 68 physician assistants, 570 nurses, 216 medical technicians and 374 administrative staff.

Primary and secondary outcome measures

Demographic data included gender, age, level of education and marital status, and work situations, such as position, work hours and work shifts, were obtained from an electronic questionnaire. Job strain and burnout were measured by two validated questionnaires, the Chinese version of the Job Content Questionnaire and the Copenhagen Burnout Inventory.

Results

Among the five medical professions, the prevalence of high work-related burnout from highest to lowest was nurses (66%), physician assistants (61.8%), physicians (38.6%), administrative staff (36.1%) and medical technicians (31.9%), respectively. Hierarchical regression analysis indicated that job strain, overcommitment and low social support explained the most variance (32.6%) of burnout.

Conclusions

Physician assistant is an emerging high burnout group; its severity is similar to that of nurses and far more than that of physicians, administrative staff and medical technicians. These findings may contribute to the development of feasible strategies to reduce the stress which results in the burnout currently plaguing most hospitals in Taiwan.
Aspirin and clonidine in non-cardiac surgery: acute kidney injury substudy protocol of the Perioperative Ischaemic Evaluation (POISE) 2 randomised controlled trial
Authors: Garg Amit X , Kurz Andrea , Sessler Daniel I , Cuerden Meaghan , Robinson Andrea , Mrkobrada Marko , Parikh Chirag , Mizera Richard , Jones Philip M , Tiboni Maria , Rodriguez Raul Gonzalez , Popova Ekaterina , Rojas Gomez Maria Fernanda , Meyhoff Christian S , Vanhelder Tomas , Chan Matthew T V , Torres David , Parlow Joel , de Nadal Clanchet Miriam , Amir Mohammed , Bidgoli Seyed Javad , Pasin Laura , Martinsen Kristian , Malaga German , Myles Paul , Acedillo Rey , Roshanov Pavel , Walsh Michael , Dresser George , Kumar Priya , Fleischmann Edith , Villar Juan Carlos , Painter Tom , Biccard Bruce , Bergese Sergio , Srinathan Sadeesh , Cata Juan P , Chan Vincent , Mehra Bhupendra , Leslie Kate , Whitlock Richard , Devereaux P J ,   on behalf of the POISE-2 Investigators
Published: February 2014

Introduction

Perioperative Ischaemic Evaluation-2 (POISE-2) is an international 2×2 factorial randomised controlled trial of low-dose aspirin versus placebo and low-dose clonidine versus placebo in patients who undergo non-cardiac surgery. Perioperative aspirin (and possibly clonidine) may reduce the risk of postoperative acute kidney injury (AKI).

Methods and analysis

After receipt of grant funding, serial postoperative serum creatinine measurements began to be recorded in consecutive patients enrolled at substudy participating centres. With respect to the study schedule, the last of over 6500 substudy patients from 82 centres in 21 countries were randomised in December 2013. The authors will use logistic regression to estimate the adjusted OR of AKI following surgery (compared with the preoperative serum creatinine value, a postoperative increase ≥26.5 μmol/L in the 2 days following surgery or an increase of ≥50% in the 7 days following surgery) comparing each intervention to placebo, and will report the adjusted relative risk reduction. Alternate definitions of AKI will also be considered, as will the outcome of AKI in subgroups defined by the presence of preoperative chronic kidney disease and preoperative chronic aspirin use. At the time of randomisation, a subpopulation agreed to a single measurement of serum creatinine between 3 and 12 months after surgery, and the authors will examine intervention effects on this outcome.

Ethics and dissemination

The authors were competitively awarded a grant from the Canadian Institutes of Health Research for this POISE-2 AKI substudy. Ethics approval was obtained for additional kidney data collection in consecutive patients enrolled at participating centres, which first began for patients enrolled after January 2011. In patients who provided consent, the remaining longer term serum creatinine data will be collected throughout 2014. The results of this study will be reported no later than 2015.

Clinical Trial Registration Number

NCT01082874.
Improving communication of inpatient blood transfusion events to GPs
Authors: Robbins Timothy
Published: February 2014

Patients who have had blood transfusions whilst in hospital must have this information communicated to their General Practitioner at discharge. Audit demonstrated that just 50% of patients (n=15) under medical specialties who had undergone a blood transfusion had this information included in their discharge letter. To improve this, a section was specifically designated on the e-discharge pro-forma for the documentation of blood transfusion events, and focused teaching was delivered to all new FY1 doctors at their induction. Post intervention, 80% of blood transfusions occurring in medical patients were documented on the e-discharge, with an improvement in how detailed this documentation was (n=40). This simple intervention is an easily reproducible, cost neutral method of ensuring that more blood transfusion events are communicated to patients' GPs; improving care and reducing risk.
INFLUENCING NURSES' COMMUNICATION STYLE THROUGH A TWO DAY INTERACTIVE COMMUNICATION SKILLS COURSE
Authors: Pilsworth Alison , Blankley Kerry , Faull Christina
Published: February 2014

Background

An audit of hospital notes of inpatients diagnosed with advanced pancreatic cancer on a tertiary heptobiliary unit found little evidence of end of life discussions and advance care planning. While patients were often told at diagnosis that their cancer was incurable, they were generally not told their prognosis. Few nurses had formal communication skills training and most had little confidence in having end of life discussions.

Aims

To examine outcomes of a two day interactive communications skills course on perceived self reflection of band 5 registered nurses.

Methods

At the start and end of the course the nurses were asked to reflect on themselves as a communicator using three self awareness describers:Informer, Ignorer, Inquirerand to consider what patients required of them. Participants were asked to identify the communication challenges they had encountered and skills which may help their practice.

Results

Over 80% of the 24 nurses identified themselves asInformers. Some said that at times they were aware that they ignored patient statements because they did not what to say and one said ignoring is the “only way to survive”.

Only two nurses identified themselves as inquirers, but they sometimes found this difficult and had both been “told about spending too long with patients”. The majority felt that their informer style matched patients' requirements.

Two main areas of challenge and specific skills development were identified: dealing with patients with difficult questions and dealing with and angry patients and relatives.

Following the course all participants said that they would be primarily an inquirer. The skills of listening, pausing, summarising and empathy were evaluated as the most useful enhanced skills. Confidence and knowledge increased in the specific challenges that were identified.

Conclusion

A two day interactive course may promote awareness, increase confidence and may enable change practice.
NO SUCH THING AS BAD PUBLICITY? QUALITATIVE STUDY OF STUDENTS AND DOCTORS LEARNING NEEDS FOR END-OF-LIFE CARE IN THE MEDIA LIMELIGHT
Authors: Edge Henrietta , Yardley Sarah
Published: February 2014

Background

Death and dying are an unavoidable part of medical practice but doctors continue to report lack of competence in end-of-life care. Negative news media has placed additional demands on doctors seeking to negotiate issues in end-of-life care.

Aims

This study addresses three questions

1. What is the awareness among final year students and newly qualified doctors of media attention to end-of-life care?

2. Do these groups expect media attention to affect practice with respect to end-of-life care?

3. What are the self-identified learning needs of these groups with respect to providing end-of-life care and responding to media attention?

Methods

This study draws on experiential learning theories, recognizing that learning of ‘good medical practice’ is influenced by context. Following a literature review we undertook a thematic analysis of coverage of the Liverpool Care Pathway in three purposively selected national newspapers. Volunteer students (n=8) and newly qualified doctors (n=8) are being recruited to participate in two sets of longitudinal focus groups. The first session explores research questions 1/2. The next introduces our media analysis to extend discussions. In the final session we will discuss the emerging analysis and specifically explore perceptions of learning needs. Data will be audio-recorded and transcribed verbatim. An iterative approach to qualitative thematic analysis concurrent with data generation will be used to describe and interpret the overall findings.

Results

We will present our findings combining data from media analysis with longitudinal focus groups. Implications including the identification of learning needs with respect to end-of-life care and professional duties when responding to media attention will be discussed.

Conclusions

External influences on medical practice, such as media attention, can influence understandings of a phenomenon, challenge or legitimize particular practices. This study provides important insights into perceptions and learning needs of students and newly qualified doctors regarding end-of-life care.
WITHDRAWAL OF VENTILATION AT THE PATIENT'S REQUEST IN MND: DOCTORS VIEWS ON THE ETHICAL CHALLENGES INVOLVED
Authors: Faull Christina , Phelps Kay , Regen Emma , Rowe-Haynes Cassy , Oliver David , McDermott Christopher
Published: February 2014

Background

Little is known about the withdrawal of NIV at the request of a patient. The NICE guidance on the use of NIV in MND (2010) identifies the lack of any clarity in how this process should be managed. NICE specifically suggests interviewing the professionals involved as a focus of research.

Aims

To explore the ethical issues that arise for doctors who have been involved in the withdrawal of NIV at the request of a patient with MND.

Methods

A retrospective qualitative interview study of 20 Doctors including specialists in palliative care, respiratory, neurology and general practice.

Results

Participants were clear that patients have the right to withdrawal from treatment and it would be unethical to continue treatment. Despite this clarity, withdrawal of NIV where the result will be death in a short timescale, can feel challenging. In such cases doctors may feel the need for a second opinion and affirmation that withdrawal of ventilation is ethically sound.

The challenge is augmented by the need for the doctor to spend considerable time discussing the ethics of each case with colleagues and family members. Even when doctors feel the ethics are clear there can be an underlying fear that colleagues and the public will not see it this way, and a fear that they will be seen as assisting death. Many doctors had experienced disagreement from colleagues who felt that assisting patients in their request and managing the consequent symptoms, was unethical.

Conclusions

Though the ethics of withdrawal of treatment at the patient's request are clear, in a situation where the result will be immediate death it feels ethically challenging for many doctors. Open ethical discussions of these situations and written guidance on the ethics of withdrawal of NIV in MND would alleviate many doctors fears.
INVESTIGATION OF BIOLOGICAL CHANGES AT THE END OF LIFE—A SYSTEMATIC REVIEW
Authors: Coyle Seamus , Debattista Maria , Mason Stephen , Ellershaw John
Published: February 2014

Background

Diagnosing when someone is in the last days of their life is an ongoing difficulty for clinicians. There is often significant clinical uncertainty and modern medical science is poor at predicting how or when patients will die.

Aim

To review the literature to assess the knowledge of the biology of dying - excepting sudden death.

Method

A systematic review of the biology of dying excepting sudden death was performed. 2661 articles on MEDLINE and 3360 articles from EMBASE were identified. Titles and abstracts from each database were examined independently for relevance.

Results

18 articles were identified. Interleukin-2 is preferentially expressed in brainstem neuronal centres in critically ill aging adults and infant patients dying from various conditions. A number of papers suggested that there may be a final common pathway to dying.

Conclusion

There are few studies investigating the biological changes during dying. Research into this area could have a potential impact on a dying persons care.
DO WE HAVE THE CORRECT HEALTH ECONOMICS METHODS TO EVALUATE END OF LIFE CARE? AN ANALYSIS OF STAKEHOLDER PERSPECTIVES
Authors: Kinghorn Philip , Coast Joanna
Published: February 2014

Background

The most common approach to health economic evaluation is based on the principle of maximising total health, with outcomes of value being gains in health and length of life, the ‘Q’ and ‘LY’ elements of quality adjusted life years (QALYs). Health is commonly defined in terms of: pain/discomfort; anxiety/depression; mobility; self care; and usual activities.

Outcomes given intrinsic value in recent reviews of palliative care, such as patient dignity and bereavement support, are not explicitly incorporated within the QALY; they are therefore given zero weight in economic evaluation. It is also feared that interventions in the last few days of life will be deemed not cost-effective because of the value given to time.

Aims

To explore: (i) What are the legitimate objectives of a healthcare system spending within a fixed budget? (ii) Should end of life care be considered a “special case” and, if so, what are the practical and theoretical implications?

Methods

20 semi-structured audio-recorded interviews with stakeholders (specialising in health economics, end of life care, ethics) analysed using constant comparative methods.

Results

Early analysis suggests stakeholders have a number of issues with the QALY model in this context. These include the inevitability of decline, short remaining life expectancy and the importance to patients and families of broader outcomes. These concerns are not held by all informants, however, with some health economists feeling that health is the legitimate objective for health systems and that end of life care should not be treated differently.

Conclusion

As currently operationalised, the QALY is narrow and restrictive, although there was little consensus about how or to what extent QALYs should be modified. The consequences of any refinement will be complex, but we argue this is inadequate justification for sticking with the status quo. We outline an agenda for future research.
THE VALUE OF LONGITUDINAL INTERVIEWS IN EXPLORING COPING STRATEGIES OF PATIENTS WITH ADVANCED CANCER AND THEIR CARERS
Authors: Roberts Diane , Grande Gunn , Williams Mari Lloyd , Calman Lynn , Appleton Lynda , Large Paul , Walshe Catherine
Published: February 2014

Background

Qualitative longitudinal methods, used successfully for research in chronic conditions, can potentially unpick the dynamics of coping with advanced cancer as both a skillset and process. Studies in palliative care commonly suffer from high attrition and raise challenges when exploiting the richness and utility of longitudinal data.

Aims

To develop longitudinal methodology by learning from a successful study exploring how and when patients with advanced cancer and their informal carers develop coping strategies.

Methods

54 participants (n=27 patients, n=27 nominated carers) were recruited to a qualitative longitudinal serial interview study. Using a core topic guide and a semi-narrative, conversational format, two interviews with each participant (n=86 interviews) were scheduled 4–12 weeks apart to encompass a range of everyday challenges and life events. A multidimensional approach combined thematic coding and framework analysis to compare patients, carers, dyads and interview points.

Results

Researcher sensitivity, responsiveness and planning of second interviews resulted in low attrition between interviews (7.5%). Interviews were welcomed by participants and their timing was central to understanding how and when participants' developed coping strategies. Participants could reflect in ways which opened up the ‘black box’ of lived experience and researchers' were able to develop more relevant follow-up questions. This assisted participants to articulate how, why and when they had (or had not) developed particular coping strategies.

Conclusions

Supporting the development of coping strategies which benefit patients and carers is both imperative and time critical in palliative care. This study shows that longitudinal qualitative research is valuable when exploring the complex ‘everyday realities’ of lived experience which are fundamental to quality of life but often develop, unremarked, over time. By integrating opportunities for participant reflection and focusing on ‘change over time’ this study was able to explore deeper patient-centred insights on which to develop robust evidence-based practice.
CHALLENGING CHANGE MANAGEMENT: LESSONS FROM THE CAMBRIDGESHIRE ELECTRONIC PALLIATIVE CARE COORDINATION SYSTEM
Authors: Petrova Mila , Merrick Ian , Barclay Stephen
Published: February 2014

Background

Locality Registers, later EPaCCS (Electronic Palliative Care Coordination Systems), were advanced as key to improving care coordination by the 2008 End of Life Care Strategy. EPaCCS were strongly supported by the National End of Life Care Programme and continue to be a Department of Health priority. In spite of some high-profile successes, most UK localities are struggling to develop their EPaCCS.

Aims

This presentation will look into difficulties accompanying the development (ultimately successful) of “Share my Care”, the Cambridgeshire EPaCCS. It will discuss “the small, vague, messy and bad things” which the project team had to manage – issues that are commonly ignored by models of change and project management or addressed by solutions that are frequently ineffective.

Methods

Analysis of field notes, minutes of team meetings, email communications and interviews with project team members, with reference to social psychology and sociological theory.

Results

Key difficulties identified included: precarious balance of different stakeholder groups' visions for the system and the “common” vision; limited interoperability of IT systems; huge challenges of information governance; the dark side of expert knowledge; subtle games of power and need for credit in an ostensibly equal and collaborative playing field; the worm of silent ignorance; the many faces of “good logic” and “highest priority”; the politics of communication, among others.

Conclusions

Although the rollout of “Share my Care” across the whole Clinical Commissioning Group is still ahead of us, the developmental project in one Local Commissioning Group has succeeded. This paper, which combines an objective analysis of preceding difficulties with an engaged perspective, self-probing yet self-compassionate, is aimed to motivate colleagues working on EPaCCS. We also aim to enrich models of change and project management in healthcare through attending to some of the non-rational factors involved.
The Use and Correlation of Patient Reported Outcome Measures (PROMs) in a Hospital Outpatient Setting
Authors: Farrington Clare , Noble Bill
Published: February 2014

Background

Consultation And Relational Empathy (CARE) and Patient Enablement Instrument (PEI) PROMs were highlighted by a task group of the association of palliative care as useful research tools for assessment of the consultation process.

Aims

Assess the feasibility and acceptability of using CARE and PEI PROMs in a hospital outpatient setting. Also the correlation between these PROMs.

Methods

Set within a feasibility study to examine the effect of Advanced Communication Skills Training ACST on PROMs. Two data collections of 75 questionnaires posted to sequential outpatients following a consultation with a participating doctor.Data analysed using descriptive statistics and Spearman rank correlation to test PROMs association.

Results

Patients returned over half the questionnaires (802, 53.5%). Respondents were representative of outpatient population with regard age and gender. Majority of questionnaires were evaluable: CARE 801 (99.9%), PEI 712 (88.8%). Spearman's rank correlation coefficient (r=0.33 p=0.01) showed a moderate positive correlation between CARE measure and PEI score in hospital outpatients. The proportion of consultations that were defined as enabling (PEI score six or more) tended to increase, and those with poor enablement (PEI score two or less) decrease, as CARE measure score increased. No full enablement occurred (PEI maximum score =12) when CARE score was 30 or less (CARE measure items averaging poor-good). Enablement occurred most frequently (52.3%) when a maximum CARE measure score (50) was assigned.

Conclusions

The postal method of administering these PROMs appears a feasible and acceptable method to assess hospital outpatient consultations. As patients' rating of their doctors communication skills and empathy (CARE scores) increase the tendency is for greater patient enablement (PEI scores) though not uniformly. Not all consultations where doctors were scored as having excellent communication skills and empathy were enabling. This indicates that empathy is a necessary but not sufficient condition for enablement.
THE ROLE OF INTERCULTURAL MEDIATION IN PROVIDING PALLIATIVE CARE IN A MULTICULTURAL SOCIETY
Authors: Van den Eynden Bart , Scheers Joke , Verrept Hans , Elseviers Monique
Published: February 2014

Introduction

Ill persons from ethnical minorities are not cared for optimally in our healthcare system. Intercultural mediation aims to improve the accessibility and the quality of care for ethnical minorities. Due to the aging of the first generation of migrants, more and more migrants in Flanders will face an growing need for palliative care. Migrants elderly and palliative services are still rather unknown to each other. So it is not unthinkable that the intercultural mediator can play a significant role when in the future undoubtedly the number of migrant patients with palliative care needs will increase. While in the past interventions of intercultural mediators occurred rather on general wards, they now more often face palliative care.

Research question

What could be the role of intercultural mediation in providing palliative care in a multicultural society?

Research Method

This study used a qualitative descriptive method from a phenomenological research perspective where for the thematic analysis the coding paradigm of grounded theory was used.

Results

Although a palliative care process must always be considered as an individual process, there are nevertheless many cultural differences. Both intercultural mediators and palliative care providers have less experience in guiding and supporting an intercultural palliative care process. The cooperation that currently exists, is considered as positive, although there are still many points waiting for improvement.

Conclusion

The framework supporting intercultural mediators in guiding a palliative care process, is currently inadequate. This aspect should be paid for more attention in the near future.
‘BEING A CONDUIT’: EXPERIENCES OF BEREAVED CARERS AND HEALTH CARE PROFESSIONALS ABOUT USING HOSPITAL BASED MACMILLAN DISCHARGE FACILITATOR SERVICE
Authors: Venkatasalu Munikumar Ramasamy , Clarke Amanda , Atkinson Joanne
Published: February 2014

Background

The drive in policy and practice is to enable individuals to achieve their preferred place of care during their last days of life. A local NHS Trust implemented a pilot project to establish a Macmillan Discharge Facilitator Service that aimed to offer individuals at the end of their lives the choice to die at home or another preferred place of care. Although the routine clinical audit provided quantitative data regarding the use of the service and associated outcomes, little is known about the service in terms of its quality, scope and impact on service users and other stakeholders.

Aims

A qualitative evaluation was undertaken to explore stakeholders' views and perceptions concerning the Macmillan Discharge Facilitator Service.

Methods

After gaining ethical approval, semi-structured interviews were conducted with bereaved carers (n=5). A focus group and individual interviews were undertaken with Healthcare Professionals who had used the service since its inception (n= 5). We also conducted individual interviews with the Discharge Facilitator and Service Manager.

Results

Framework analysis revealed five key themes: achieving preferred place of care; the Discharge Facilitator Service as the “conduit” between hospital and community settings; the personal attributes of the Discharge Facilitator; delays in hospital discharge; and, stakeholders' perceptions of the way forward for the service. Bereaved carers reported that the Discharge Facilitator helped to facilitate choice through the exploration of the patient's wishes, advocacy and the coordination of seamless discharge across care delivery settings.

Conclusions

Stakeholders reported that the Discharge Facilitator acted as a reliable resource and support in order to facilitate fast tracking for patients at the end of life. Recommendations for future service development were suggested by all stakeholders; these included: increased profile of the service, expansion of service provision, further development of education opportunities, and the Discharge Facilitator's earlier involvement in the discharge process.
KNOWLEDGE AND EXPERIENCE WITH HOSPICE AND PALLIATIVE CARE IN SLOVENIA AMONG HEALTHY ADULTS
Authors: Bobnar Albina
Published: February 2014

Background

In Slovenia we started with the process of working and informing the public about palliative care as an integral part of the health care system after 2003, in preparation for entry into the European Union. The National Palliative Care Program was published in 2010. For the patients and relatives had organized palliative care in the same year in two hospitals and hospice care in one Hospice house. Due to the lack of palliative services, very few people involved in hospice or palliative care.

Aim

The aim of this study was to identify differences between healthy adults' knowledge of and experience with hospice and palliative care.

Methods

In the academic year 2010/2011, students of nursing to do interviews with 695 healthy adults. Bivariate analysis were made to determine statistically significant differences among healthy adults about the knowledge and experience with hospice and palliative care regarding of gender, age, place of residence, employment status, education, marital status.

Results

Among the 59,4% women and 40,6% of men aged 18–59 years (56,3%) and 43,7% of those aged >60 years, living in the city (49,9%) and villages (51,1%), the women in the younger age group who live in the city, better known hospice and palliative care. Greater knowledge among employees (47,6%) and participants with education >13 years (21%). Marital status does not affect their knowledge of hospice and palliative care, as well as no differences in experience with this type of care among healthy adults.

Conclusion

The healthy adults know little about hospice and palliative care, much less they have experience in this field. Might on this affect the satisfactory implementation of health services to all parts of Slovenia and the healthy adults are not interested in the other alternative forms of care at the end of life.
CLARITY THROUGH THE KALEIDOSCOPE: GAINING CONSENSUS ON THE MAIN CAUSES OF CARER BURDEN FROM PROFESSIONAL AND CARER PERSPECTIVES
Authors: Knighting Katherine , Jack Barbara , Roe Brenda , O'Brien Mary , Nolan Mike , Lloyd-Williams Mari , Pine Kirsty , Gandy Rob
Published: February 2014

Background

Family caregivers of patients with cancer and other advanced progressive illnesses, especially during the final year of life, can incur increasing burden, affecting their health, ability to care and likelihood of hospital admission for the patient. It is essential carers' needs are assessed to alert health and social care professionals to their increasing level of burden and trigger additional support. This multi-phase study developed and piloted a Carers' Alert Thermometer (CAT), for use by the generalist healthcare workforce, to alert staff to increasing carer burden and provide guidance on appropriate interventions.

Aim of the study

To gain consensus on the most important burdens raised by carers for inclusion in the CAT (Phase 1) subsequently rated and ranked by professionals and carers (Phases 2 and 3).

Methods

Phase 2: A two-round Delphi survey was conducted with carers, health and social care professionals and organisations supporting carers. Round 1 involved 44 burdens in eight main themes. Round 2 contained 29 burdens which had been rated as‘extremely important’or where a high level of disagreement between carers and professionals existed.

Phase 3: A virtual panel, comprised of carers together with professionals from national and regional organisations with strategic roles in end-of-life care and carer support, commented on the Delphi findings ranking their top 10 burdens for inclusion in the CAT.

Results

There was a high level of agreement between the professionals and carers on the main burdens for inclusion in the CAT. Understanding the current caring situation and supporting carer's health and well-being were the main priorities. Interestingly, end-of-life planning was ranked lowest by both groups.

Conclusions

Despite the complex needs of carers clear consensus on the main burdens exists which can be utilised in an alert tool to identify increasing burden and guide appropriate targeting of support and resources.
TICKING THE BOXES FOR CULTURAL CARE AT END-OF-LIFE
Authors: Batten Lesley , Holdaway Maureen , Clark Jean , Allan Simon , Randall Clare , Marshall Bridget
Published: February 2014

Background

Clinical pathways including the Liverpool Care Pathway for the Dying Patient (LCP) construct the documentation of care in ways that can have benefits and consequences. In New Zealand unique cultural goals related to the care of patients and their families were added to the LCP, and research into their use is underway.

Aims

As part of an investigation into the utility, comprehensiveness and cultural appropriateness of the cultural goals, the aim was to examine the content of cultural care documentation to ascertain documentation practices.

Methods

A retrospective chart audit of 100 LCP documents, with 25 each from home care, aged residential care, hospital and hospice, and semi-structured interviews with stakeholders including clinical staff and managers.

Results

A number of patterns emerged including: very high rates (99% of 1360 entries) of the goals being recorded as ‘achieved’, even when one of the goals related to family needs and the family was not present; minimal documentation of cultural needs; and minimal variance documentation. In addition a further pattern related the use of the yes or no format in version 11 (rather than achieved or variance in version 12). A variance was documented only 1% of the time, however when the yes or no format was used, goals were documented as not met 20% of the time.

Conclusions

Ticking the box, or in this case, documenting an ‘A’ for achieved provides little information or evidence that the cultural goals have been addressed in an appropriate and comprehensive manner. In addition, the variance-reporting format appears to be misunderstood when documenting the care of patients who are unconscious, or families who are not present. The constraints placed on writing a holistic patient story potentially impede the meeting of cultural needs based on beliefs and values.