bluuebunny/crossref_metadata_2025 huggingface dataset:
Nurses' encounters with children in child and school health care: negotiated guidance within a given frame
Authors: Golsäter Marie , Enskär Karin , Harder Maria
Published: October 2013

Background

Throughout childhood, children take part in health visits according to a health‐monitoring programme. The visits are aimed to promote the children's development and health and to strengthen them to take own responsibility for their health. Nurses' actions when encountering children at these visits are not explored to any great extent. Exploring nurses' actions can facilitate their reflections on their actions towards children and thereby promote children's involvement in such visits.

Aim

The aim of this study was to explore nurses' actions when encountering children at health visits.

Method

A qualitative explorative design, based on 30 video recordings of health visits in child and school health care, was used in this study. These visits were ordinary real‐life health visits. The data were subjected to qualitative content analysis. The right to conduct video recordings during health visits was approved by appropriate research ethics committees.

Results

The findings show that nurses, in order to carry out the health visits, encounter children through negotiated guidance. This guidance is understood as the process through which the nurses reach agreement with the children, and is comprised of directed and pliable strategies. At one moment, the nurse can use a directed strategy to inform the child and at the next moment a pliable strategy to provide the child space within the given frame, the health‐monitoring programme. By using these strategies intertwined, the nurse can provide the child space within the given frame and, at the same time, fulfil his/her responsibility to promote children's health and development.

Conclusion

The results highlight nurses' challenging and complex assignment of guiding children to promote their engagement in the health visits, thereby enabling the nurses to promote the children's health and development according to the national health‐monitoring programme.
Trends in δ18O and δ13C values in lacustrine tufa mounds: Palaeohydrology of Searles Lake, California
Authors: Guo Xuan , Chafetz Henry S.
Published: October 2013

Four tufa facies have been identified in abundant tufa mounds that accumulated in Searles Lake, California, USA, during the Pleistocene. Covariance of δ18O and δ13C values within the tufa facies has been analysed and correlated with palaeo‐lake history. This study demonstrates that characteristics of δ18O and δ13C values are different in each of the tufa facies and can be related to palaeo‐lake stages. The first facies of tufa formation (P) has relatively low average δ18O and δ13C values (δ18O = −2·7‰ and δ13C = +1·2‰, n = 14). These low values are attributed to rapid increases in the lake volume. This increase was followed by higher average δ18O and δ13C values of both the nodular (N) facies (δ18O = +1·8‰ and δ13C = +4·1‰, n = 24) and the columnar (C) facies (δ18O = +0·6‰ and δ13C = +4·0‰, n = 7). These higher values are interpreted to record a decrease in lake volume due to high evaporation and increased biogenic productivity. Following formation of facies C, the lake was essentially dry during formation of the finely laminated (LC) facies. Facies LC formed subaerially as spring water flowed up through the central conduit of the mounds and cascaded down their periphery. The relatively high δ18O and δ13C values for this facies (δ18O = +1·4‰ and δ13C = +4·4‰, n = 12) are due to evaporation and fast CO2 degassing. Although covariant trends are well‐displayed, variations in lake chemistry alter some of these trends due to periods of hyper‐alkalinity. This study confirms the utility of stable isotopic analyses of lacustrine tufa facies to determine palaeo‐lake history.
Continuous Invertibility and Stable QML Estimation of the EGARCH(1,1) Model
Authors: Wintenberger Olivier
Published: October 2013

I introduce the notion of continuous invertibility on a compact set for volatility models driven by a stochastic recurrence equation. I prove strong consistency of the quasi‐maximum likelihood estimator (QMLE) when the quasi‐likelihood criterion is maximized on a continuously invertible domain. This approach yields, for the first time, the asymptotic normality of the QMLE for the exponential general autoregressive conditional heteroskedastic (EGARCH(1,1)) model under explicit but non‐verifiable conditions. In practice, I propose to stabilize the QMLE by constraining the optimization procedure to an empirical continuously invertible domain. The new method, called stable QMLE, is asymptotically normal when the observations follow an invertible EGARCH(1,1) model.
Oral quercetin supplementation hampers skeletal muscle adaptations in response to exercise training
Authors: Casuso R. A. , Martínez‐López E. J. , Nordsborg N. B. , Hita‐Contreras F. , Martínez‐Romero R. , Cañuelo A. , Martínez‐Amat A.
Published: October 2013

We aimed to test exercise‐induced adaptations on skeletal muscle when quercetin is supplemented. Four groups of rats were tested: quercetin sedentary, quercetin exercised, placebo sedentary, and placebo exercised. Treadmill exercise training took place 5 days a week for 6 weeks. Quercetin groups were supplemented with quercetin, via gavage, on alternate days throughout the experimental period. Sirtuin 1 (SIRT1), peroxisome proliferator‐activated receptor γ coactivator‐1α mRNA levels, mitochondrial DNA (mtDNA) content, and citrate synthase (CS) activity were measured on quadriceps muscle. Redox status was also quantified by measuring muscle antioxidant enzymatic activity and oxidative damage product, such as protein carbonyl content (PCC). Quercetin supplementation increased oxidative damage in both exercised and sedentary rats by inducing higher amounts of PCC (P < 0.001). Quercetin supplementation caused higher catalase (P < 0.001) and superoxide dismutase (P < 0.05) activity in the non‐exercised animals, but not when quercetin is supplemented during exercise. Quercetin supplementation increased SIRT1 expression, but when quercetin is supplemented during exercise, this effect is abolished (P < 0.001). The combination of exercise and quercetin supplementation caused lower (P < 0.05) mtDNA content and CS activity when compared with exercise alone. Quercetin supplementation during exercise provides a disadvantage to exercise‐induced muscle adaptations.
An Examination of Various Methods of Minimising Strain Gradients in 3D Embedded Strain Gauge Analysis
Authors: O'Driscoll C. , Stanley W. , Little E. G.
Published: October 2013

This paper is a review of different methods used to reduce the effect of strain gradients in experimental models with 3D embedded strain gauged transducers. A detailed analysis of various methods used in relation to research carried out on a prosthetic hip implant is investigated. The methods to reduce these gradient effects detail the importance of the selection of the most suitable 3D transducer pattern and establishing the locations on the model where strain gradients are least problematic. It is also shown that the use of large‐scale models helps minimise the effect a gradient may have on data. Another way of avoiding strain gradients is to use axisymmetric models and embed the gauges at the same radius in the model but at a different angular orientation from the central axis. The strain gradient across the 3D embedded strain gauge transducer can be reduced using the methods described here so that significant errors in the final tensor do not materialise.
Phylogeny of xanthopygine rove beetles (Coleoptera) based on six molecular loci
Authors: CHATZIMANOLIS STYLIANOS
Published: October 2013

The rove beetle subtribe Xanthopygina (Coleoptera: Staphylinidae: Staphylininae: Staphylinini) is a species‐rich group of 27 neotropical genera that contains some of the largest and most brightly coloured of all staphylinid beetles. The monophyly of the subtribe has never been tested before, using a large dataset of taxa and genes. Bayesian and maximum likelihood analyses are used on individual genes (COI, 28S rDNA, wingless, arginine kinase, CAD and topoisomerase I) and the partitioned concatenated dataset to test for monophyly and examine the relationships among Xanthopygina genera. Xanthopygina (excluding Philothalpus) are shown to be a monophyletic group with strong support values. The genus Philothalpus is removed from Xanthopygina and placed in the tribe Staphylinini as incertae sedis. Four distinct clades of Xanthopygina genera are recognized. The origin of Xanthopygina is hypothesized to be in the Late Cretaceous or later and the origin of myrmecophilous adaptations is discussed.
Elizabethkingia species sepsis after lung transplantation: case report and literature review
Authors: Ramanan P. , Razonable R.R.
Published: October 2013

Elizabethkingia species are environmental bacteria that rarely cause infection in neonates and immunocompromised adults, usually as part of nosocomial outbreaks. We report an isolated fatal case of disseminated Elizabethkingia species infection in a lung transplant recipient and review the literature of this bacterial infection in transplant recipients.
Aztreonam for febrile neutropenia in patients with beta‐lactam allergy
Authors: McCullough B.J. , Wiggins L.E. , Richards A. , Klinker K. , Hiemenz J.W. , Wingard J.R.
Published: October 2013

Background

Beta‐lactam antibiotics are the mainstay of empiric therapy for febrile neutropenia. Aztreonam may benefit certain patients because of a lack of cross‐hypersensitivity to penicillins and cephalosporins. This is the first study, to our knowledge, to evaluate the efficacy of aztreonam as monotherapy for febrile neutropenia (FN).

Methods

Our study was a single‐center retrospective chart review of patients ≥18 years of age receiving aztreonam for the treatment of FN. Primary outcome was treatment success of aztreonam monotherapy. Secondary analyses included need for modification to antimicrobial therapy, patients transitioned to aztreonam from another empiric regimen, and patients receiving aztreonam in combination with other antibacterial agents.

Results

In patients prescribed aztreonam for first fever, 11 of 27 (40.7%) patients who received aztreonam alone and 19 of 40 (47.5%) given aztreonam plus another antibiotic responded within 96 h (P = 0.62). Twenty‐four (89%) patients prescribed aztreonam monotherapy were alive when FN resolved or treatment ended. Infectious mortality was low (1 patient, 3.7%). In patients prescribed aztreonam monotherapy following an adverse reaction to cefepime, 6 of 11 (54.5%) responded within 96 h of initiating aztreonam; 10 (91%) were alive when FN resolved or treatment ended.

Conclusion

Aztreonam monotherapy may be acceptable for use in patients with a history of beta‐lactam hypersensitivity or following an adverse reaction with another beta‐lactam. Further studies are needed to compare efficacy of aztreonam monotherapy with other therapies for the treatment of FN.
Proteomic evidence for genetic epistasis: ClpR4 mutations switch leaf variegation to virescence in Arabidopsis
Authors: Wu Wenjuan , Zhu Ying , Ma Zhaoxue , Sun Yi , Quan Quan , Li Peng , Hu Pengzhan , Shi Tieliu , Lo Clive , Chu Ivan K. , Huang Jirong
Published: October 2013

Chloroplast development in plants is regulated by a series of coordinated biological processes. In this work, a genetic suppressor screen for the leaf variegation phenotype of the thylakoid formation 1 (thf1) mutant combined with a proteomic assay was employed to elucidate this complicated network. We identified a mutation in ClpR4, named clpR4‐3, which leads to leaf virescence and also rescues the var2 variegation. Proteomic analysis showed that the chloroplast proteome of clpR4‐3 thf1 is dominantly controlled by clpR4‐3, providing molecular mechanisms that cause genetic epistasis of clpR4‐3 to thf1. Classification of the proteins significantly mis‐regulated in the mutants revealed that those functioning in the expression of plastid genes are oppositely regulated while proteins functioning in antioxidative stress, protein folding, and starch metabolism are changed in the same direction between thf1 and clpR4‐3. The levels of FtsHs including FtsH2/VAR2, FtsH8, and FtsH5/VAR1 are greatly reduced in thf1 compared with those in the wild type, but are higher in clpR4‐3 thf1 than in thf1. Quantitative PCR analysis revealed that FtsH expression in clpR4‐3 thf1 is regulated post‐transcriptionally. In addition, a number of ribosomal proteins are less expressed in the clpR4‐3 proteome, which is in line with the reduced levels of rRNAs in clpR4‐3. Furthermore, knocking out PRPL11, one of the most downregulated proteins in the clpR4‐3 thf1 proteome, rescues the leaf variegation phenotype of the thf1 and var2 mutants. These results provide insights into molecular mechanisms by which the virescent clpR4‐3 mutation suppresses leaf variegation of thf1 and var2.
Papillomavirus‐associated multicentric squamous cell carcinoma in situ in a cat: an unusually extensive and progressive case with subsequent metastasis
Authors: Ravens Philippa A. , Vogelnest Linda J. , Tong Lydia J. , Demos Lauren E. , Bennett Mark D.
Published: October 2013

Background

Multicentric squamous cell carcinoma in situ (MSCCIS) is an uncommon cutaneous disease of middle‐aged to older cats, with some cases being linked to papillomavirus infection. The disease course is usually benign. Initial eruption of multifocal, pigmented, hyperkeratotic plaques is typical, with gradual progression to thickly crusted ulcerative lesions.

Animal

A 5‐year‐old male neutered Devon rex cat in apparent good health was initially presented with a 16 month history of over 40 nonpruritic dorsally distributed hyperpigmented patches. Lesions progressed gradually over 2 years to larger, more pigmented, crusted plaques and ulcerated nodules. At 7 years of age the cat developed neurological signs and systemic illness and was euthanized.

Methods and results

Initial skin histopathology revealed discrete regions of epidermal and follicular epithelial hyperplasia, with moderate numbers of apoptotic keratinocytes, and mild focal epithelial dysplasia. A diagnosis of erythema multiforme was considered; feline herpesvirus‐1 immunohistochemistry was negative. Repeat histopathology 22 months after initial presentation confirmed MSCCIS with foci of invasive squamous cell carcinoma (SCC). Postmortem examination 1 month later revealed SCC within the thoracic wall, lungs and vessels of the thoracic spinal cord and heart base, presumed to be metastases from skin lesions. Fluorescent in situ hybridization of initial and later histopathology samples was positive for Felis domesticus papillomavirus type 2. Immunoreactivity of p16 was prominent within early and late cutaneous lesions and internal SCCs.

Conclusions

This case represents an unusual presentation of papillomavirus‐associated MSCCIS with extensive lesions, atypical initial histopathology and progression to SCC with distant metastases.
Dacryocystography in a cat with orbital pneumatosis
Authors: Meomartino Leonardo , Pasolini Maria P. , Lamagna Francesco , Santangelo Bruna , Mennonna Giuseppina , Della Valle Giovanni , Lamagna Barbara
Published: October 2013

A 2‐year‐old neutered male European short‐haired cat was presented for a persistent discharge from the scar of previous left eye enucleation, performed 6 months prior by the referring veterinarian. A surgical exploration of the orbit was performed and retained nictitating membrane glandular and conjunctival tissues were removed. Eleven days later, the cat developed an orbital pneumatosis caused by retrograde movement of air through a patent nasolacrimal system and diagnosed by survey radiographic examination of the skull. Nasolacrimal system patency was assessed by dacryocystography performed by injection of iodinated contrast medium under pressure into the orbital cavity. Computed tomography dacryocystography confirmed the radiographic findings. The condition resolved following dacryocystography, possibly as an inflammatory response to the contrast medium. To our knowledge, this is the first case of orbital pneumatosis reported in a cat.
An unusually high troponin I result in association withLegionellainfection
Authors: Gill Abhijit , Dubrey Simon William
Published: October 2013

A 77-year-old man presented himself with shortness of breath that was initially felt to be due to an acute coronary event, largely due to a very elevated troponin I result and his medical history. He subsequently showed evidence to suggest a significant pneumonia. The most likely candidate organism responsible, from the history and test results, appeared to beLegionella. We present the case for a spuriously and extremely elevated troponin I result, being at least in part due the production of heterophil antibodies byLegionella.
Reducing Hospital Stay in Neonates with Suspected Sepsis
Authors: Somauroo James , Nyika Linda
Published: October 2013

'Suspected sepsis' is one of the most commonly made diagnoses on any neonatal intensive care unit (NICU). Most neonates are discharged after 48 hours following negative blood culture results, thus inefficient analyses of these samples leads to delays in discharge. A baseline study demonstrated that, on average, discharge was delayed by four hours per neonate, with a range of up to 21 hours, with the longest delays being incurred as samples were not being analysed when they were received by the microbiology department out of hours. Furthermore, problems were due to increase, as the microbiology department was imminently moving to another hospital. In the short term, samples were couriered to another microbiology department, which incubates them overnight. The long-term solution is for the department to purchase their own in-house analyser, for which a business case was developed, presented, and agreed to by the lead neonatal consultant. Unfortunately, the Trust does not believe the venture is financially viable at present.
Can a multi-factorial assessment and interventional programme decrease inpatient falls in an elderly care ward?
Authors: Gibson Rebecca SJ , Heaney April , Hull Karen
Published: October 2013

Each year approximately 282,000 inpatient falls are reported to the National Patient Safety Agency (NPSA). A significant number result in death, or moderate to severe injury. (1) Research shows that falls may be reduced by 18 to 31% through multi-factorial assessments and interventions. (4) If a fall cannot be prevented, the patient should receive a prompt and effective response to achieve the best possible recovery and avoidance of further falls.

Using 'Plan-Do-Study-Act' learning cycles, our aims were to decrease the inpatient falls rate in an Elderly Care ward by 20% and to improve post-fall care. A baseline audit reviewed incident report forms to establish the number of falls per 1000 patient bed days for one calendar year; the baseline falls rate was 14.70 falls per 1000 bed days between November 2010 and October 2011. A care plan to highlight at-risk patients and allow adaptation of care, a 'walking-stick' incentive poster to encourage nursing staff, and post-fall guidelines, were introduced. Feedback sessions with ward staff and a re-audit were organised subsequent to each intervention. Completion of the care plan was monitored to improve compliance. A re-audit at one year was conducted to assess impact.

Feedback was positive regarding the interventions. Monthly monitoring of care plans achieved a compliance rate of 89% and highlighted up to 81% of patients were considered high-risk. The inpatient falls rate, re-audited at one year, was 12.44 falls / 1000 patient bed days, November 2011 to October 2012; a 15.4% reduction.

This study demonstrates a 15.4% reduction in falls through use of a multi-factorial assessment and care plan and an incentive poster. As we are yet to obtain our initial goal of 20%, implementation and re-audit is ongoing.
Rapid access rather than open access leads to improved effectiveness of an ENT emergency clinic
Authors: Smyth Catherine , Moran Michael , Diver Catherine , Hampton Susanne
Published: October 2013

An Ear, Nose and Throat (ENT) emergency clinic provides important access to specialist care for patients referred by General Practitioners (GPs), Emergency Departments and doctors on non-ENT hospital wards. The aim is to enable the prompt diagnosis and management of acute conditions, within an optimum environment containing appropriate clinical and staff resources.

Amid concerns that an open access ENT casualty service had become overburdened we performed a four week audit of all attendances. We identified 45% of patients presenting to the clinic without having evidence of first accessing primary care assessment or treatment. Waiting times were unpredictable, averaging 75 minutes and clinic numbers above those recommended to be safe in national guidelines. 60% of attendances to the department were judged to be inappropriate.

Subsequently the ENT emergency service was changed to an appointment based Rapid Access Clinic, with an easily accessible and prompt triage facility provided by a trained triage nurse. Concurrently the opportunity was taken to improve record keeping and formalise post consultation communication.

Re-audit confirmed a 43% reduction in the number of patients accessing the ENT emergency clinic facility, allowing individual clinic numbers to fall to safe levels. Average patient waiting times fell by 70% to 22 minutes. The number of referrals judged to be inappropriate was halved.

The transformation of our service has enabled time and resources to be more effectively directed towards a smaller number of patients, whose needs are more urgent.
Emergency suction equipment: barriers to use and effective interventions
Authors: Carpenter Alexander , Glenn Laura
Published: October 2013

Both investigators had personally experienced situations when they were let down by emergency suctioning equipment on the wards: due to either lack of, or operator inability to use, equipment. Failings in emergency suction have been highlighted in a recent National Patient Safety Agency signal.

We focused on improving the usability of cardiac arrest trolley suction: a complex process involving turning a small, hidden lever. We produced three clearly visible bright labels which provided simple prompts to the operator.

Two wards and two sampling periods were used in a randomised controlled design. Medical, nursing and allied healthcare staff participated. A scenario of a vomiting patient was given and staff were asked to use emergency suction. This was timed.

On the control ward, 5/10 staff members were able to successfully suction on day 1 and the mean time spent trying to activate suction was 43 seconds. On the second sampling day 6 were able to successfully suction and the mean time taken was 50 seconds. On the intervention ward, 7/10 staff members were able to suction with a mean time of 53 seconds spent. Post-intervention, all 10 staff members successfully suctioned with an average time of 30 seconds. The intervention gathered strongly positive feedback. These interventions are being incorporated into sustainable systems changes.

Poor equipment design is a needless distraction during an emergency in a busy ward setting. Simple, innovative solutions provide assistance in a pressured situation. Ideally these would become uniform and lead to a culture shift towards simple, intuitive design.
Using a proforma to improve standards of documentation of an orthopaedic post-take ward round
Authors: Duxbury Oliver , Hili Stephanie , Afolayan John
Published: October 2013

In Trauma and Orthopaedics, a daily Trauma Meeting (TM) occurs, where the previous 24-hour take is discussed and a management plan is decided by the consultant on-take. The post-take ward-round (PTWR) usually follows. In the district general hospital (DGH) where this audit was conducted, clinical incidents and root-cause analysis revealed that the TM/PTWR documentation were suboptimal.

We identified gold standards. Variables included clear documentation of PTWR, date/time, consultant on-take, clinician leading the ward-round, and management plan. 50 cases were reviewed retrospectively.

72% were seen on PTWR. 47% of these were clearly labeled PTWR. 64% of the cases not seen on PTWR were weekend admissions. Documentation of the previously mentioned fields were also poor.

Audit results were presented at the department meeting and a Trauma Meeting/Post-Take Ward Round Proforma was implemented. A prospective re-audit of 50 cases revealed that patients not seen on a PTWR decreased to 18%; 4% of these were weekend admissions. 88% of patients seen had a proforma completed. 18% of all cases did not have a proforma.

Introduction of the proforma established a system to document discussions at the TM and improved the quality of documentation of the consultant-led plans. Such a simple tool can improve the overall care of patients and potentially protect staff.
Preventing the co-prescription of tamoxifen and fluoxetine in General Practice
Authors: Stonier Thomas , Harrison Michael
Published: October 2013

In 2010 a population-based cohort study showed that there was decreased efficacy of the breast cancer drug tamoxifen when used in combination with fluoxetine, a commonly used SSRI antidepressant. The aim of this project was to identify patients who may be affected by this co-prescription and suggest a change in medication. The project was conducted across two GP practices in Clevedon (The Riverside Practice & The Green Practice), Bristol. The patients were all from the active patients register at each surgery. A search was conducted to find all those on tamoxifen and fluoxetine, using the EMIS computer system. These patients would then be sent a letter to attend clinic. The new data would then be discussed with them before recommending a change of antidepressant (typically to sertraline). Three patients were found to be on both medications. They were all called into clinic and changed from fluoxetine to sertraline. Furthermore a presentation was given to all GPs at the two surgeries alerting them to the new guidelines. A message was also set up to flash on the computer system whenever an attempt was made to co-prescribe the two drugs. All the patients on tamoxifen in these two practices are now receiving the optimum treatment. Furthermore interventions have been put in place to ensure that this remains the case in future. Another data collection should be conducted in one year. This project provides a good example of how this problem could be resolved at other GP surgeries.
Bidding for and setting up a Comprehensive Stroke Unit
Authors: Cohen David , Fenwick Elliott Sue
Published: October 2013

Northwick Park is a district teaching hospital in NW London. In Jul 2009, Healthcare for London agreed to commission hyperacute stroke care in only eight units. These had to provide guaranteed minimum staffing levels, daily ward rounds including weekends and public holidays, and thrombolysis (clotbusting) treatment) 24/7. We were the only unit to bid that was not already a major neurology centre. Our successful bid had to be implemented to a very tight timetable and has now been operating for three years. Our results are audited nationally and demonstrate the success of the project. Before the project the Unit had 20 beds, one consultant and only three whole time equivalent therapists. We had thrombolysed 12 patients in two years. Patients did not go straight to the Stroke Unit from A&E. Although our rehabilitation processes were good we were limited by patients having to wait to get onto the Unit and by staff numbers. Now, there are 50 beds and over 130 staff. Performance is intensively monitored by the Stroke Network. Every patient is entered into the Royal College of Physicians continuous audit, and assessed against national standards. Our reputation is national and we have hosted teams from many units in the UK and abroad to demonstrate our processes and pathways. We conclude that with good planning, robust care pathways and a strong local management team backed by financial and Board level support, it is possible to implement a widespread change in treatment of a common and disabling condition.
Improving spinal trauma management in non-specialist centres
Authors: Magnussen Alex , Galloway Kate , Dinneen Alexander
Published: October 2013

Fractures of the vertebral column are increasing in incidence. Even though spinal trauma is increasingly being managed in specialist units, these patients often still initially present to district general hospitals. Due to lack of exposure to these patients, the attending Orthopaedic Senior House Officer may not always be aware of current best practice in the acute management of these patients beyond immediate Advance Trauma Life Support measures.

There is concern that initiation of management may be delayed as a result of lack of a concise documented plan. The physiotherapy team requires specific instructions from the orthopaedic team before they can attempt to mobilise these patients. Lack thereof may lead to inappropriate prolonged immoblisation, prolonged hospital admission and, as a result, medical complications such as aspiration pneumonia, other nosocomial infections or pressure sores.

An audit of departmental practice in two district general hospitals in the London and KSS deaneries demonstrated that a lack of easily accessible guidelines led to delays in definitive management of these patients with several episodes of medical concern.

A proforma was devised in conjunction with the physiotherapy department and the regional spinal orthopaedic service in order to aid doctors in formulation of these management plans. These were rolled out effectively in both centres and re-audit in the first centre demonstrated marked improvement in patient care. Re-audit in the second hospital is ongoing.
Facillitating diabetes care - a community approach
Authors: Goulder Tim , Kar Partha
Published: October 2013

Instigated through the vision of a local GP, the South East Hampshire Community Diabetes Team (CDT) is provided by Southern Health NHS Foundation Trust. Through taking an integrated, multidisciplinary, community based specialist approach, the team works in partnership with colleagues across primary and secondary care. The team support care of both newly diagnosed people with diabetes (PWD), and those requiring ongoing follow up, unless they fall into the 'super six' categories. The key focus of the team is to optimise the knowledge and self management of diabetes through clinician and patient education programmes.
An inter-professional education programme for diabetes care in London
Authors: Ching Daniel L , A Earle Kenneth
Published: October 2013

Over the years there has been a steady increase in avoidable referrals from primary to secondary care for newly diagnosed diabetic patients. Audits have shown that diabetes referral rates were rising yearly. Secondary care is becoming overwhelmed with the heavy workload and increasing cost, which also led to compromising care for complex patients. This led to the design and implementation of a diabetes based inter-professional education (IPE) programme.

The IPE programme was taught in cycles. Each cycle consists of 10 sessions. One session was taught for one afternoon a week over 10 weeks. On the 11th week an OSCE style end of course assessment was performed. Health care professionals (HCPs) from different professions were taught in the same classroom, using the same material.

A re-audit of diabetes referral rates showed a change in referral ratio post-programme. Qualitative interviews using Kirkpatrick and Barr's hierarchy were performed 2 years post-programme to assess learners' outcomes. Results show that the effects of the programme were sustained beyond 2 years and that these changes were carried into practice. There was a change in HCPs attitude and perception and more importantly it showed improvement in patient outcomes. This represents a novel IPE programme for diabetes care which has shown to be able to increase confidence, capacity and scope of care provided by HCPs in the community.
How can we reduce violence and aggression in psychiatric inpatient units?
Authors: Antonysamy Arokia
Published: October 2013

The inpatient environments in psychiatric units are not always conducive to patients' recovery. Male patients can easily feel bored especially when they are not interested in indoor activities like arts and crafts. Outdoor activities were little explored in our psychiatric intensive care unit and partly this may reflect a 'risk averse' approach. Like a pressure cooker, the patients' anger and frustration build up and unfortunately they may lash out on staff and other patients placing them at risk. The incidents of violence and aggression in our unit rose to 482 in 2011.

The Blackpool zoo was close to our unit and it was felt that our patients may benefit a weekly trip to the zoo. Other activities like computer and gym sessions were maintained. Although there were initial reluctance and anxiety amongst staff to escort patients outside the unit, regular support and encouragement made them more confident and less risk averse. Our patients provided lots of positive feedback and felt better equipped to 'fit in' with their community after discharge. The initial discrimination against our patients at the zoo slowly transformed into partnership working and the authorities at the zoo have offered a training programme for our patients on animal care and hygiene. Over a period of 12 months, the incidence of aggression and violence in the ward reduced to 126. The average length of stay reduced by about 50%. We also discharged patients who recovered remarkably well, directly from the unit rather than stepping down to acute wards. Staff motivation and enthusiasm continued to improve and this was reflected in the reduction in staff sickness rates by more than 50%. Student nurses and doctors were able to understand the positive aspects of patients' lives and skills and felt able to boost their hope and determination.
The utilisation of the MUST nutritional screening tool on vascular surgical wards
Authors: Tewari Nilanjana , Rodrigues Jeremy , Bothamley Lydia , Altaf Nishath , Awad Sherif
Published: October 2013

Whilst malnutrition is prevalent in approximately 40% of general surgical patients, the prevalence of malnutrition and nutritional screening practices amongst vascular patients remain unknown. The Malnutrition Universal Screening Tool (MUST) is recommended for risk screening and provides 3 scores for risk classification: 0=low risk, 1=intermediate risk, 2=high risk. The aim of this preliminary study was to evaluate the use of MUST on vascular wards.

This prospective study was undertaken in a tertiary referral vascular unit in the UK. Patient demographics, utilisation of MUST by nursing staff (N-MUST) and referral to nutritional support teams (NST) were studied. When MUST was not completed by nursing staff, the study team (S-MUST) performed it.

Fifty-three patients, median (interquartile range, IQR) age 67 (59-75 ) years were initially studied. For N-MUST: Overall MUST score was recorded in 18/25 (72%) patients, of whom 1 (4%) scored 2, whilst the remainder scored 0. For S-MUST: Overall MUST scores were recorded in 28 patients, MUST=0 in 75% and ≥2 in 21%.

An educational session on use of MUST was delivered to nursing staff, as well as a Trust-wide educational initiative to improve assessment of nutritional status and, after a 2-month period, the study was repeated. The second cohort comprised forty-two patients, median (IQR) age 72 (64-79) years. For N-MUST: Overall MUST score was recorded in 37/40 (93%) patients, of whom 3 (8%) scored ≥2. For S-MUST: Overall MUST scores were recorded in 2 patients, MUST = 0 in 67% and ≥ 2 in 33%.

Despite the ease of use of MUST, it was under-utilised on vascular wards. However, following provision of a dedicated educational programme to ward nursing staff, utilisation of MUST for risk scoring patients on admission increased to over 90%.
Delivering preference for place of death in a specialist palliative care setting
Authors: Oxenham David , Finucane Anne , Arnold Elizabeth , Russell Papiya
Published: October 2013

Over the last 10 years, one of the key themes of public policy in palliative care has been achievement of choice in place of death.

In Marie Curie Hospice Edinburgh a baseline audit conducted in 2006 showed that only a small proportion (18%) of patients referred to hospice services died at home. The audit also revealed that only 31% of those who expressed a preference to die at home were able to do so, whereas 91% of those who chose a setting other than home achieved their preference. Overall achievement of preferred place of death was 56%. However a significant number of patients (29%) did not have a recorded preference.

A programme of quality improvement has continued over the last 7 years to improve identification, communication and achievement of preferred place of death for all patients. The mechanisms to change practice have been: changes to documentation; changes to clinical systems to support use of documentation; support for clinical staff to recognise the value of discussing preferences; and support for clinical staff to develop new skills. In addition the programme has been incorporated into local clinical strategy and this has enabled gaps in service to be addressed with a new service to support early discharge of those patients who wish to die at home.

A recent audit showed that all patients had a recorded preference or a documented reason why their preference was unclarified. One third of patients died at home – nearly double the proportion that died at home in the baseline audit. Seventy one per cent of patients who wished to die at home actually died at home - a substantial increase from 31% at baseline. Achievement of preferred place of death for patients wishing to die in the hospice remained high at 88%.

The focus on assessment of preference for place of death has led to substantial improvements in the identification and achievement of preference for patients dying under the care of the hospice. Furthermore, it has been associated with an increase in the overall proportion of patients who die at home.
Improving treatment provision of Wet AMD with intravitreal ranibizumab
Authors: Ghazala Fadi , Hovan Marta , Mahmood Sajjad
Published: October 2013

Wet age-related macular degeneration (AMD) treatment using intravitreal ranibizumab needs to be started as soon as possible and treatment must be administered based on regular review to achieve the best results. In clinical practice this tight schedule is a challenge and methods of carrying out such timely treatment is the objective of this quality improvement work. A departmental audit was carried out on the service providing treatment for patients with wet AMD in 2009. This audit identified that the appointment system did not meet the ideal standards and subsequently wet AMD patients' visual outcome were poorer than the standard set in trials where the patients were seen and treated at predetermined intervals. In order to enhance the visual benefit of the administered therapy for our patients we thought it necessary to find ways to see and treat patients sooner as well as reduce time intervals between follow-up appointments. The quality improvement was carried out through redesigning the service in the macular treatment centre of Manchester Royal Eye Hospital. Three main strategies were implemented including: changes to the appointment system, expansion of the treatment facility and employment of additional staff. Following changes made, regular re-audits were used to analyse the effectiveness of the new strategies. The changes introduced have brought appointment standards to the level of Royal College of Ophthalmologists' recommendations. Consequently visual outcomes were approaching the standards set by landmark studies. The visual improvement of treated patients seen in the 2011 audit are comparable to other reports outside clinical trials in the UK. In order to enhance the efficacy of ranibizumab for wet AMD it is essential for treatment to be initiated as soon as possible and administered to patients at the recommended time intervals. The actions we have taken were effective in helping develop a service performing to higher standards.
Telephone consultations in primary care, how to improve their safety, effectiveness and quality
Authors: Khan Muhammad Naseer Babar
Published: October 2013

Consultations on telephone are ever increasing especially in primary healthcare. Currently the estimated total number consultations in England rose from 224.5 million to 243.1 million in 1995/1996 to 303.9 million to 313.6 million in 2008/2009, out of which 3% of consultations in 1995/1996 were telephone consultations which increased to 12% in 2008/2009. Literature search was done on published articles on tele-healthcare which resulted in devising a telephone consultation model. An audit was carried out in urban Cambridge family practice over the period of one year after implementing this telephone consultation model. Following proposed consultation model by healthcare staff, it has improved patient satisfaction survey from 75% to 94%, face to face consultation rate was reduced by 1.6%, home visits were reduced by 2.9% however the direct economic saving could not be determined. Further research is required to assess the detailed economic analysis of using effective telephone consultation in healthcare. The data shown in this article is related to primary care in the UK, but its concept can be replicated by any country in Europe or rest of the world providing primary healthcare to public.
Written medical discharge communication from an acute stroke service: a project to improve content through development of a structured stroke-specific template
Authors: Mäkelä Petra , Haynes Chiara , Holt Katherine , Kar Arindam
Published: October 2013

Specific guidelines for the content of discharge summaries from acute stroke services do not currently exist. The aims of this project were to assess the strengths and weaknesses of stroke discharge communication from Imperial College Healthcare NHS Trust, to develop a structured template to guide completion, and to re-audit discharge communication following its implementation. The audit compared local performance against record standards from the Academy of Medical Royal Colleges (1), which was augmented by criteria generated from the British Association of Stroke Physicians (BASP) Stroke Service Standards (2). Discharge information was examined within the Trust’s Electronic Discharge Communication (EDC) system to determine the recording of selected items for consecutively discharged patients from the hyperacute and acute stroke units. The audit was repeated following implementation of a newly developed stroke-specific discharge summary template. Fifty-one EDC summaries were examined at baseline (July 2012) and 30 summaries at re-audit (January 2013). The criteria which showed low adherence initially and which showed the most significant improvement following the introduction of the template were the guidance on blood pressure and lipids targets (increased from 2% and 0% respectively at baseline, to 93% post intervention), and the driving and flying advice (from 3% to 79%). Documentation was also seen to improve for measures of physical and cognitive function, discharge arrangements, and follow up plans.

This audit cycle has demonstrated improvement in the consistency of content within written discharge communication following the introduction of a structured stroke-specific template adhering to combined criteria from identified standards.
Checklist clerking document improves health promotion among medical admissions
Authors: Cousins Sarah
Published: October 2013

Health promotion, as defined by the Ottawa Charter (1) is the 'process of enabling people to increase control over, and to improve their health'. Four life style risk factors: smoking, alcohol, obesity and physical activity are recognised as leading to health inequalities. These factors have implications at an individual, community and national level and the burden of disease has large cost implications for the NHS and country as a whole. Therefore the assessment of these risk factors, and the provision of good health promotion assist to address these problems. A pilot and initial audit demonstrated that assessment for the key life style risk factors and the provision of health promotion was poor. This quality improvement audit developed an easy to use, checklist based, amended clerking document. This improved both assessment and provision of health promotion and will be carried forward to influence the designing of a new clerking document.
Introduction of 'Anaphylaxis Packs' to improve patient safety in a hospital setting
Authors: Meade Susanna , Douglas Jenny
Published: October 2013

Three reported episodes of anaphylaxis, where 1:1000 adrenaline was not immediately obtainable, triggered us to assess its availability on all adult wards. We found adrenaline was unavailable on 50% of audited wards. A questionnaire for doctors and nurses revealed lack of knowledge on both the management of anaphylaxis and location of emergency drugs. Given that anaphylaxis is a treatable but potentially fatal condition, we held a meeting to discuss the situation with senior pharmacists, resuscitation managers, and senior doctors. Our intervention was to advise the production of 'anaphylaxis packs' as part of the crash trolley kit. This was to be added to the laminated crash trolley check list and to include adrenaline, chlorphenamine, hydrocortisone, and the anaphylaxis algorithm. The aim was to improve ward stock, staff knowledge, and create a consistent location for emergency drugs, so minimising human error, and patient harm. With a PDSA approach we trialled the intervention on four pilot wards. The packs have now been dispersed trust-wide. Re-audit at four months showed 100% ward stock of anaphylaxis packs, more consistent drug location and improved staff knowledge. There were 17 coded incidents of anaphylaxis at this hospital in 2011, the actual figure likely being higher. We feel our project has greatly improved patient safety in this area.
Therapeutic Effects of Chinese Osteopathy in Patients with Lumbar Disc Herniation
Authors: Zhang Wei , Guo Wei , Zhao Ping , Zhou Wei , Wei Jie , Li Xi-De , Liu Liang
Published: October 2013

A clinical study was conducted in 72 lumbar disc herniation (LDH) patients and 40 asymptomatic subjects to evaluate the efficacy of Feng's spinal manipulation (FSM). FSM was performed twice a week for less than 20 days. Changes in the symmetrical index of spinal column (SISC) and quantified symptom index (QSI) before and after FSM in both groups were collected. The QSI consisted of the visual analogue scale (VAS), score of the Japanese Orthopedic Association, and straight leg raising test, for measurement of pain perception, dysfunction of lower limb extension or flexion, and symptomatic relief. A correlation analysis was conducted to compare the difference in protruded nucleus pulposus size using computerized projection grating profilometry, SISC, and QSI before and after the therapy. The results showed that the SISC and QSI significantly decreased after treatment in the LDH group (p < 0.01). The SISC before and after treatment was closely correlated with the improvement of QSI, although there was no change in protruded nucleus pulposus following the therapy. Among the five components in SISC, the LR was found to be an ideal indicator for evaluation of the real circumstances in LDH patients. Our data suggested that FSM achieved satisfactory therapeutic effects in relieving the symptom of LDH while no effects were observed in asymptomatic subjects.