bluuebunny/crossref_metadata_2025_split huggingface dataset:
The State of Basic Surgical Training in the UK: Ophthalmology as a Case Example
Authors: Watson M P , Boulton M G , Gibson A , Murray P I , Moseley M J , Fielder A R 
Published: November 2017

Concern is being expressed about the state of basic surgical training in the context of growing demands to improve service provision in the National Health Service. Taking ophthalmology as a case example, we sent questionnaires to all 466 senior house officers (SHOs) in recognized surgical training posts in England, Wales, Scotland and Northern Ireland. The main outcome measures were intraocular surgery performed in the previous two weeks and since starting as an SHO in ophthalmology; access to protected teaching time or cases on theatre lists; and supervision during surgery. Phakoemulsification, the most common type of cataract surgery, was used as a generic indicator of intraocular procedures. 314 (67%) of the SHOs responded. Of those working in the hospital in the previous two weeks, 50% had performed at least one component part of a phakoemulsification (phako) operation and 44% had performed at least one full phako operation. The average number of full phako operations done per week was 0.741. 77% reported some protected surgical teaching time over the two weeks and those with protected teaching time reported more full phako operations per week. Of those who had performed at least one surgical procedure in the previous two weeks, 79% had been supervised by a consultant. Of those who had completed two or more years’ training as an SHO, only 42% met the Royal College of Ophthalmologists minimum requirement of 50 complete intraocular operations performed under supervision. Women were less likely than men, and SHOs in district general hospitals were less likely than those in teaching hospitals, to have achieved this target. As many as half the SHOs in ophthalmology are not receiving an adequate basic surgical training. If this continues it may prove difficult to train sufficient new surgeons to an acceptable standard to meet the increasing demands of an ageing population. This is not an issue for ophthalmology alone but for all surgical specialties.
Clinical Management of Children and Young Adults with Heterozygous Familial Hypercholesterolaemia in the UK
Authors: Greene Owen , Durrington Paul 
Published: November 2017

Life expectancy in familial hypercholesterolaemia (FH) has been greatly improved by the advent of statin therapy. In the UK, however, these agents are not licensed for use in children. We approached 169 physicians responsible for lipid clinics for information on their practice in young patients, and valid responses were received from 54%. A typical lipid clinic has only 3.5 patients aged under 16 with FH. In boys aged 10-15 years 65% of physicians were prepared to treat with bile acid sequestrants but only 23% with statins. There was greater reluctance to treat in girls of the same age, corresponding figures being 52% and 12%. Despite the efficacy of statins in reducing low-density-lipoprotein cholesterol, these agents are little used in children with FH. Their safety and clinical efficacy should be assessed by a randomized double-blind trial.
Prehospital Thrombolysis—Calculated Health Benefit for Catchment Population of One Hospital
Authors: Kroese Mark , Kanka David , Weissberg Peter , Arch Barbara , Scott John 
Published: November 2017

The health benefit of thrombolysis in acute myocardial infarction is greatest when patients are treated soon after onset of symptoms. One approach to reducing treatment delay is to give thrombolysis before the patient reaches hospital. When an ambulance trust proposed a prehospital thrombolysis service, local commissioners requested an estimate of its possible health impact. Clinical audit and ambulance trust data were obtained for 165 patients who received thrombolysis for acute myocardial infarction in the coronary care unit of a local hospital in one year. This information was then used to estimate the health impact of prehospital thrombolysis in the local population in a mathematical model derived from the results of trials comparing prehospital and hospital thrombolysis. The best predicted local health benefit from the proposed prehospital thrombolysis service is that, if 45 minutes can be cut off the call-to-needle time, 61 cases of acute myocardial infarction need to be treated to save one additional life at 35 days. By use of published research data, the health benefits of prehospital thrombolysis can be estimated for a local population. Variables in the treatment population and ambulance service will influence the size of the health benefit that can be achieved.
Hospital Bathrooms and Showers: A Continuing Saga of Inadequacy
Authors: Monro Andy , Mulley Graham P 
Published: November 2017

Previous surveys of UK hospitals have highlighted many deficiencies in the standards of hospital inpatient washing and bathing facilities–-especially inadequate access for wheelchair users, insufficient bathing equipment, and unsatisfactory cleanliness and privacy. We conducted a qualitative survey in three hospitals in the North of England to see whether these facilities have improved. There have been some improvements, particularly in the provision of bath hoists, adapted taps, alarm call systems, shower seats and wheelchair access to bathrooms. But many basic problems remain–-absent locks and signs, inadequate heating, poor standards of privacy, insufficient bath aids, wet floors, and the inappropriate use of bathrooms as store rooms. The overall condition of hospital bathrooms and showers remains unsatisfactory. Too many hospital bathrooms are austere, cold, smelly and poorly maintained.
Predictors for Falls among Hospital Inpatients with Impaired Mobility
Authors: Vassallo Michael , Vignaraja Raj , Sharma Jagdish C , Briggs Roger , Allen Stephen C 
Published: November 2017

Gait and balance disturbances have been shown to predispose to falls in hospital. We aimed to investigate the patient characteristics associated with an unsafe gait and to determine what features predispose to falling in this group of hospital inpatients. In a prospective open observational study we studied 825 patients admitted for rehabilitation following acute medical illness or a surgical procedure. The patient's gait was assessed with the ‘get up and go’ test and classified into one of four categories—normal; abnormal but safe with or without mobility aids; unsafe; or unable. 72.6% of patients were assessed as having an unsafe gait. The factors independently associated with an unsafe gait were confusion, abnormal lower limbs, hearing defects and the use of tranquillizers. Patients with an unsafe gait who fell were more likely than the non-fallers within the group to have had falls in the past (85.3% versus 73.8%) and to be confused (66.2% versus 34.1%). Patients with both these characteristics had a 37.5% chance of falling compared with 15.4% in patients with one and 11.2% in patients with none of these characteristics. The presence of confusion and a history of falls identifies those patients who are at greatest risk of falls. Such patients might be the focus of special efforts at falls prevention.
Needle-Stick Injuries in the National Health Service: A Culture of Silence
Authors: Elmiyeh B , Whitaker I S , James M J , Chahal C A A , Galea A , Alshafi K 
Published: November 2017

Injury by contaminated sharp instruments and needles constitutes a major occupational hazard for healthcare workers. In a confidential survey at a district general hospital, 300 healthcare professionals were asked about their personal experience of needle-stick injury and their attitudes to reporting. 279 individuals responded, of whom 38% had experienced at least one needle-stick (mean 1.8) in the past year and 74% had sustained such an injury during their careers (mean 3.0). Although 80% of respondents were aware that such incidents should be notified, only 51% of those affected had reported all needle-stick injuries. Doctors were less likely to report than nurses, despite a higher liability to injury. This survey adds to evidence of a culture of silence pertaining to needle-stick injuries. The consequent risks to health, and the ethical and financial implications, remain uncertain.
Keep in a Cool Place: Exposure of Medicines to High Temperatures in General Practice during a British Heatwave
Authors: Crichton Brian 
Published: November 2017

Exposure of medicines to high temperatures in storage or in transit could reduce their efficacy, and most licences specify storage at 25°C or less. To assess whether this criterion was being met, maximum temperatures in a general practice drug cupboard and in drug bags placed in car boots were recorded for two weeks during a British heatwave (average peak daily ambient temperature 26°C). Also, ten neighbouring dispensing pharmacies were questioned about their temperature-control policies. On every day of the study, maximum temperatures in the drug cupboard and in the car boots exceeded 25°C. Mean daily maxima (range) were: drug cupboard 30.7 (27.5-37.0); silver car 37.5 (32.0-43.5); dark blue car 41.8 (35.0-49.5). None of the local dispensaries had air conditioning or kept a temperature log. In the course of a British summer, medicines were exposed to temperatures that might in theory have reduced their efficacy. This aspect of quality control deserves more attention.
Assessment of Patient Pain at Colonoscopy: Are Nurses Better than Endoscopists?
Authors: Ramakrishnan S , Yiannakou J Y , Ellis W R , Bain I 
Published: November 2017

The pain that patients recollect having experienced at colonoscopy is likely to influence uptake of the procedure. We used visual analogue scales to assess recollected pain shortly before discharge, and compared these scores with assessments by the endoscopist and the attending nurse. Data were complete for 426 procedures (90%). The mean perceived pain score for patients was 3.2, for endoscopists 2.8 and for nurses 3.1. On multivariate analysis, the endoscopists’ assessments of pain had little predictive value over and above those of nurses, whereas nurses’ assessments remained significant when adjusted for endoscopists’ assessments. Nurses were more accurate than endoscopists in gauging the pain of colonoscopy. This may be because endoscopists are focused on the video monitor while nurses are focused on the patient. More active use of nurses’ assessments might help keep pain to a minimum.
Methicillin-Resistant Staphylococcus Aureus in a General Intensive Care Unit
Authors: Thompson D S 
Published: November 2017

Methicillin-resistant Staphylococcus aureus (MRSA) has presented special problems in intensive care units (ICUs) because of the difficulties in implementing infection control measures. The prevalence and rate of acquisition of MRSA were studied over thirty months in a nine-bed ICU. Nasal and groin swabs were taken on admission and then weekly, and other cultures as clinically indicated. Of 1361 admissions 119 were MRSA-positive on arrival. 21 cases had been identified before admission and the remainder were detected by screening; in 57 the positive result was known only after discharge. Of the 1242 admissions initially negative 68 acquired MRSA while in the ICU. The ICU had no known MRSA-positive patients on 185 (20.3%) of 914 days, the longest sequence being 17 days. Positive patients occupied 1387 (16.9%) of the 8226 available bed days. Length of stay predicted the risk of acquiring MRSA. Estimated from patients who completed each weekly screening cycle, the risk was 7.5% per week in the first week and 20.3% per week thereafter. The risk was not influenced by initial APACHE II score, the use of haemofiltration, or the number of MRSA-positive patients in the unit. The data suggest that a further 38 of those discharged between weekly screenings acquired MRSA, giving an incidence of 8.5%. MRSA was grown from blood in 17 patients, and from sputum in 53 (ICU-acquired in 18% and 47%). This study suggests that nearly 10% of admissions to a general ICU will be MRSA-positive, of whom only half will be identified before discharge. With standard prevention the risk of previously negative patients acquiring MRSA approximates to 1% per day in the first week and 3% per day thereafter, with nearly one-fifth progressing to bacteraemia; one-half will have MRSA in sputum. Patients with longer stays constitute a high-risk minority for whom additional measures such as decontamination with oropharyngeal and enteral vancomycin should be considered.
Biochemical Recovery Time Scales in Elderly Patients with Osteomalacia
Authors: Allen S C , Raut S 
Published: November 2017

Osteomalacia is not rare in the UK and climatically similar countries, particularly in elderly people and those of Asian descent. Overt clinical osteomalacia is usually treated with a loading dose of vitamin D, followed by a regular supplement. However, little is known of the time taken to reach a stable biochemical state after starting treatment. Such information would shed light on the duration of the bone remineralization phase and guide decisions on the length of follow-up. To address this we conducted a 2-year follow-up study of 42 patients (35 female, mean age 80.8 years) with biopsy proven osteomalacia treated with a standard replacement regimen and general nutritional support. Although normocalcaemia was attained within 4 weeks the mean values continued to rise, to a mid-range plateau at 52 weeks. The phosphate and alkaline phosphatase values also took at least a year to reach a stable mean, with a slight further trend towards the mid-range for the entire 104 weeks. The mean serum albumin also rose throughout the first 52 weeks, indicating an effective response to the general nutritional support measures. Our observations suggest that the dynamic relationship between calcium, phosphate and bone requires at least a year, and probably longer, to reach an equilibrium after treatment for osteomalacia in elderly patients. The findings emphasize the need for close medical and social follow-up in this clinical context.
Clinical Implications of ST-Segment Non-Resolution after Thrombolysis for Myocardial Infarction
Authors: Bhatia L , Clesham G J , Turner D R 
Published: November 2017

Failed reperfusion after thrombolytic therapy for acute myocardial infarction is common and signifies a poor prognosis. We investigated the clinical consequences of non-resolution of the ST segment after thrombolytic therapy for acute ST-elevation myocardial infarction, in 85 consecutive patients admitted to a coronary care unit lacking rapid access to angioplasty. Failed thrombolysis was defined as <50% ST-segment resolution 180 minutes after the start of thrombolytic treatment. Outcomes were measured in terms of in-hospital adverse events, length of hospital stay, and mortality at 6 weeks and 1 year. Thrombolysis was successful, in terms of ST-segment resolution, in 45 patients (53%). After adjustment for other factors, ST resolution was the only independent predictor of an uncomplicated recovery in hospital (odds ratio 6.8, 95% confidence interval 2.3 to 19.9; P < 0.001). At 6 weeks and 1 year, overall mortality was lower in the ST resolution group, though these differences became non-significant on multivariate analysis. In patients who survived to hospital discharge, median length of stay was greater in successfully thrombolysed patients (9 days versus 8 days) despite their lower rate of complications. ST-segment resolution is a useful marker of successful thrombolysis and relates to clinical outcome. If assessed routinely it might assist, along with other clinical markers, in the identification of low-risk patients who can be discharged early.
Curtailment of Higher Surgical Training in the UK: Likely Effects in Otology
Authors: Ray J , Hadjihannas E , Irving R M 
Published: November 2017

Higher surgical training in the UK faces a cut of two years. We conducted a questionnaire survey to assess the operative experience of current higher surgical trainees in otological surgery and the likely effect of the proposed reduction from six to four years. 91 (65%) of the 142 higher surgical trainees responded with details of major otological procedures performed (independently or assisting) over one year. In the present six-year scheme a typical trainee performs 72 myringoplasties, 79 mastoidectomies, 7 skull base procedures and 28 other procedures. In the first four years, however, his or her experience is only 39 myringoplasties, 44 mastoidectomies, 4 skull base procedures and 7 others. The large shortfall in experience that might result from shortening of the training programme would need to be met by intensification of the training or institution of accredited otology fellowships. Very similar dilemmas are faced by other surgical specialties.
Jaundice as a Presentation of Heart Failure
Authors: van Lingen R , Warshow U , Dalton H R , Hussaini S H 
Published: November 2017

On rare occasions the first manifestation of heart disease is jaundice, caused by passive congestion of the liver or acute ischaemic hepatitis. We looked for this presentation retrospectively in 661 patients referred over fifty-six months to a ‘jaundice hotline’ (rapid access) service. The protocol included a full clinical history, examination and abdominal ultrasound. Those with no evidence of biliary obstruction had a non-invasive liver screen for parenchymal liver disease and those with suspected heart disease had an electrocardiogram, chest X-ray and echocardiogram. 8 patients (1.2%), bilirubin 31–79 μmol/L, mean 46 μmol/L, had a primary cardiac cause for their jaundice. All had dyspnoea, an increased cardiothoracic ratio on chest X-ray and an abnormal electrocardiogram. The jugular venous pressure was raised in the 3 in whom it was recorded. In 6 patients the jaundice was attributed to hepatic congestion and in 2 to ischaemic hepatitis. All patients had severe cardiac dysfunction. Jaundice due to heart disease tends to be mild, and a key feature is breathlessness. The most common mechanism is hepatic venous congestion; ischaemic hepatitis is suggested by a high aminotransferase.
Brain Drain from Developing Countries: How can Brain Drain be Converted into Wisdom Gain?
Authors: Dodani Sunita , LaPorte Ronald E 
Published: November 2017

Brain drain is defined as the migration of health personnel in search of the better standard of living and quality of life, higher salaries, access to advanced technology and more stable political conditions in different places worldwide. This migration of health professionals for better opportunities, both within countries and across international borders, is of growing concern worldwide because of its impact on health systems in developing countries. Why do talented people leave their countries and go abroad? What are the consequences of such migrations especially on the educational sector? What policies can be adopted to stem such movements from developing countries to developed countries? This article seeks to raise questions, identify key issues and provide solutions which would enable immigrant health professionals to share their knowledge, skills and innovative capacities and thereby enhancing the economic development of their countries.
Research Governance: Where did it Come From, What Does it Mean?
Authors: Shaw Sara , Boynton Petra M , Greenhalgh Trisha 
Published: November 2017

For a variety of historical and social reasons, research has become increasingly formalized and regulated. This change has potential benefits (reduction in fraud and misconduct, protection of vulnerable groups, financial probity) but also disadvantages (increased paperwork, time delays, constraints on research freedom). The terms ‘research’ and ‘governance’ mean different things in different contexts. Even with explicit guidance, ambiguities must be resolved by human judgement. Variation in the nature and outcome of approval decisions is therefore a fact of life. The type of approval needed for a research study depends on the official remit of the approval body, the question to be addressed; the methods to be used; the context in which the work will take place; the level of analysis and interpretation; and the plans for how the findings will be presented and used.
Venous Thromboprophylaxis in Uk Medical Inpatients
Authors: Rashid S T , Thursz M R , Razvi N A , Voller R , Orchard T , Rashid S T , Shlebak A A 
Published: November 2017

We prospectively assessed the implementation of venous thromboembolism (VTE) prophylaxis guidelines and the impact of grand round presentation of the data in changing clinical practice. Two NHS teaching hospitals were studied for 24 months from January 2003. Patients were risk stratified according to the THRIFT (thromboembolic risk factor) consensus group guidelines and compared with the recommendations of the THRIFT and ACCP (American College of Chest Physicians) consensus groups. Six months following presentation of the initial results, a further analysis was made to assess changes in clinical practice. 1128 patients were assessed of whom 1062 satisfied the inclusion criteria for thromboprophylaxis. 89% of all patients were stratified as having high or moderate risk of developing VTE. Of these only 28% were prescribed some form of thromboprophylaxis–-4% received the THRIFT-recommended and 22% received the ACCP-recommended thromboprophylaxis. The vast majority (72%) received no thromboprophylaxis at all. Reassessment, following data presentation at grand rounds, showed a significant increase to 31% in patients receiving THRIFT (P<0.0001) and ACCP (P=0.002) recommended thromboprophylaxis. However, the proportion of patients receiving no form of prophylaxis barely changed (72% to 69%: P=0.59). We found a gross underutilization of thromboprophylaxis in hospitalized medical patients. A simple grand-round presentation of the data and recommended guidelines to clinicians significantly increased the proportion of patients receiving recommended thromboprophylaxis but did not increase the overall proportion of patients receiving it. We therefore conclude that a single presentation of guidelines is not enough to achieve the desired levels. Such presentations may only serve to make DVT (deep venous thromboembolism) aware clinicians prescribe prophylaxis more accurately.
A Surrealistic Mega-Analysis of Redisorganization Theories
Authors: Oxman Andrew D , Sackett David L , Chalmers Iain , Prescott Trine E 
Published: November 2017

Background We are sick and tired of being redisorganized. Objective To systematically review the empirical evidence for organizational theories and repeated reorganizations. Methods We did not find anything worth reading, other than Dilbert, so we fantasized. Unfortunately, our fantasies may well resemble many people's realities. We are sorry about this, but it is not our fault. Results We discovered many reasons for repeated reorganizations, the most common being ‘no good reason’. We estimated that trillions of dollars are being spent on strategic and organizational planning activities each year, thus providing lots of good reasons for hundreds of thousands of people, including us, to get into the business. New leaders who are intoxicated with the prospect of change further fuel perpetual cycles of redisorganization. We identified eight indicators of successful redisorganizations, including large consultancy fees paid to friends and relatives. Conclusions We propose the establishment of ethics committees to review all future redisorganization proposals in order to put a stop to uncontrolled, unplanned experimentation inflicted on providers and users of the health services.