A new quality of life consultation template for patients with venous leg ulceration

OBJECTIVE

Chronic venous leg ulcers (CVLUs) are common and recurrent, however, care for patients predominantly has a focus which overlooks the impact of the condition on quality of life. The aim of this study was to develop a simple, evidence-based consultation template, with patients and practitioners, which focuses consultations on quality of life themes.

METHOD

A nominal group was undertaken to develop a new consultation template for patients with CVLUs based on the findings of earlier qualitative study phases.

RESULTS

A user-friendly two-sided A4 template was designed to focus nurse-patient consultations on the quality of life challenges posed by CVLUs.

CONCLUSION

CVLUs impact negatively on the quality of life of the patient but this receives inadequate attention during current consultations. This new template will help to ensure that key concerns are effectively raised, explored and addressed during each consultation.

DECLARATION OF INTEREST

The NHS West Midlands Strategic Health Authority funded this study. The authors have no conflicts of interest to declare.

An evaluation of foundation doctor training: a mixed-methods study of the impact on workforce well-being and patient care [the Evaluating the Impact of Doctors in Training (EDiT) study]

Background

A major reform of junior doctor training was undertaken in 2004–5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood.

Objectives

This study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients.

Methods

Phase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD).

Results

Phase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be ‘in difficulty’); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD.

Conclusions

There are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Standardization and safety of alveolar bone-derived stem cell isolation

Cell therapies utilizing mesenchymal stem cells (MSCs) could overcome limitations of traditional treatments for reconstructing craniofacial tissues. This large-scale study explored a standardized methodology for the isolation and clinical-scale expansion of alveolar bone marrow-derived MSCs (aBMSCs). We harvested 103 alveolar bone marrow samples from 45 patients using 1 of 3 standardized methodologies. Following aBMSC isolation, cells were characterized through cell-surface marker expression and lineage-specific differentiation. Long-term cultures (> 50 population doublings [PDs]) were evaluated for transformational changes through senescence, gene expression, and karyotyping. Finally, aBMSC bone-forming potential was determined in vivo. More than 0.5 cc of bone marrow was needed to predictably isolate aBMSCs, and, regardless of methodology for harvest, cell-surface marker expression of CD73, CD90, CD105, and Stro-1 was similar for aBMSCs, being 89.8%, 98.8%, 93.8%, and 3.2%, respectively; all cells were negative for CD11b, CD19, and CD45. aBMSCs exhibited multipotency, and karyotypes were normal up to 30 PDs, with significant cell senescence beginning following 35 PDs. Additionally, aBMSCs induced ectopic bone formation following subcutaneous transplantation into mice. These findings demonstrate a predictable approach for the isolation and safe clinical-scale expansion of aBMSCs, and thus, their clinical use could be considered for craniofacial regenerative therapies.

Risk factors for psychological distress following injury

OBJECTIVES

To identify predictors of psychological morbidity among injured patients admitted to an Emergency Department (ED).

DESIGN

A prospective cohort study.

PARTICIPANTS

Participants were consecutive male ED attenders. 210 (97.7%) patients consented to participate. At one month, 128 (61.0%) responded, at six months, 114 (54.3%), at eighteen months 96 (45.7%).

MAIN OUTCOME MEASURES

Measures immediately following injury were the Hospital Anxiety and Depression Scale, the Eysenck Personality Questionnaire and the McGill pain questionnaire. Recovery at one month was recorded using the SF-36 Health Survey, COPE scale, Perceived Stress Scale and Revised Impact of Events Scale. At six and eighteen months outcome was measured using the General Health Questionnaire (28 items) and Revised Impact of Events Scale. Multivariate analysis identified pre-morbid, accident-related and recovery factors influencing outcome at six and eighteen months.

RESULTS

The strongest predictors of outcome were initial levels of anxiety and depression, prior history of mental health problems, early PTSD symptoms and involvement in litigation. These factors predicted between 40-60% of the variance at six months (p<0.001), and 50-60% of the variance in psychological distress at eighteen months (p<0.001).

CONCLUSION

Factors identifying individuals at-risk from psychological distress following injury include those related to the immediate response and the recovery phases of injury. Further development is needed to convert identified predictors into a comprehensive screening tool for clinical use.

Home-based monitoring and assessment of Parkinson's disease

As a clinically complex neurodegenerative disease, Parkinson's disease (PD) requires regular assessment and close monitoring. In our current study, we have developed a home-based tool designed to monitor and assess peripheral motor symptoms. An evaluation of the tool was carried out over a period of ten weeks on ten people with idiopathic PD. Participants were asked to use the tool twice daily over four days, once when their medication was working at its best ("on" state) and once when it had worn off ("off" state). Results showed the ability of the data collected to distinguish the "on" and "off" state and also demonstrated statistically significant differences in timed assessments. It is anticipated that this tool could be used in the home environment as an early alert to a change in clinical condition or to monitor the effects of changes in prescribed medications used to manage PD.

Risk factors for herd breakdown with bovine tuberculosis in 148 cattle herds in the south west of England

Bovine tuberculosis (bTB) is caused by Mycobacterium bovis. The disease has a long latent period, heterogenous spread, can infect many species and can persist in the environment. In the UK, the rate of herd breakdowns (HBD) with bTB is increasing. A retrospective cohort study of 148 cattle herds was set up to investigate risk factors for HBD from October 2001 to November 2004. Herds were selected from farms located in the randomised badger culling trial (RBCT) and comprised holdings (24%) that were restocked with cattle after the foot and mouth disease (FMD) epidemic in 2001 and holdings (76%) that were continuously stocked throughout the FMD epidemic. Farmers were interviewed between June 2003 and February 2004. Questions on herd and farm management were asked for the period October 2001 to June 2003. Data on herd testing for bTB were sourced from the VetNet database and historic data from 1995 were used in the analysis. A discrete time survival analysis was used to examine factors associated with the risk of HBD. By the end of the study period, November 2004, 50% of study herds had experienced a HBD with bTB at least once. Farms that were restocked for less than 1 year after FMD had a reduced risk of HBD (P<0.01) compared with continuously stocked farms in the same year. This reduced risk did not persist after 1 year of restocking. Feeding vitamin and mineral lick supplements compared with not feeding these supplements also reduced the risk of HBD. Factors associated with an increased risk of HBD were storing manure and slurry indoors or in a closed container, spreading manure all year round, herds with dairy cattle compared with herds without dairy cattle, increasing herd size, purchase of cattle from markets, location of the farm in the proactive area of the RBCT compared with survey only and location of farms in Somerset and North Devon. The lower risk of HBD in the first year after restocking but not the second or third year suggests that removal of all cattle might have lowered the infectious load of M. bovis on these premises for a period of time but that this did not persist once cattle were reintroduced. Purchase of cattle from markets suggests that there was a risk of introduction or re-introduction of bTB from these cattle. Method of storage or lack of storage of slurry might aid persistence of M. bovis in the environment if M. bovis survives in slurry in some circumstances.