Assessment of the implementation of a national patient safety alert to reduce wrong site surgery

BACKGROUND

In 2005, guidance on how to prevent wrong site surgery in the form of a national safety alert was issued to all NHS hospital trusts in England and Wales by the National Patient Safety Agency.

OBJECTIVE

To investigate the response to the alert among clinicians in England and Wales 12-15 months after it had been issued.

METHODS

A before-after study, using telephone/face-to-face interviews with consultant surgeons and senior nurses in ophthalmology, orthopaedics and urology in 11 NHS hospitals in England & Wales in the year prior to the alert and 12-15 months after. The interviews were coded and analysed thematically.

RESULTS

The study revealed marked heterogeneity in organisational processes in response to a national alert. There was a significant change in surgeons' self-reported practice, with only 48% of surgeons routinely marking patients prior to the alert and 85% after (p<0.001). However, inter-specialty differences remained and change in practice was not always matched by change in attitude. Compliance with the detailed recommendations about how marking should be carried out was inconsistent. There were unintended consequences in terms of greater bureaucracy and concerns about diffusion of responsibility and hastily performed marking to enable release of patients from wards.

CONCLUSION

The alert was effective in promoting presurgical marking and encouraging awareness of safety issues in relation to correct site surgery. However, care should be taken to monitor unintended consequences and whether change is sustained. Greater flexibility for local adaptation coupled with better design and early testing of safety alerts prior to national dissemination may facilitate more sustainable changes in practice.

Use of technology in children's dietary assessment

BACKGROUND

Information on dietary intake provides some of the most valuable insights for mounting intervention programmes for the prevention of chronic diseases. With the growing concern about adolescent overweight, the need to accurately measure diet becomes imperative. Assessment among adolescents is problematic as this group has irregular eating patterns and they have less enthusiasm for recording food intake.

SUBJECTS/METHODS

We used qualitative and quantitative techniques among adolescents to assess their preferences for dietary assessment methods.

RESULTS

Dietary assessment methods using technology, for example, a personal digital assistant (PDA) or a disposable camera, were preferred over the pen and paper food record.

CONCLUSIONS

There was a strong preference for using methods that incorporate technology such as capturing images of food. This suggests that for adolescents, dietary methods that incorporate technology may improve cooperation and accuracy. Current computing technology includes higher resolution images, improved memory capacity and faster processors that allow small mobile devices to process information not previously possible. Our goal is to develop, implement and evaluate a mobile device (for example, PDA, mobile phone) food record that will translate to an accurate account of daily food and nutrient intake among adolescents. This mobile computing device will include digital images, a nutrient database and image analysis for identification and quantification of food consumption. Mobile computing devices provide a unique vehicle for collecting dietary information that reduces the burden on record keepers. Images of food can be marked with a variety of input methods that link the item for image processing and analysis to estimate the amount of food. Images before and after the foods are eaten can estimate the amount of food consumed. The initial stages and potential of this project will be described.

Robust face recognition via sparse representation

We consider the problem of automatically recognizing human faces from frontal views with varying expression and illumination, as well as occlusion and disguise. We cast the recognition problem as one of classifying among multiple linear regression models and argue that new theory from sparse signal representation offers the key to addressing this problem. Based on a sparse representation computed by l{1}-minimization, we propose a general classification algorithm for (image-based) object recognition. This new framework provides new insights into two crucial issues in face recognition: feature extraction and robustness to occlusion. For feature extraction, we show that if sparsity in the recognition problem is properly harnessed, the choice of features is no longer critical. What is critical, however, is whether the number of features is sufficiently large and whether the sparse representation is correctly computed. Unconventional features such as downsampled images and random projections perform just as well as conventional features such as Eigenfaces and Laplacianfaces, as long as the dimension of the feature space surpasses certain threshold, predicted by the theory of sparse representation. This framework can handle errors due to occlusion and corruption uniformly by exploiting the fact that these errors are often sparse with respect to the standard (pixel) basis. The theory of sparse representation helps predict how much occlusion the recognition algorithm can handle and how to choose the training images to maximize robustness to occlusion. We conduct extensive experiments on publicly available databases to verify the efficacy of the proposed algorithm and corroborate the above claims.

Insulin analogues: an example of applied medical science

Insulin analogues were developed to try and achieve more physiological insulin replacement from injection in the subcutaneous site. Their pharmacokinetics and pharmacodynamics differ from human insulin when injected subcutaneously because of alterations in the amino acid sequence of the insulin molecule. The rapid-acting insulin analogues, lispro, aspart and glulisine, have a rapid onset of action and shorter duration of action because of changes to the B26-30 portion of insulin inhibiting formation of dimers and hexamers. They appear to improve postprandial glucose, incidence of hypoglycaemia and patient satisfaction and, when used in combination with basal insulin analogues, improve glycosylated haemoglobin in comparison to conventional insulin therapy. Additionally, they have been successfully used in children, pregnant women, in pump therapy and as part of premixed biphasic regimens. The two basal insulin analogues, glargine and detemir, developed by adjusting the isoelectric point and adding a fatty acid residue, respectively, have a protracted duration of action and a relatively smooth profile. Their pharmacokinetic and pharmacodynamic profiles have been assessed using euglycaemic clamp protocols. Both analogues have a longer duration of action, less of a peak of activity and a reduced variability with repeated injection. There is some evidence to suggest that detemir may have a slight hepatoselective effect. Clinical studies have shown a lower relative risk of hypoglycaemia and detemir appears to have a weight-sparing action. Insulin analogues represent a successful example of applied medical science.

Histone deacetylase inhibitor romidepsin has differential activity in core binding factor acute myeloid leukemia

PURPOSE

Recruitment of histone deacetylases (HDAC) is a mechanism of transcriptional repression implicated in the differentiation block in acute myeloid leukemia (AML). We hypothesized that the HDAC inhibitor romidepsin could cause transcriptional derepression, up-regulation of specific target genes in AML, and differentiation of the leukemic clone. The primary objectives of the study were to evaluate the safety and efficacy of romidepsin in advanced AML.

EXPERIMENTAL DESIGN

Twenty patients were stratified into cohort A or B based on the absence or presence of chromosomal abnormalities known to recruit HDACs, including those involving core binding factor (CBF). Romidepsin was administered i.v. at 13 mg/m(2)/d on days 1, 8, and 15 of a 28-day cycle. Pharmacodynamic endpoints were evaluated at serial time points.

RESULTS

Common adverse effects noted were grade 1 to 2 nausea, anorexia, and fatigue. No objective evidence of antileukemic activity was seen in cohort A. In cohort B, although there were no clinical responses by standard criteria, antileukemic activity was observed in 5 of 7 patients. Two patients had clearance of bone marrow blasts and 3 patients had a >50% decrease in bone marrow blasts. Furthermore, in cohort B, at 24 h, there was a significant increase in MDR1 (P=0.005), p15 (P=0.01), and p14 (P<0.0001) expression. In cohort A, although there was a trend toward up-regulation of MDR1, p15, and p14 expression, these changes were not statistically significant.

CONCLUSION

Romidepsin has differential antileukemic and molecular activity in CBF AML. Development of this agent in CBF AML should focus on combinations that target related mechanisms of gene silencing such as DNA methylation.

A phase I study of tipifarnib combined with conventional induction and consolidation therapy for previously untreated patients with acute myeloid leukemia aged 60 years and over

Patients aged 60 years and over with previously untreated acute myeloid leukemia were enrolled in a Phase I study combining tipifarnib with standard induction therapy. The regimen consisted of cytarabine 100 mg/m(2)/day continuous intravenous (i.v.) infusion on days 1-7, daunorubicin 60 mg/m(2)/day i.v. push x 3 on days 6-8 and tipifarnib twice daily on days 6-15. Tipifarnib was escalated over four dose levels (200, 300, 400 and 600 mg). Patients achieving complete response (CR) were eligible to receive one consolidation using the same regimen. The following dose-limiting toxicities (DLTs) were identified during induction: dose level I: 2/6 (hyperbilirubinemia, respiratory arrest), level II: 0/3, level III: 0/3 and level IV: 4/10 (one each of diarrhea, neutropenic enterocolitis, arrhythmia and delayed hematologic recovery post-consolidation). There were no DLTs due to delayed hematologic recovery post-induction. Of 22 evaluable patients, there were 10 CR, 2 morphologic leukemia-free state (MLFS), 2 partial remission (PR) and 8 non-responders. Of seven patients with adverse risk cytogenetics, there were four CR/MLFS and one PR. In summary, this regimen was well tolerated and the maximum tolerated dose was not reached, although somewhat more severe gastrointestinal toxicity was seen at dose level IV. Tipifarnib 600 mg b.i.d. is considered the recommended dose for further study using this regimen.

Determinants of burden in those who care for someone with dementia

OBJECTIVES

Caregiver burden is a key measure in caregiver research and is frequently used as a baseline measure in intervention studies. Previous research has found numerous factors associated with caregiver burden such as the relationship quality between carer and patient, the patient's cognitive ability, behavioural and psychological symptoms displayed by the patient, caregiver gender, adverse life events to name a few. Many studies have investigated these factors singularly however current thought suggests a multi-factorial role and inter-dependence of these factors. Based on this it was decided to investigate factors associated with caregiver burden using a multiple regression analysis in order to ascertain the predictive quality of these factors of caregiver burden.

METHOD

Cross-sectional study using validated measures of a patient's cognitive ability, ability to carry out day-to-day tasks and behavioural and psychological symptoms. Caregiver outcomes used are caregiver burden, relationship quality, caregiver confidence, experience of adverse life events, neuroticism, age and gender. Interviews and questionnaires were carried out on 74 patients diagnosed with dementia and their main caregivers from the Midlands of England.

RESULTS

Multiple regression analysis showed that caregiver overload, carer-patient relationship quality, the experience of adverse life events, caregiver gender, caregivers' level of neuroticism, caregiver role captivity and the level of caregiver confidence accounted for over 80% of the variance in caregiver burden.

CONCLUSION

These results confirm previous correlational research on caregiver burden. Furthermore, due to the use of multiple regression analysis the findings also show factors that are clear predictors of caregiver burden and we offer possible suggestions from these findings on future clinical practice interventions on caregiver burden.

Electronic medical records in diabetes consultations: participants' gaze as an interactional resource

Two routine consultations in primary care diabetes clinics are compared using extracts from video recordings of interactions between nurses and patients. The consultations were chosen to present different styles of interaction, in which the nurse's gaze was either primarily toward the computer screen or directed more toward the patient. Using conversation analysis, the ways in which nurses shift both gaze and body orientation between the computer screen and patient to influence the style, pace, content, and structure of the consultation were investigated. By examining the effects of different levels of engagement between the electronic medical record and the embodied patient in the consultation room, we argue for the need to consider the contingent nature of the interface of technology and the person in the consultation. Policy initiatives designed to deliver what is considered best-evidenced practice are modified in the micro context of the interactions of the consultation.

Phase II preradiation R115777 (tipifarnib) in newly diagnosed GBM with residual enhancing disease

Glioblastoma multiforme (GBM) is a lethal primary malignant brain tumor in adults. R115777 (tipifarnib) is an oral agent with antiproliferative effects, being a potent and selective inhibitor of farnesyltransferase. This multicenter, open-label phase II study was designed to evaluate the efficacy and safety of R115777 given after surgery and prior to radiation in patients with newly diagnosed and residual enhancing GBM. Following surgery, an MRI confirmed the presence of residual enhancing tumor. Patients on enzyme-inducing antiseizure drugs (EIASDs) received 600 mg twice per day, and those not on EIASDs received 300 mg twice per day. One to three monthly cycles of R115777 were administered, and radiation was initiated with progression or after three cycles. A cycle consisted of 3 weeks of continuous R115777 followed by a 1-week rest. MRI was done monthly. The primary end point was overall survival; secondary end points were tumor response rate and toxicity. A total of 28 confirmed GBM patients entered the study; 15 patients (54%) were on EIASDs. The overall median time of survival was 7.7 months. There were no tumor responses. Eight patients (29%) had stable disease as the best response. The study was stopped early due to progression of the disease in 12 patients (48%). A total of 24 patients (85%) were off study before the planned treatment schedule for radiation therapy. R115777 administered prior to radiation therapy in patients with newly diagnosed GBM and residual enhancing disease did not result in any measurable responses or improvement in survival. R115777 administered prior to radiation therapy is not recommended for patients with newly diagnosed GBM.

Experimental verification of dynamical diffraction focusing by a bent crystal wedge in Laue geometry

Recent X-ray optical experiments have validated previous theoretical work on focusing by bent crystals in Laue geometry. It was shown that a suitable choice of the crystal thickness significantly improves the focusing performance of the crystal by combining the dynamical focusing of the Borrmann triangle with the geometrical focusing obtained by the crystal bending. The best focus size achieved during the experiments was less than 5 µm and is in practice limited by the source demagnification for the considered setup.

Adapted Couple Therapy (ACT) for pathological gamblers: a promising avenue

The study of the effectiveness of treatment for pathological gambling constitutes a field that is still largely unexplored. To date, the models assessed primarily target the individual and include little or no involvement of the family circle. Yet, the deleterious effects of gambling on loved ones and especially spouses are well recognized. Further, the addition of a couple modality to individual treatment has been shown to be effective on many levels in the treatment of substances use disorders. This article therefore proposes a critical review of (1) the literature providing a better understanding of the complex interactions between the couple relationship and pathological gambling, (2) studies on the effects of couple therapies on gamblers and their partners. We then present the therapeutic model developed by our team of clinician-researchers in collaboration with actors from Québec clinical settings: Adapted Couple Therapy (ACT) for pathological gamblers. In the Québec context, this model will serve as a complement to an individual cognitive-behavioral treatment model that has been proven effective and is employed throughout the Canadian province. The assessment of couple therapies could reveal avenues of solutions to better assist pathological gamblers who tend to drop-out of treatment and relapse.