Students' perceptions of interprofessional learning through facilitated online learning modules

BACKGROUND

Asynchronous e-learning is an appealing option for interprofessional education (IPE) as it addresses the geographic and timetabling barriers often encountered when organizing activities across educational programs.

AIM

This study examined the extent to which pre-licensure students were able to learn with, from, and about each other through completion of innovative online IPE learning modules.

METHODS

Seventy-seven students completed e-learning modules developed through a consortium of educational institutions. Evaluation was primarily qualitative through focus groups, interviews, analyses on off-line discussions and an online feedback form.

RESULTS

Qualitative analyses of the discussion fora revealed that students were able to solve problems collaboratively, clarify their professional roles, and provide information from their professional perspective. Focus groups and interviews reinforced that students recognized the importance of working together and implicate clinical education as an important venue to reinforce learning about collaborative practice. Analyses of the online feedback form suggest the need for clear processes related to group assignments and deadlines.

CONCLUSION

Students learned about each other's role, solved problems together and had positive perceptions of the online modules as a venue for interprofessional learning. Results are encouraging to those interested in using e-learning in IPE as part of an overall curriculum.

Case management of patients who frequently present to a Scottish emergency department

AIMS

To assess whether case management of frequent attenders to the emergency department (ED) reduces subsequent attendances made by these patients.

METHODS

Patients who attended the ED 10 times or more over a 6-month period were identified. Their cases were assessed and care plans put in place, if appropriate. Patient attendances over the subsequent 6 months were compared.

RESULTS

57 patients attended the ED 10 times or more over the 6-month period (1.4% of the departmental workload). The median number of ED attendances in this patient group was 12.0 (interquartile range (IQR) 10-14). In the subsequent 6 months following case management of these patients, median attendances in the same 57 patients dropped to 6.0 (IQR 2-13, p<0.001). The total number of attendances in this patient group dropped from 720 to 499, a reduction of 31%.

CONCLUSIONS

The findings of this study suggest that individual case management and implementation of care plans may help to reduce subsequent attendances in patients who frequently attend ED.

Patients from care homes who attend the emergency department: could they be managed differently

AIMS

To describe the demographics of patients from care homes who attend the emergency department (ED) and to estimate whether appropriate alternative care pathways could have been delivered to this patient group.

METHODS

A prospective descriptive study that gathered data on consecutive patients who presented to the ED of the Royal Infirmary of Edinburgh from adult care homes over a one-month period. A proforma was used to record details such as diagnosis, communication from the care home, referral details, patient transport and resuscitation status. Three general practitioners (GPs) assessed whether the patients could have been managed appropriately outwith the ED.

RESULTS

114 patients were recruited over the month of the study. Seven patients were missed. Results showed that 40 care home patients (35%) came to the ED without an accompanying letter. 99 patients (87%) were brought to the department by ambulance. 58 patients (51%) who came to the ED from care homes were discharged, and of these 41 (71%) were transported back to the care home by non-ambulance transport. Three patients (3%) had a resuscitation status documented. GP review of case notes suggested that between nine (8%) and 46 (40%) could have been managed appropriately outwith the ED.

CONCLUSION

In this study between 8% and 40% of patients could have been cared for outwith the ED. The findings highlight the importance of the provision of appropriate healthcare to care home residents and the current deficits that exist.

Patient health outcomes in psychiatric mental health nursing

This integrative literature review examined evidence concerning the relationship between psychiatric mental health nursing interventions and patient-focused outcomes. Empirical studies, published between 1997 and 2007, were identified and gathered by searching relevant databases and specific data sources. Although 156 articles were critically appraised, only 25 of them met the inclusion criteria. Findings from this review showed that the most frequently used outcome instruments assessed psychiatric symptom severity. Most of the instruments targeted two symptom categories: altered thoughts/perceptions and altered mood. Other outcome instruments were categorized in the following domains: self-care, functioning, quality of life and satisfaction. The most important finding of this review is the lack of consistently strong evidence to support decisions concerning which outcome instrument or combination of instruments to recommend for routine use in practice. Based on this review, additional research to conceptualize, measure and examine the feasibility of outcome instruments sensitive to psychiatric mental health nursing interventions is recommended.

Online interprofessional health sciences education: From theory to practice

Online learning (e-learning) has a nascent but established history. Its application to interprofessional education (IPE), however, is relatively new. Over the past 2 decades the Internet has been used increasingly to mediate education. We have come past the point of "should we use the Internet for education" to "how should we use the Internet for education." Research has begun on the optimal development of online learning environments to support IPE. Developing online IPE should follow best practices in e-learning generally, though there are some special considerations for acknowledging the interprofessional context and clinical environments that online IPE is designed to support. The design, development, and deployment of effective online IPE must therefore pay special attention to the particular constraints of the health care worker educational matrix, both pre- and postlicensure. In this article we outline the design of online, interprofessional health sciences education. Our work has involved 4 educational and 4 clinical service institutions. We establish the context in which we situate our development activities that created learning modules designed to support IPE and its transfer into new interprofessional health care practices. We illustrate some best practices for the design of effective online IPE, and show how this design can create effective learning for IPE. Challenges exist regarding the full implementation of interprofessional clinical practice that are beginning to be met by coordinated efforts of multiple health care education silos.

Efficacy of a novel formulation of metaflumizone for the control of fleas (Ctenocephalides felis) on cats

A novel spot-on formulation containing metaflumizone (ProMeris for Cats, Fort Dodge Animal Health, Overland Park, KS) was evaluated in five laboratory studies to determine the duration of residual efficacy in cats against fleas after a single spot treatment. In each study, eight domestic shorthair cats were randomly allocated to each treatment group and individually housed. One group in each study remained non-treated. In one study, an additional group of eight cats was treated with a placebo formulation. Cats were treated topically with metaflumizone formulation to provide a dose of at least 40mg metaflumizone/kg. Cats were infested with 100 cat fleas (Ctenocephalides felis felis) once per week for approximately 8 weeks. Cats were comb counted 48h after treatment and each infestation to determine the number of viable fleas present. There were no significant differences in flea counts between the non-treated control and the placebo-treated control (P>0.05) other than a 26% reduction at week 1, demonstrating that the formulation excipients had no activity. Metaflumizone treatment resulted in significantly lower flea numbers relative to non-treated controls on all post-treatment count days (P<0.05). Metaflumizone provided >90% control of flea infestations up to 7 weeks following a single treatment.

Death from overwhelming odontogenic sepsis: a case report

A case of fatal Ludwig's angina from an odontogenic origin complicated by chronic lymphocytic leukaemia is presented. This case highlights that death from odontogenic infection is a reality, particularly in those with systemic disease causing immunocompromise. Early surgical intervention, aggressive intravenous antimicrobial therapy and supportive care is imperative.

SPINE bioinformatics and data-management aspects of high-throughput structural biology

SPINE (Structural Proteomics In Europe) was established in 2002 as an integrated research project to develop new methods and technologies for high‐throughput structural biology. Development areas were broken down into workpackages and this article gives an overview of ongoing activity in the bioinformatics workpackage. Developments cover target selection, target registration, wet and dry laboratory data management and structure annotation as they pertain to high‐throughput studies. Some individual projects and developments are discussed in detail, while those that are covered elsewhere in this issue are treated more briefly. In particular, this overview focuses on the infrastructure of the software that allows the experimentalist to move projects through different areas that are crucial to high‐throughput studies, leading to the collation of large data sets which are managed and eventually archived and/or deposited.

Ethical issues in using a cocaine vaccine to treat and prevent cocaine abuse and dependence

A "cocaine vaccine" is a promising immunotherapeutic approach to treating cocaine dependence which induces the immune system to form antibodies that prevent cocaine from crossing the blood brain barrier to act on receptor sites in the brain. Studies in rats show that cocaine antibodies block cocaine from reaching the brain and prevent the reinstatement of cocaine self administration. A successful phase 1 trial of a human cocaine vaccine has been reported. The most promising application of a cocaine vaccine is to prevent relapse to dependence in abstinent users who voluntarily enter treatment. Any use of a vaccine to treat cocaine addicts under legal coercion raises major ethical issues. If this is done at all, it should be carefully trialled first, and only after considerable clinical experience has been obtained in using the vaccine to treat voluntary patients. There will need to be an informed community debate about what role, if any, a cocaine vaccine may have as a way of preventing cocaine addiction in children and adolescents.

A procedure for setting up high-throughput nanolitre crystallization experiments. II. Crystallization results

An initial tranche of results from day-to-day use of a robotic system for setting up 100 nl-scale vapour-diffusion sitting-drop protein crystallizations has been surveyed. The database of over 50 unrelated samples represents a snapshot of projects currently at the stage of crystallization trials in Oxford research groups and as such encompasses a broad range of proteins. The results indicate that the nanolitre-scale methodology consistently identifies more crystallization conditions than traditional hand-pipetting-style methods; however, in a number of cases successful scale-up is then problematic. Crystals grown in the initial 100 nl-scale drops have in the majority of cases allowed useful characterization of X-ray diffraction, either in-house or at synchrotron beamlines. For a significant number of projects, full X-ray diffraction data sets have been collected to 3 Å resolution or better (either in-house or at the synchrotron) from crystals grown at the 100 nl scale. To date, five structures have been determined by molecular replacement directly from such data and a further three from scale-up of conditions established at the nanolitre scale.

Intensive lifestyle intervention combined with the choice of pharmacotherapy improves weight loss and cardiac risk factors in the obese

BACKGROUND

Obesity is on the increase yet within the National Health Service (NHS) treatment approaches differ greatly and service is patchy. Our aim was to compare current practice within a general dietetic clinic with a new clinic developed specifically for patients of higher morbidity risk.

METHODS

Locally referred patients to the dietitians from within or without Hammersmith Hospitals NHS Trust of higher morbidity risk were invited to attend a new Lifestyle Clinic. Treatment was of a contractual nature and included more time with the dietitian, the offer of pharmacotherapy if appropriate and an emphasis on achieving a realistic weight loss of 10% within a 6-month period. Cognitive behavioural strategies were utilized focusing on achieving changes in dietary intake and physical activity levels.

RESULTS

A total of 103 patients have been enrolled of whom 34 have been discharged before completion of the clinic programme. Twenty-six patients have completed (18 started pharmocotherapy with Orlistat and eight remained on lifestyle advice only), with the remainder still attending the Lifestyle Clinic. The results for these 26 patients demonstrate clinically significant benefits with regard to exercise tolerance 390.8 +/- 37.5 m vs. 473 +/- 46.6 m (P < 0.001), waist measurement 121.5 +/- 4.4 cm vs. 110.9 +/- 3.6 cm (P < 0.001), and total cholesterol : HDL ratio 1.17 +/- 0.05 mmol L-1 vs. 1.27 +/- 0.07 mmol L-1 (P < 0.05). A weight loss comparison with historical data collected in the general dietetic clinic achieves a 7.8 +/- 0.7 kg reduction in weight (with pharmocotherapy 8.96 +/- 0.98 kg, with lifestyle only 5.23 +/- 0.657) vs. 1.7 +/- 0.4 kg (P < 0.05).

CONCLUSION

Lifestyle clinics facilitate beneficial lifestyle changes which impact positively on morbidity risk factors demonstrating an improvement on current service offered within the NHS. There is an obvious resource implication of offering an intensive management package. There is need for a randomized control trial with analysis to evaluate whether there is cost benefit from this type of intervention.

The use of portable radiometry to assess Raynaud's phenomenon: a practical alternative to thermal imaging

OBJECTIVES

To compare the performance of a portable radiometer with thermal imaging and to assess the potential for radiometry to provide a practical alternative for assessing vascular responsiveness in Raynaud's phenomenon (RP).

METHODS

Subjects comprised 18 patients with diagnosed RP and 19 non-RP subjects. A thermal imager (Starsight) and a portable radiometer (Cyclops) measured digital temperature at baseline and the subsequent drop and rise in temperature following a cold challenge test.

RESULTS

The intra-class correlations between the two instruments for all three measures exceeded 80%. The overall performance of each instrument was almost the same, the Starsight thermal imager correctly classifying 84% of subjects as RP or non-RP and the Cyclops portable radiometer correctly classifying 86% of subjects. The sensitivity of the thermal imager was 83%, compared with 89% for the portable radiometer; the specificity of both instruments was 84%. The positive and negative predictive values of the thermal imager were 83 and 84% respectively, and those for the portable radiometer were 84 and 89%.

CONCLUSIONS

The two instruments performed equally well and the differences between them in their absolute measurements did not influence their ability to detect RP. Portable radiometry provides a practical, cheap, accurate and reliable alternative to thermal imaging and has the potential to be used in range of clinical and epidemiological settings.

Effects of the long-acting insulin analog insulin glargine on cultured human skeletal muscle cells: comparisons to insulin and IGF-I

The aim of this study was to determine whether the long-acting insulin analog, insulin glargine, behaves like human insulin for metabolic and mitogenic responses in differentiated cultured human skeletal muscle cells from nondiabetic and diabetic subjects. Human insulin and insulin glargine were equipotent in their ability to compete for [(125)I]insulin binding. Insulin glargine displaced [(125)I]IGF-I from the IGF-I-binding site with approximately 0.5% the potency of IGF-I. In nondiabetic muscle cells, all three ligands stimulated glucose uptake similarly, whereas the sensitivity of glucose uptake was greatest in response to IGF-I and lower and equal for human insulin and insulin glargine. In diabetic muscle cells, the final responsiveness of glucose uptake was greatest for IGF-I and equivalent for human insulin and insulin glargine; sensitivities were the same as those for nondiabetic cells. Thymidine uptake into DNA was stimulated foremost by IGF-I, whereas human insulin and insulin glargine showed equivalent, but greatly reduced, sensitivities and potencies (<1% IGF-I). Stimulation of Akt phosphorylation was slightly more responsive to IGF-I compared with human insulin and insulin glargine, with sensitivities similar to glucose uptake stimulation. We conclude that in human skeletal muscle cells, insulin glargine is equivalent to human insulin for metabolic responses and does not display augmented mitogenic effects.

Traumatic head injury in the anticoagulated elderly patient: a lethal combination

Warfarin is the most common oral anticoagulant used for chronic anticoagulation therapy. Even without any antecedent trauma overanticoagulation can result in intracranial hemorrhage. The triad of anticoagulation with warfarin, age greater than 65 years, and traumatic head injury frequently produces a lethal brain hemorrhage. A retrospective review of more than 2000 patients admitted to the Trauma Service between September 1998 and May 2000 produced 278 patients with head injury and CT-documented intracranial hemorrhage. Of these patients 21 were admitted with an elevated prothrombin time (PT) due to anticoagulation with warfarin. Eighteen patients (86%) were above the age of 70. The most common indications for anticoagulation were atrial fibrillation (71%), deep venous thrombosis (19%), aortic valve replacement (9%), and ischemic cerebral infarcts (9%). Fourteen injuries were the result of a fall, one resulted from a gunshot wound, and one resulted from an assault. The remaining five patients were excluded as their history, workup, and evaluation by neurosurgery suggested a spontaneous bleed leading to fall rather than a fall causing a traumatic bleed. The average Glasgow Coma Score on admission was 11. The average PT and International Normalized Ratio (INR) on admission were 19.2 and 2.99 respectively. Eight of the 16 patients analyzed died. The risk of intracranial hemorrhage with relatively minor head injury is increased dramatically in the anticoagulated patient. A mortality rate of 50 per cent far exceeds the mortality rate in patients with similar head injuries who are not anticoagulated. In addition the risk/benefit equation of anticoagulation for the elderly is more complex and differs from that for younger patients. Perhaps more frequent and judicious monitoring of prothrombin time levels with lower therapeutic ranges (INR 1.5-2) is necessary.

Impaired muscle glycogen synthase in type 2 diabetes is associated with diminished phosphatidylinositol 3-kinase activation

Insulin signaling pathways potentially involved in regulation of skeletal muscle glycogen synthase were compared in differentiated human muscle cell cultures from nondiabetic and type 2 diabetic patients. Insulin stimulation of glycogen synthase activity as well as phosphorylation of MAPK, p70 S6 kinase, and protein kinase B (Akt) were blocked by the phosphatidylinositol 3-kinase inhibitors wortmannin (50 nM) and LY294002 (10 microM). In contrast to lean and obese nondiabetic subjects, where there were minimal effects (15-20% inhibition), insulin stimulation of glycogen synthase in muscle cultures from diabetic subjects was greatly diminished ( approximately 75%) by low concentrations of wortmannin (25 nM) or LY294002 (2 microM). This increased sensitivity of diabetic muscle to impairment of insulin-stimulated glycogen synthase activity occurs together with diminished insulin-stimulation (by 40%) of IRS-1-associated phosphatidylinositol 3-kinase activity in the same cells. Protein expression of IRS-1, p85, p110, Akt, p70 S6 kinase, and MAPK were normal in diabetic cells, as was insulin-stimulated phosphorylation of Akt, p70 S6 kinase, and MAPK. These studies indicate that, despite prolonged growth and differentiation of diabetic muscle under normal metabolic culture conditions, defects of insulin-stimulated phosphatidylinositol 3-kinase and glycogen synthase activity in diabetic muscle persist, consistent with intrinsic (rather than acquired) defects of insulin action.

Retinoid X receptor expression in skeletal muscle of nondiabetic, obese and type 2 diabetic individuals

Retinoid X receptor (RXR) is a nuclear receptor that functions as an obligate heterodimeric partner of peroxisome proliferator-activator receptor (PPAR). Studies have shown that the alpha isoform of RXR and PPARgamma act synergistically to regulate gene expression and insulin action. The aim of the current study was to compare the expression and regulation of RXR in the primary insulin-sensitive tissue, skeletal muscle, of various degrees of insulin-resistant states including obese type 2 diabetic (T2D), obese nondiabetic (OND), and lean nondiabetic (LND) subjects. Insulin action/resistance was determined by a 3-hour hyperinsulinemic, euglycemic (5.0 to 5.5 mmol/L) clamp. Percutaneous biopsy of the vastus lateralis muscle was performed before and after the clamp. RXRalpha mRNA was measured using a quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) assay, while protein was determined by Western blotting. All 3 isoforms of RXR, alpha, beta, and gamma, were present in skeletal muscle. Protein expression of RXR isoforms did not differ between groups; RXR alpha mRNA was also similar between groups. Neither RXR alpha mRNA, RXR -beta nor -gamma protein displayed significant relationships with any of the clinical or laboratory parameters measured, including insulin sensitivity. RXR alpha exhibited a negative correlation with free fatty acids levels (r, -.42, P <.05). There was also no relationship between RXR alpha and PPARgamma protein levels. RXR alpha mRNA was unaltered following insulin infusion. We conclude that RXR isoform (alpha, beta, gamma) expression is not tightly controlled by insulin, insulin resistance or type 2 diabetes. Instead, RXR isoforms are likely constitutive proteins or controlled by other factors.

Peroxisome proliferator-activated receptor (PPAR) gamma and retinoid X receptor (RXR) agonists have complementary effects on glucose and lipid metabolism in human skeletal muscle

AIMS/HYPOTHESIS

To determine the independent and potentially synergistic effects of agonists for PPAR gamma and RXR on glucose and lipid metabolism, as well as gene expression, in human skeletal muscle cell cultures.

METHODS

Fully differentiated myotubes from non-diabetic subjects and subjects with Type II (non-insulin-dependent) diabetes mellitus were chronically (2 days) treated with LG100268 (4 mumol/l), an RXR agonist, or troglitazone (4.6 mumol/l), a PPAR gamma agonist or both, to determine the effects on glucose uptake, activity of glycogen synthase and palmitate oxidation.

RESULTS

The combination of both agents increased glucose uptake (60 +/- 9% compared to control subjects) but not either agent alone (16 +/- 9 and 26 +/- 6% for LG100268 and troglitazone, p < 0.01, respectively). The agent LG100268 alone had little effect on the activity of glycogen synthase but the effect of troglitazone increased with LG100268 (p < 0.05). With chronic exposure, LG100268 upregulated palmitate oxidation (53 +/- 12% increase, p < 0.005), in a way similar to troglitazone (68 +/- 23%, p < 0.005). Synergism was observed when both agonists were combined (146 +/- 38%, p < 0.005 vs either agent alone). Treatment with either agent led to about a twofold increase in the expression of fatty acid transporter (FAT/CD36). Troglitazone upregulated PPAR gamma protein expression, whereas LG100268 had no effect. Furthermore, neither LG100268 nor troglitazone had any effect on the protein expression of RXR isoforms or PPAR alpha.

CONCLUSION/INTERPRETATION

Co-activation of PPAR gamma and RXR results in additive or synergistic effects on glucose and lipid metabolism in skeletal muscle, but unlike troglitazone, LG100268 does not alter expression of its own receptor.