General Practitioners involvement in enteral tube feeding at home: a qualitative study

Background

Complex medical treatment is moving from hospital to primary care and General Practitioners (GPs) are increasingly asked to undertake new roles. There are now an estimated 19,500 patients being fed in the UK in the community on enteral tube feeding using a variety of different feeding tubes (Percutaneous endoscopic gastrostomy (PEG), Jejunostomy, or nasogastric (NG). The majority of patients are over the age of 65 years when they had artificial feeding initiated and mainly because of dysphagia. The aim of this study was to explore GPs knowledge, attitudes and skills relating to enteral feeding in the community.

Methods

Semi-structured one-to-one interviews with a convenience sample of GPs in Northern Ireland.

Results

Twenty-three GPs in three health boards in Northern Ireland participated in the study. Most found dealing with enteral feeding to be a predominantly negative experience. They had little involvement in patient selection for the procedure and poor or no discharge information. GPs felt inadequately trained, there was poor communication between primary and secondary care and little support. There was anger and frustration among GPs about lack of resources (funding and training), and the perception that primary care was used as a dumping ground.

Conclusion

Moving complex medical treatment from secondary to primary care has major implications for GPs who should be included in the patient selection process, have adequate discharge information about their patients, be adequately resourced and have appropriate support and training.

New knowledge, new insights, and new recommendations

Scientific controversy and media hype in unexpected infant deaths

Oculo-facio-cardio-dental syndrome in a mother and daughter

Oculo-facio-cardio-dental (OFCD) syndrome is a rare X-linked dominant syndrome characterized by canine teeth with extremely large roots (radiculomegaly), congenital cataract, dysmorphic facial features and congenital heart disease. A case of mother-daughter vertical transmission of OFCD is reported. Dental findings were important in confirming the diagnosis in the mother.

Nurses' smoking behaviour related to cessation practice

AIM

To examine the smoking behaviour, knowledge and attitudes of nurses, their willingness to provide smoking cessation support to patients, the accessibility of training in this area and their willingness to undertake future training in this area.

METHOD

A randomised sample of qualified nurses (n = 1,074) in statutory, private and voluntary sectors and across a variety of specialties were surveyed by postal questionnaire. Four focus groups were conducted in various settings before and after the survey.

RESULTS

Of those who took part in the survey, 55% had never smoked, 19% were ex-smokers and 26% were smokers. Most agreed that nurses have a responsibility to help those who want to quit smoking. However, nurses who smoked rated their ability to help patients and their effectiveness as a role model lower than nurses who were ex-smokers or non-smokers.

CONCLUSION

Smoking prevalence among nurses is no greater than in the general female population. Nurses who smoke are less motivated to provide cessation support for patients, have less positive attitudes to the value of smoking cessation, are less likely to have received smoking cessation training and are less likely to want further training. These results have implications for nurses' own smoking status, as well as their attitudes to cessation training, health promotion practice and future research.

Using focus groups to investigate the educational needs of female injecting heroin users in Taiwan in relation to HIV/AIDS prevention

This study investigated educational needs of female injecting heroin users in Taiwan relating to HIV/AIDS prevention via six focus group discussions in a prison. All sessions were audio-taped with respondents' consent and the discussions transcribed verbatim. The findings indicated that respondents had adequate knowledge about HIV/AIDS, but held misconceptions regarding the modes of HIV transmission. Many respondents who did not perceive themselves susceptible to AIDS rarely used condoms and occasionally shared needles. Stigma surrounding AIDS is pervasive among respondents and they considered contracting cancer would be preferable to having AIDS; the latter could precipitate suicide. Lastly, many respondents had no confidence in assurances of confidentiality regarding HIV testing. Issues of misconceptions, high-risk behaviors, stigma surrounding AIDS and confidentiality of HIV testing must be addressed in appropriate HIV/AIDS education programmes with respect to the needs of female injecting heroin users.

Perceived safety of donor blood and blood substitutes for transfusion: the role of informational frame, patient groups and stress appraisals

Patients express concerns about the safety of donated blood. Do they have similar concerns about potential 'blood substitutes' and does the way information is presented on these options alter patients' perceptions? A two (informational frame: gain or loss) by four (transfusion type: human donor blood, human haemoglobin, bovine haemoglobin or perfluorocarbon emulsion substitutes) by three (patient group: adult haemophiliac/leukaemia patients, relatives/friends of haemophiliac/leukaemia patients and controls) between-subjects design was used. There were 82 patients, 118 relatives/friends and 263 controls from the UK. Blood substitutes were perceived as being significantly less safe than donor blood. Perceptions of safety were greater when transfusion information (regardless of transfusion type or patient group) was presented as gains rather than losses. Different demographic and psychological factors predicted perceived safety (e.g. sex) and perceived risk (e.g. age and experience).

Orientation of oxazolidinones in the active site of monoamine oxidase

Oxazolidinone inhibitors of monoamine oxidase (MAO) and oxazolidinone antibacterials are two distinct classes of drug, often with linear structures and overlapping activities for some derivatives. By synthesizing novel dimerised derivatives with identical substitution of the two C-5 side chains, we have obtained experimental evidence for the orientation of oxazolidinones in the active site of MAO A. Two types of spectral changes, either increasing the absorbance at 510 nm or decreasing it at 495 nm depending on the group nearest to the flavin cofactor, were seen on ligand binding to MAO A. Side chain derivatives with amine substituents are very poor substrates so that it was possible to examine the spectral change due to binding of a substrate before reduction of the flavin occurred. Binding of these amino derivative substrates to MAO A induced a spectral change characterized by a strong decrease in absorbance at 495 nm. These substrates reduced the enzyme fully without any trace of a semiquinone intermediate. Only oxazolidinone inhibitors with a bromo-imidazole substituent increased the yield of semiquinone intermediate obtained during chemical reduction. In accord with the experimental data, results of docking experiments showed that binding of the oxazolidinone ring in the aromatic cage close to the flavin was favored and that the nitrogen of the derivatives that were substrates was within van der Waals distance of N-5 of the flavin.

Who should have a sleep study for sleep related breathing disorders?

By the time children are 5 years old more of their life will have been spent asleep than awake. Sleep medicine is therefore especially relevant in paediatrics. However, one recent survey showed that paediatricians' knowledge of sleep medicine is poor and that few paediatricians enquire about sleep as part of their general consultation.1

Sudden unexplained infant death in 20 regions in Europe: case control study

BACKGROUND

After striking changes in rates of sudden unexplained infant death (SIDS) around 1990, four large case-control studies were set up to re-examine the epidemiology of this syndrome. The European Concerted Action on SIDS (ECAS) investigation was planned to bring together data from these and new studies to give an overview of risk factors for the syndrome in Europe.

METHODS

We undertook case-control studies in 20 regions. Data for more than 60 variables were extracted from anonymised records of 745 SIDS cases and 2411 live controls. Logistic regression was used to calculate odds ratios (ORs) for every factor in isolation, and to construct multivariate models.

FINDINGS

Principal risk factors were largely independent. Multivariately significant ORs showed little evidence of intercentre heterogeneity apart from four outliers, which were eliminated. Highly significant risks were associated with prone sleeping (OR 13.1 [95% CI 8.51-20.2]) and with turning from the side to the prone position (45.4 [23.4-87.9]). About 48% of cases were attributable to sleeping in the side or prone position. If the mother smoked, significant risks were associated with bed-sharing, especially during the first weeks of life (at 2 weeks 27.0 [13.3-54.9]). This OR was partly attributable to mother's consumption of alcohol. Mother's alcohol consumption was significant only when baby bed-shared all night (OR increased by 1.66 [1.16-2.38] per drink). For mothers who did not smoke during pregnancy, OR for bed-sharing was very small (at 2 weeks 2.4 [1.2-4.6]) and only significant during the first 8 weeks of life. About 16% of cases were attributable to bed-sharing and roughly 36% to the baby sleeping in a separate room.

INTERPRETATION

Avoidable risk factors such as those associated with inappropriate infants' sleeping position, type of bedding used, and sleeping arrangements strongly suggest a basis for further substantial reductions in SIDS incidence rates.

The experience of the family caregivers' role: a qualitative study

In Ireland, there is a dearth of research exploring the perceived health and social care needs and experiences of family caregivers of older people. In response, this research study was conducted to explore the profile, role and needs of family caregivers as a means of understanding their experience of caring. The study also set out to identify coping strategies employed by caregivers and explore positive aspects of the caring relationship in relation to quality of life, information needs, day care and respite care, transport and emotional support. A multimethod approach used interviews, focus groups and postal questionnaires. In the main study a pretested questionnaire, comprising closed and open questions was used with a stratified, systematically randomized sample of caregivers in urban and rural home care settings, of which 52% of respondents to the questionnaire volunteered to partake in in-depth interviews. This article per deals predominantly with the findings arising from 10 in-depth qualitative interviews. The data yielded a rich and meaningful picture of the caregiving experience, profiling the complex nature of this diverse and multifaceted role. Findings showed that three main categories emanated from the data: the caring role-context and attitudes, the impact of caring and the need to support the carers' role. The need to develop continually an understanding of the effectiveness of specific health and social care interventions was also of paramount importance. The anticipated continuing demand for family care means that caregivers' needs and perspectives need to be integrated into future service planning and decision-making processes, in partnership with statutory and voluntary bodies. While this was the first study of its type in Ireland, the issues raised reflect the findings of other published studies and have important lessons for family carers and health care practitioners generally.

Strain on the human sciatic nerve in vivo during movement of the hip and knee

Injuries to the sciatic nerve are an occasional complication of surgery to the hip and acetabulum, and traction is frequently the causative mechanism. In vitro and animal experiments have shown that increased tensile strain on peripheral nerves, when applied for prolonged periods, impairs nerve function. We have used video-extensometry to measure strain on the human sciatic nerve during total hip replacement (THR). Ten consecutive patients with a mean age of 72 years undergoing primary THR by the posterior approach were recruited, and strains in the sciatic nerve were measured in different combinations of flexion and extension of the hip and knee, before dislocation of the hip. Significant increases (p = 0.02) in strain in the sciatic nerve were observed in flexion of the hip and extension of the knee. The mean increase was 26% (19% to 30%). In animal studies increases of this magnitude have been shown to impair electrophysiological function in peripheral nerves. Our results suggest that excessive flexion of the hip and extension of the knee should be avoided during THR.

Tibial shaft fractures in amateur footballers

BACKGROUND

Footballers constitute a unique group of patients with tibial shaft fractures. They tend to have excellent general health and well developed musculature in the leg, and their fractures are generally closed injuries caused by low velocity trauma. However, little has been reported on the outcome after tibial shaft fractures in this group.

OBJECTIVE

To identify patterns of injury, response to treatment, and functional outcome in such a group.

METHOD

Fifty consecutive tibial shaft fractures in adult footballers treated at Merlin Park Regional Hospital over a five year period were analysed.

RESULTS

Most of the fractures were type A injuries (AO/ASIF classification). The incidence of complications was low. All patients reported good or excellent satisfaction with their outcome. However, only 54% of patients returned to playing competitive football.

CONCLUSION

Tibial shaft fractures in amateur footballers are associated with good results when traditional outcome criteria are used, but many patients do not regain their previous level of function.

The readability and audience acceptance of printed health promotion materials used by environmental health departments

A significant part of the work of an environmental health professional is the communication of information to clients, customers, and the public in the context of safety and health promotion or as an adjunct to enforcement activities. While a wide range of communication methods are available today, printed material still forms an important aspect of the communications methodology of environmental health departments. This paper raises a number of questions about the effectiveness of environmental health promotion brochures in common use in the United Kingdom and the problems that could arise from simply assuming that the brochures are conveying the intended message to the target audience. Through a series of case studies conducted in environmental health departments, evaluative data on a range of brochures were gathered in two interlinked stages: a readability test and a target-audience questionnaire survey. The sources of the brochures included the central government, charities, trade unions, and commercial enterprises; some brochures were produced "in house." Results indicated a common mismatch between the estimated reading age of the target audience and the reading age determined by the readability test; concern about the efficacy of using commercially sourced brochures carrying advertising that may conflict with advice on other environmental health issues; "in-house" brochures that appeared to optimize self-promotion rather than the conveyance of topic information; ineffective brochures used as an adjunct to enforcement activity; and the possibility that the latter could be introduced as defense evidence in related legal proceedings. Overall, the study showed that a well-structured method for brochure choice and ongoing evaluation are essential tools for environmental health departments seeking to maximize their resources and effectiveness.

One-third, two-thirds: Relationship of the radial nerve to the lateral intermuscular septum in the arm

The radial nerve penetrates the lateral intermuscular septum of the arm before dividing into deep and superficial branches. It may be encountered in both anterior and posterior approaches to the humerus. An ability to accurately predict the point at which the nerve pierces the septum would be valuable during surgery in the arm, and would facilitate planning an approach to exploring the radial nerve after fractures of the distal humeral shaft. It would, in particular, make minimally invasive surgical techniques less dangerous. We dissected 20 cadaver upper limbs to establish whether the radial nerve enters the anterior compartment of the arm at a predictable level. We found that in almost every case the radial nerve entered the anterior compartment at a point within 5 mm of the junction of the distal and middle thirds of a line joining the lateral epicondyle of the humerus to the most lateral point of the acromion process of the scapula. This has not previously been described, and we believe is a useful aide-de-memoir to predicting the level at which the radial nerve penetrates the lateral intermuscular septum.

Strategy development in dealing with violence against employees in the workplace

The creation of health promoting workplaces is a key development in contemporary workplace health. This paper focuses on the issue of workplace violence and the efforts which must be made to address its prevention and to deal with its consequences as a contribution towards developing a health promoting workplace. A critical overview of the issue as it is currently addressed in the international literature is a precursor to the formulation of an inclusive definition of workplace violence. This forms the basis for a framework for the development and implementation of workplace violence policies. The framework takes account of needs assessment, policy formulation in terms of prevention, incident management and reporting, and post-incident support strategies. The needs for effective education and training and good internal and external communications are also explored. The paper concludes by highlighting the necessity for workplaces to take seriously the need for a coherent and well-planned workplace violence strategy.

Ethical dilemmas and human rights considerations arising from the evaluation of a smoking policy in a health promoting setting

One of the key challenges in managing the Health Promoting Workplace is the development of an effective policy for the control of environmental tobacco smoke (ETS). This paper explores the ethical consequences raised when the implementation of such a policy was evaluated in a large multi-campus university. In a three-stage evaluation, the first stage involved a qualitative enquiry with the Health and Safety Committee to obtain the management perspective on the working of the policy. A survey of the perception of the ETS policy and smoking behaviours with a representative sample of staff and students constituted the second stage. In the final stage the Health and Safety Committee was engaged with the findings of stages 1 and 2 to develop a response to the evaluation. The ethical implications which arise from this evaluation centre, firstly, on the underlying reasons for undertaking an evaluation. Secondly, consideration is given to the consequences of applying utilitarian principles to smoking policy for the minority who smoke and thus find their work or study patterns affected by a smoking ban. Such a ban limits their autonomy and while it may be helpful (beneficent) in terms of their longer-term physical health, it may have harmful (maleficent) effects on their psychological wellbeing and the potential for negative consequences if they choose to contravene the ban on smoking. The implications of addressing this situation are explored.