An assistive listening device improves hearing following aneurysmal subarachnoid haemorrhage

BACKGROUND AND PURPOSE

Hearing impairment is common following aneurysmal subarachnoid haemorrhage (aSAH). Previous studies have demonstrated that auditory processing disorder (APD) is the primary underlying pathology. Assistive listening devices (ALDs) can be used to manage APD but have not been explored in aSAH. The aim of this study was to assess the benefit of an ALD for patients reporting hearing difficulty after aSAH.

METHODS

This was a prospective pilot single-arm intervention study of an ALD for APD following aSAH. Patients who reported subjective hearing difficulty following aSAH were identified from the Wessex Neurological Centre aSAH database. Speech-in-noise was evaluated using the Bamford-Kowal-Bench (BKB) test under 60 and 65 dB noise conditions. BKB performance was compared with and without an ALD. Cognition was assessed using the Addenbrooke's Cognitive Examination-III.

RESULTS

Fourteen aSAH patients with self-reported hearing loss were included in the analysis. Under both noise conditions the ALD significantly improved BKB performance (60 dB, Z = -3.30, p < 0.001; 65 dB, Z = -3.33, p < 0.001). There was no relationship between cognition and response to the ALD.

CONCLUSIONS

This study demonstrates the marked benefit of ALDs to manage APD following aSAH, regardless of cognitive status. This finding has implications for the management of this common yet disabling deficit which impacts quality of life and employment. A further trial of ALDs in this patient group is needed to test whether these large, short-term benefits can be practically translated to the community for long-term benefit when used at home.

O-215 How common is add-on use and how do patients decide whether to use them? A national survey of IVF patients

Study question

How common is IVF add-on use in Australia, and what drives the use?

Summary answer

Most women (82%) had used one or more IVF add-ons and more than half (54%) first learned about the add-ons from their fertility specialist.

What is known already

IVF add-ons are procedures, techniques or medicines which may be considered nonessential to IVF, usually used in attempts to improve the probability of conception and live birth. Despite widespread concern about unproven IVF add-ons, information about the prevalence of their use is limited because these data are not available in national registries or datasets.

Study design, size, duration

Women who had undergone IVF in Australia since 2017 were recruited via social media. Women were excluded if they were gestational surrogates, had used a surrogate, or underwent IVF for oocyte donation or elective oocyte cryopreservation only. Eligible women completed an online survey which was open from 21st June to 14th July 2020.

Participants/materials, setting, methods

Survey questions included demographics, IVF and medical history, and questions specifically about IVF add-ons such as: the type of add-ons used, information sources consulted, and where participants first heard about add-ons. Women also responded to questions about the importance of scientific evidence regarding safety and effectiveness, factors considered in decision-making around add-on use and the presence of any decision regret.

Main results and the role of chance

A total of 1,590 responses were analyzed after excluding 287 ineligible responses. Participants were generally representative of women who undergo IVF in Australia in terms of age, indication for IVF, and use of ICSI for fertilisation. Most women had used at least one add-on (82%), and these were usually associated with an additional fee (72%). It was most common to first learn about IVF add-ons from the fertility specialist (54%), and most women reported that they and their specialist contributed equally to the decision to use add-ons.

Women viewed scientific evidence for safety and effectiveness as very important

on a scale from 0-100, an importance score over 90 was selected by more than half of the participants. Additionally, many (49%) assumed that add-ons were risk-free. Most women experienced regret at the decision to use IVF add-ons (66%), and this regret was greatest among women who experienced IVF failure when using add-ons (83%) and those who believed that the specialist drove the decision to use the add-ons (75%).

Limitations, reasons for caution

This was a retrospective survey of IVF patients, therefore it may suffer from bias due to patient recall. It does not consider the perspective of the IVF clinic or fertility specialist. Certain questions may be more prone to biased responses, such as those regarding who contributed to decision making.

Wider implications of the findings

The high prevalence of add-on use is likely generalizable to other settings where IVF treatment is largely private. Although women viewed scientific evidence as very important, most had used unproven IVF add-ons. This might suggest that women were not aware of the lack of robust evidence to support their use.

Trial registration number

Not applicable

How common is add-on use and how do patients decide whether to use them? A national survey of IVF patients

STUDY QUESTION

What is the prevalence and pattern of IVF add-on use in Australia?

SUMMARY ANSWER

Among women having IVF in the last 3 years, 82% had used one or more IVF add-on, most commonly acupuncture, preimplantation genetic testing for aneuploidy and Chinese herbal medicine.

WHAT IS KNOWN ALREADY

IVF add-ons are procedures, techniques or medicines which may be considered nonessential to IVF, but usually used in attempts to improve the probability of conception and live birth. The use of IVF add-ons is believed to be widespread; however, there is little information about the prevalence and patterns of use in different settings.

STUDY DESIGN, SIZE, DURATION

An online survey was distributed via social media to women in Australia who had undergone IVF since 2017. Women were excluded if they were gestational surrogates, used a surrogate, or underwent ovarian stimulation for oocyte donation or elective oocyte cryopreservation only. The survey was open from 21 June to 14 July 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Survey questions included demographics, IVF and medical history, and use of IVF add-ons including details of the type of add-on, costs and information sources used. Participants were also asked about the relative importance of evidence regarding safety and effectiveness, factors considered in decision-making and decision regret.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1590 eligible responses were analysed. Overall, 82% of women had used one or more add-ons and these usually incurred an additional cost (72%). Around half (54%) had learned about add-ons from their fertility specialist, and most reported that the decision to use add-ons was equally shared with the specialist. Women placed a high level of importance on scientific evidence for safety and efficacy, and half (49%) assumed that add-ons were known to be safe. Most women experienced some regret at the decision to use IVF add-ons (66%), and this was more severe among women whose IVF was unsuccessful (83%) and who believed that the specialist had a larger contribution to the decision to use add-ons (75%).

LIMITATIONS, REASONS FOR CAUTION

This retrospective survey relied on patient recall. Some aspects were particularly prone to bias such as contributions to decision-making. This approach to capturing IVF add-on use may yield different results to data collected directly from IVF clinics or from fertility specialists.

WIDER IMPLICATIONS OF THE FINDINGS

There is a very high prevalence of IVF add-on use in Australia which may be generalisable to other settings with similar models of IVF provision. Although women placed high importance on scientific evidence to support add-ons, most add-ons do not have robust evidence of safety and effectiveness. This suggests that IVF patients are not adequately informed about the risks and benefits of IVF add-ons, or are not aware of the paucity of evidence to support their use.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by a McKenzie Postdoctoral Fellowship Grant (University of Melbourne), a Department of Obstetrics and Gynaecology Innovation Grant (University of Melbourne) and an NHMRC Investigator Grant (APP1195189). A.P. declares that he provides fertility services at Melbourne IVF (part of Virtus Health). J.W. reports grants from Wellcome Trust, during the conduct of the study, and that publishing benefits his career. The remaining authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Guaiac faecal occult blood test performance at initial and repeat screens in the English Bowel Cancer Screening Programme

BACKGROUND

In many countries, screening for colorectal cancer (CRC) relies on repeat testing using the guaiac faecal occult blood test (gFOBT). This study aimed to compare gFOBT performance measures between initial and repeat screens.

METHODS

Data on screening uptake and outcomes from the English Bowel Cancer Screening Programme (BCSP) for the years 2008 and 2011 were used. An existing CRC natural history model was used to estimate gFOBT sensitivity and specificity, and the cost-effectiveness of different screening strategies.

RESULTS

The gFOBT sensitivity for CRC was estimated to decrease from 27.35% at the initial screen to 20.22% at the repeat screen. Decreases were also observed for the positive predictive value (8.4-7.2%) and detection rate for CRC (0.19-0.14%). Assuming equal performance measures for both the initial and repeat screens led to an overestimate of the cost effectiveness of gFOBT screening compared with the other screening modalities.

CONCLUSIONS

Performance measures for gFOBT screening were generally lower in the repeat screen compared with the initial screen. Screening for CRC using gFOBT is likely to be cost-effective; however, the use of different screening modalities may result in additional benefits. Future economic evaluations of gFOBT should not assume equal sensitivities between screening rounds.

Can lower risk patients presenting with transient ischaemic attack be safely managed as outpatients?

This study aimed to examine outcome in low risk transient ischaemic attack (TIA) patients presenting to emergency departments (ED) in a regional Australian setting discharged on antiplatelet therapy with expedited neurology review. All patients presenting to Gosford or Wyong Hospital ED with TIA, for whom faxed referrals to the neurology department were received between October 2008 and July 2010, were included in this prospective cohort study. Classification of low risk was based on an age, blood pressure, clinical features, duration of symptoms and diabetes (ABCD2) score <4 and the absence of high risk features, including known carotid disease, crescendo TIA, or atrial fibrillation. Patients with ABCD2 scores > or =4 or with high risk features were discussed with the neurologist on call (a decision regarding discharge or admission was then made at the neurologist's discretion). Patients were investigated with a brain CT scan and/or CT angiography, routine pathology, and an electrocardiogram. All discharged patients were commenced on antiplatelet therapy and asked to follow up with their local medical officer within 7 days. The patients were contacted by the neurology department to arrange follow-up. Our primary outcome was the number of subsequent strokes occurring within 90 days. Of 200 discharged patients for whom referrals were received, three patients had a stroke within 90 days. None of these would have been prevented through hospitalisation. In conclusion, medical assessment, expedited investigation with immediate commencement of secondary prevention and outpatient neurology review may be a reasonable alternative to admission for low risk patients presenting to the ED with TIA.

Reappraisal of the options for colorectal cancer screening in England

AIM

The aim was to use newly available data to estimate the cost effectiveness and endoscopy requirements of screening options for colorectal cancer (CRC) to inform screening policy in England.

METHODS

A state transition model simulated the life experience of a cohort of individuals in the general population of England with normal colon/rectal epithelium through to the development of adenomas and CRC and subsequent death. CRC natural history model parameters and screening test characteristics were estimated simultaneously by a process of model calibration. This process was fitted to observed data on CRC incidence in the absence of screening, data from existing screening programmes, and data from the UK flexible sigmoidoscopy (FS) screening trial. The costs, effects and resource impact were evaluated for a range of screening options involving the guaiac or immunochemical faecal occult blood test (gFOBT/iFOBT) and FS.

RESULTS

The model suggests that screening strategies involving FS or iFOBT may produce additional benefits compared with the current policy of biennial gFOBT for 60-74-year-olds. The age at which a single FS screen results in the greatest quality-adjusted life year gain was 55, with similar gains for ages between 52 and 58. Strategies which combined FS and iFOBT showed further benefits and improved economic outcomes.

CONCLUSIONS

Strategies which combine different screening modalities may provide greater clinical and economic benefits. The collection of comprehensive screening data using a uniform format will enable comparative analysis across screening programmes in different countries, will improve our understanding of the disease and will allow identification of optimal screening modalities.

Cost-effectiveness of population-based screening for colorectal cancer: a comparison of guaiac-based faecal occult blood testing, faecal immunochemical testing and flexible sigmoidoscopy

BACKGROUND

Several colorectal cancer-screening tests are available, but it is uncertain which provides the best balance of risks and benefits within a screening programme. We evaluated cost-effectiveness of a population-based screening programme in Ireland based on (i) biennial guaiac-based faecal occult blood testing (gFOBT) at ages 55-74, with reflex faecal immunochemical testing (FIT); (ii) biennial FIT at ages 55-74; and (iii) once-only flexible sigmoidoscopy (FSIG) at age 60.

METHODS

A state-transition model was used to estimate costs and outcomes for each screening scenario vs no screening. A third party payer perspective was adopted. Probabilistic sensitivity analyses were undertaken.

RESULTS

All scenarios would be considered highly cost-effective compared with no screening. The lowest incremental cost-effectiveness ratio (ICER vs no screening euro 589 per quality-adjusted life-year (QALY) gained) was found for FSIG, followed by FIT euro 1696) and gFOBT (euro 4428); gFOBT was dominated. Compared with FSIG, FIT was associated with greater gains in QALYs and reductions in lifetime cancer incidence and mortality, but was more costly, required considerably more colonoscopies and resulted in more complications. Results were robust to variations in parameter estimates.

CONCLUSION

Population-based screening based on FIT is expected to result in greater health gains than a policy of gFOBT (with reflex FIT) or once-only FSIG, but would require significantly more colonoscopy resources and result in more individuals experiencing adverse effects. Weighing these advantages and disadvantages presents a considerable challenge to policy makers.

FASTER (Face, Arm, Speech, Time, Emergency Response): experience of Central Coast Stroke Services implementation of a pre-hospital notification system for expedient management of acute stroke

Despite benefit in acute ischaemic stroke, less than 3% of patients receive tissue plasminogen activator (tPA) in Australia. The FASTER (Face, Arm, Speech, Time, Emergency Response) protocol was constructed to reduce pre-hospital and Emergency Department (ED) delays and improve access to thrombolysis. This study aimed to determine if introduction of the FASTER protocol increases use of tPA using a prospective pre- and post-intervention cohort design in a metropolitan hospital. A pre-hospital assessment tool was used by ambulance services to screen potential tPA candidates. The acute stroke team was contacted, hospital bypass allowed, triage and CT radiology alerted, and the patient rapidly assessed on arrival to ED. Data were collected prospectively during the first 6 months of the new pathway and compared to a 6-month period 12 months prior to protocol initiation. In the 6 months following protocol introduction, 115 patients presented within 24 hours of onset of an ischaemic stroke: 22 (19%) received thrombolysis, significantly greater than five (7%) of 67 patients over the control period, p=0.03. Overall, 42 patients were referred via the FASTER pathway, with 21 of these receiving tPA (50%). One inpatient stroke was also treated. Only two referrals (<5%) were stroke mimics. Introduction of the FASTER pathway also significantly reduced time to thrombolysis and time to admission to the stroke unit. Therefore, fast-track referral of potential tPA patients involving the ambulance services and streamlined hospital assessment is effective and efficient in improving patient access to thrombolysis.

Bevacizumab in combination with fluoropyrimidine-based chemotherapy for the first-line treatment of metastatic colorectal cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of bevacizumab in combination with fluoropyrimidine-based chemotherapy for the first-line treatment of metastatic colorectal cancer based on the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. Evidence was available in the form of one phase III, multicentre, multinational, randomised, open-label study (NO16966 trial). This two-arm study was originally designed to demonstrate the non-inferiority of oral capecitabine plus oxaliplatin (XELOX) compared with 5-fluorouracil plus folinic acid plus oxaliplatin (FOLFOX)-4 in adult patients with histologically confirmed metastatic colorectal cancer who had not previously been treated. Following randomisation of 634 patients, the open-label study was amended to include a 2 × 2 factorial randomised (partially blinded for bevacizumab) phase III trial with the coprimary objective of demonstrating superiority of bevacizumab in combination with chemotherapy compared with chemotherapy alone. Measured outcomes included overall survival, progression-free survival, response rate, adverse effects of treatment and health-related quality of life. The manufacturer's primary pooled analysis of superiority (using the intention-to-treat population) showed that after a median follow-up of 28 months, the addition of bevacizumab to chemotherapy significantly improved progression-free survival and overall survival compared with chemotherapy alone in adult patients with histologically confirmed metastatic colorectal cancer who were not previously treated [median progression-free survival 9.4 vs 7.7 months (absolute difference 1.7 months); hazard ratio (HR) 0.79, 97.5% confidence interval (CI) 0.72 to 0.87; p = 0.0001; median overall survival 21.2 vs 18.9 months (absolute difference 2.3 months); HR 0.83, 97.5% CI 0.74 to 0.93; p = 0.0019]. The NO16966 trial was of reasonable methodological quality and demonstrated a significant improvement in both progression-free survival and overall survival when bevacizumab was added to XELOX or FOLFOX. However, the size of the actual treatment effect of bevacizumab is uncertain. The ERG believed that the modelling structure employed was appropriate, but highlighted several key issues and areas of uncertainty. At the time of writing, NICE was yet to issue the guidance for this appraisal.

Bevacizumab in combination with fluoropyrimidine-based chemotherapy for the first-line treatment of metastatic colorectal cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of bevacizumab in combination with fluoropyrimidine-based chemotherapy for the first-line treatment of metastatic colorectal cancer based on the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. Evidence was available in the form of one phase III, multicentre, multinational, randomised, open-label study (NO16966 trial). This two-arm study was originally designed to demonstrate the non-inferiority of oral capecitabine plus oxaliplatin (XELOX) compared with 5-fluorouracil plus folinic acid plus oxaliplatin (FOLFOX)-4 in adult patients with histologically confirmed metastatic colorectal cancer who had not previously been treated. Following randomisation of 634 patients, the open-label study was amended to include a 2 × 2 factorial randomised (partially blinded for bevacizumab) phase III trial with the coprimary objective of demonstrating superiority of bevacizumab in combination with chemotherapy compared with chemotherapy alone. Measured outcomes included overall survival, progression-free survival, response rate, adverse effects of treatment and health-related quality of life. The manufacturer’s primary pooled analysis of superiority (using the intention-to-treat population) showed that after a median follow-up of 28 months, the addition of bevacizumab to chemotherapy significantly improved progression-free survival and overall survival compared with chemotherapy alone in adult patients with histologically confirmed metastatic colorectal cancer who were not previously treated [median progression-free survival 9.4 vs 7.7 months (absolute difference 1.7 months); hazard ratio (HR) 0.79, 97.5% confidence interval (CI) 0.72 to 0.87; p = 0.0001; median overall survival 21.2 vs 18.9 months (absolute difference 2.3 months); HR 0.83, 97.5% CI 0.74 to 0.93; p = 0.0019]. The NO16966 trial was of reasonable methodological quality and demonstrated a significant improvement in both progression-free survival and overall survival when bevacizumab was added to XELOX or FOLFOX. However, the size of the actual treatment effect of bevacizumab is uncertain. The ERG believed that the modelling structure employed was appropriate, but highlighted several key issues and areas of uncertainty. At the time of writing, NICE was yet to issue the guidance for this appraisal.

Quality of diabetes care in patients with schizophrenia and bipolar disorder: cross-sectional study

AIMS

To determine whether patients with severe mental illness receive poorer health care for diabetes than patients without.

METHODS

This population-based cross-sectional survey used electronic general practice records from 481 UK general practices contributing to the QRESEARCH database. The records of 11 043 patients with diabetes, drawn from a database population of over 9 million patients, were extracted. Unadjusted and adjusted odds ratios were calculated using unconditional logistic regression for each of 17 quality indicators for diabetes care from the new General Medical Services contract for general practitioners.

RESULTS

The presence of severe mental illness did not reduce the quality of care received; the only significant difference between groups showed that such patients were more likely to have glycated haemoglobin < 7.5%[adjusted odds ratio = 1.45 (99% confidence interval 1.20-1.76)]. Increasing age was associated with better care [adjusted odds ratios from 1.06 (1.02-1.11) to 1.61 (1.52-1.70)], but other confounding variables had no consistent effect across indicators. Overall, performance against government targets was good.

CONCLUSIONS

The hypothesis of poorer diabetes care for those with severe mental illness is disproved, perhaps surprisingly, in the light of other recent UK studies showing inequalities in care for the mentally ill. The study does not reveal who is providing this good care (general practitioners, psychiatrists or diabetologists) or take account of the estimated 600 000 people in the UK with undiagnosed diabetes.

Longitudinal prevalence and determinants of early mood disorder post-stroke

BACKGROUND

Early identification of mood disorder post-stroke (MDPS) or its determinants could improve stroke outcomes. However, the natural history, prevalence and determinants of MDPS within the first weeks post-stroke require further investigation.

METHODS

Consecutive hospitalised stroke survivors were assessed within 2-5 days of stroke, and at 1 and 3 months post-stroke. Baseline data included demographics, co-morbidities, stroke subtype, pre-stroke disability and cognition. At baseline, 1- and 3-month interviews physical impairment, disability, cognition and social support were assessed. MDPS was defined as a score of >8 on the depression subscale of the Hospital Anxiety Depression Scale. Factors independently associated with MDPS at each time-point were determined using regression analyses.

RESULTS

One hundred and twenty-five subjects were included. The prevalence of MDPS within 5 days and at 1 and 3 months post-stroke was 5%, 16% and 21% respectively. The independent determinants for MDPS at 1 month were disability, social support and change in impairment score between initial and 1-month assessments; and at 3 months were disability, social support and institutionalisation. Individuals moved in and out of the subset of depressed patients over time. MDPS was independently associated with mortality at 3 months post-stroke.

CONCLUSION

Mood disorder post-stroke increases in prevalence over the initial weeks post-stroke despite an improvement in disability, and is associated with mortality. Patients with MDPS at 1 month were not necessarily affected at 3 months and vice versa, indicating the dynamic nature of MDPS in the early stages.

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR

BACKGROUND

Pilot studies of complex interventions such as a team checklist are an essential precursor to evaluating how these interventions affect quality and safety of care. We conducted a pilot implementation of a preoperative team communication checklist. The objectives of the study were to assess the feasibility of the checklist (that is, team members' willingness and ability to incorporate it into their work processes); to describe how the checklist tool was used by operating room (OR) teams; and to describe perceived functions of the checklist discussions.

METHODS

A checklist prototype was developed and OR team members were asked to implement it before 18 surgical procedures. A research assistant was present to prompt the participants, if necessary, to initiate each checklist discussion. Trained observers recorded ethnographic field notes and 11 brief feedback interviews were conducted. Observation and interview data were analyzed for trends.

RESULTS

The checklist was implemented by the OR team in all 18 study cases. The rate of team participation was 100% (33 vascular surgery team members). The checklist discussions lasted 1-6 minutes (mean 3.5) and most commonly took place in the OR before the patient's arrival. Perceived functions of the checklist discussions included provision of detailed case related information, confirmation of details, articulation of concerns or ambiguities, team building, education, and decision making. Participants consistently valued the checklist discussions. The most significant barrier to undertaking the team checklist was variability in team members' preoperative workflow patterns, which sometimes presented a challenge to bringing the entire team together.

CONCLUSIONS

The preoperative team checklist shows promise as a feasible and efficient tool that promotes information exchange and team cohesion. Further research is needed to determine the sustainability and generalizability of the checklist intervention, to fully integrate the checklist routine into workflow patterns, and to measure its impact on patient safety.

Communication failures in the operating room: an observational classification of recurrent types and effects

BACKGROUND

Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR.

METHODS

Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions.

RESULTS

421 communication events were noted, of which 129 were categorized as communication failures. Failure types included "occasion" (45.7% of instances) where timing was poor; "content" (35.7%) where information was missing or inaccurate, "purpose" (24.0%) where issues were not resolved, and "audience" (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error.

CONCLUSION

Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.

Communication failures in the operating room: an observational classification of recurrent types and effects

BACKGROUND

Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR.

METHODS

Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions.

RESULTS

421 communication events were noted, of which 129 were categorized as communication failures. Failure types included "occasion" (45.7% of instances) where timing was poor; "content" (35.7%) where information was missing or inaccurate, "purpose" (24.0%) where issues were not resolved, and "audience" (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error.

CONCLUSION

Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.

Verbal working memory and solvent exposure: a positron emission tomography study

Neuropsychological studies have documented frontal dysfunction in patients with a history of exposure to organic solvents. The deficits typically observed in these patients appear to be related to working memory (WM). This study used [15O] water positron emission tomography (PET) to examine the pattern of neural activation during verbal working memory in patients with a history of exposure to solvents. Six individuals with solvent exposure were compared with 6 age- and education-matched controls. On the 2 WM tasks examined with PET, with equivalent task performance, participants with solvent exposure demonstrated frontal peaks that were atypical for the tasks, whereas the posterior peaks were typical for the tasks. The results support frontal dysfunction and compensatory use within anterior regions of the WM system in patients with solvent exposure.

Verbal working memory and solvent exposure: a positron emission tomography study

Neuropsychological studies have documented frontal dysfunction in patients with a history of exposure to organic solvents. The deficits typically observed in these patients appear to be related to working memory (WM). This study used [15O] water positron emission tomography (PET) to examine the pattern of neural activation during verbal working memory in patients with a history of exposure to solvents. Six individuals with solvent exposure were compared with 6 age- and education-matched controls. On the 2 WM tasks examined with PET, with equivalent task performance, participants with solvent exposure demonstrated frontal peaks that were atypical for the tasks, whereas the posterior peaks were typical for the tasks. The results support frontal dysfunction and compensatory use within anterior regions of the WM system in patients with solvent exposure.

Specialist nurses in Australia: the ICN and international regulation

This article focuses on the relationship between specialist nurses in Victoria (Australia) and the International Council of Nurses (ICN). A major consideration is whether international standards can be applied across international boundaries. The ICN has represented the worldwide nursing community for the past 100 years. In 1997 the Royal College of Nursing (Australia) gained membership to the ICN and to its Regulation Network. With growing interest about internationalization, a key question is whether Australian nurses will accept the Council recommendations on regulation. In a report on specialist nurse education in Australia, recommendations were made that included the adoption of the ICN definition for specialist practice. A survey of the opinions of 75 nurses practicing in Victoria, toward a selection of recommendations from the report, showed strong agreement on definition and much less agreement on minimum credentials. Findings from the survey are discussed in relation to the international profile that is now expected of specialist nurses in Australia and a potential future role for professional organizations.

The specialist nurse: a classification system

This paper focuses on the important developments of specialty nursing practice within Australia and reports the results of a recent survey of specialist nurses in Victoria. Debate among the worldwide nursing community reflects confusion and ambiguity about specialist practice. Similarly, variation, duplication and inconsistency characterise the status of specialist nurse education in Australia. This situation contributes to role problems for specialist nurses and may arise from their lack of contribution to the decision making process. Seventy-five nurses undertaking a range of specialist nursing courses offered by three educational providers (a university, major teaching hospital and professional organisation) completed a survey questionnaire to establish the extent to which they agreed with the major recommendations proposed in the National Review of Specialist Nurse Education (Specialist Review) (Russell et al 1997). Despite contention within the profession, specialist nurses in Victoria show support for a unified approach toward definition, title and credentials. The discussion specifically addresses the implications for the future classification of specialist nurses in Australia.

Novel Leu723Pro amyloid precursor protein mutation increases amyloid beta42(43) peptide levels and induces apoptosis

A novel missense mutation, Leu723Pro, in the amyloid precursor protein (APP) gene was discovered in an early-onset Alzheimer's disease family. Expression of L723P mutant APP complementary DNA in CHO cells resulted in a 1.4- to 1.9-fold increased production of the 42(43)-amino acid length amyloid beta peptide compared with the wild-type sequence and was capable of causing apoptosis. The mutation is predicted to alter the luminal transmembrane length and helical arrangement of the APP molecule and thus affect the gamma-secretase cleavage site.

Premedication before intubation in UK neonatal units

AIMS

To establish the extent and type of premedication used before intubation in neonatal units in the United Kingdom.

METHODS

A structured telephone survey was conducted of 241 eligible units. Units were subdivided into those that routinely intubated and ventilated babies (routine group) and those that transferred intubated and ventilated babies (transfer group).

RESULTS

Of the units contacted, 239 (99%) participated. Only 88/239 (37%) gave any sedation before intubating on the unit and only 34/239 (14%) had a written policy covering this. Morphine was used most commonly (66%), with other opioids and benzodiazepines used less frequently. Of the 88 units using sedation, 19 (22%) also used paralysis. Suxamethonium was given by 10/19 (53%) but only half of these combined it with atropine. Drug doses varied by factors of up to 200, even for commonly used drugs.

CONCLUSION

Most UK neonatal units do not sedate babies before intubating, despite evidence of physiological and practical benefits. Only a minority have written guidelines, which prohibits auditing of practice.

Specialisation in nursing. A survey of reactions of Victorian nurses to the national review of specialist nurse education

This article reports on the opinions of specialist nurses practising in Victoria toward recommendations proposed in the National Review of Specialist Nurse Education (Specialist Review) (Russell et al 1997). Seventy-five nurses undertaking a range of specialist nursing courses offered by three educational providers (a university, major teaching hospital and professional organisation) completed a survey questionnaire to establish the extent to which they agreed with the major recommendations from the Specialist Review. Results showed strong endorsement for most recommendations but with less agreement about issues of minimum credentials and future provisions. Comparison of responses across age, experience, employment and professional education subgroups identified significant differences of opinions on some recommendations. Findings from this study are discussed in relation to the Specialist Review and to implications for the future development of specialist nursing education in Australia.

The effects of age and mood on saccadic function in older individuals

To investigate the effect of age and mood on saccadic function, we recorded prosaccades, predictive saccades, and antisaccades from 238 cognitively normal, physically healthy volunteers aged 44 to 85 years old. Mood levels were measured using the State-Trait Anxiety Inventory and Center for Epidemiological Studies Depression Scale inventories. Small, but significant, positive relationships with age were observed for the mean latency and associated variability of latency for all types of saccades, as well as the antisaccade error rate. Saccade velocity or accuracy was unaffected by age. Increasing levels of depression had a minor negative influence on the antisaccade latency, whereas increasing levels of anxiety raised the antisaccade error rate marginally.

Patient-controlled analgesia: epidural fentanyl and i.v. morphine compared after caesarean section

We have compared patient-controlled epidural fentanyl (PCEF) and patient-controlled i.v. morphine (PCIM) after Caesarean section in 84 patients, in a randomized, double-blind study. All patients had an epidural and an i.v. patient-controlled analgesia (PCA) device, one of which delivered normal saline. Group PCEF received epidural fentanyl 20 micrograms with a 10-min lockout. Group PCIM received i.v. morphine 1 mg with a 5-min lockout. PCA use was lower for PCEF patients (P = 0.0007). The highest pain score recorded at rest for PCEF patients was median 20 (interquartile range 10-33) mm compared with 32 (14-52) mm for PCIM patients (P = 0.02). The highest pain score recorded on coughing was 31 (21-41) mm with PCEF compared with 56 (30-71) mm for PCIM (P = 0.001). There was less nausea (P = 0.02) and drowsiness (P = 0.0003) with PCEF. There was no difference in the overall incidence and severity of pruritus (P = 0.77). However, pruritus started earlier with PCEF.

The 3' end CCA of mature tRNA is an antideterminant for eukaryotic 3'-tRNase

Cytoplasmic tRNAs undergo posttranscriptional 5' and 3' end processing in the eukaryotic nucleus, and CCA (which forms the mature 3' end of all tRNAs) must be added by tRNA nucleotidyl transferase before tRNA can be aminoacylated and utilized in translation. Eukaryotic 3'-tRNase can endonucleolytically remove a 3' end trailer by cleaving on the 3' side of the discriminator base (the unpaired nucleotide 3' of the last base pair of the acceptor stem). This reaction proceeds despite a wide range in length and sequence of the 3' end trailer, except that mature tRNA containing the 3' terminal CCA is not a substrate for mouse 3'-tRNase (Nashimoto, 1997, Nucleic Acids Res 25:1148-1154). Herein, we extend this result with Drosophila and pig 3'-tRNase, using Drosophila melanogaster tRNAHis as substrate. Mature tRNA is thus prevented from recycling through 3' end processing. We also tested a series of tRNAs ending at the discriminator base (-), with one C added (+C), two Cs added (+CC), and CCA added (+CCA) as 3'-tRNase inhibitors. Inhibition was competitive with both Drosophila and pig 3'-tRNase. The product of the 3'-tRNase reaction (-) is a good 3'-tRNase inhibitor, with a KI approximately two times KM for the normal 3'-tRNase substrate. KI increases with each nucleotide added beyond the discriminator base, until when tRNA+CCA is used as inhibitor, KI is approximately forty times the substrate KM. The 3'-tRNase can thus remain free to process precursors with 3' end trailers because it is barely inhibited by tRNA+CCA, ensuring that tRNA can progress to aminoacylation. The active site of 3'-tRNase may have evolved to make an especially poor fit with tRNA+CCA.

No association of presenilin-1 intronic polymorphism and Alzheimer's disease in Australia

We screened 703 Australian subjects for an intronic polymorphism in the presenilin-1 (PS-1) gene. PS-1 intronic allele 1 homozygosity was not associated with individuals with early- or late-onset sporadic Alzheimer's disease (EOAD or LOAD). Carriers for the PS-1 intronic allele 1 were also not associated with significantly increased risk for AD regardless of gender. Our results for the Australian population are consistent with those of recent reports for other populations and do not support the conclusion that the PS-1 intronic polymorphism is associated with AD.

Secretion of Alzheimer's disease Abeta amyloid peptide by activated human platelets

Alzheimer's disease (AD) is characterized by the deposition of Abeta (betaA4) peptides of 39 to 43 amino acid residues, which are normal cellular metabolic products derived by proteolysis of the amyloid precursor protein (APP). The physiologic function of Abeta/APP in vivo is poorly understood. We analyzed human platelets for Abeta production by immunoprecipitation coupled to immunoblotting. A 4-kd Abeta fragment that comigrates with an Abeta40 synthetic peptide and reacts with several antibodies specific for the N- and C-termini of Abeta is detected. The majority of platelet Abeta appears to end at residue 40, as determined by immunoreactivity with an Abeta40-specific antibody. Furthermore, Abeta is secreted upon platelet stimulation with the physiologic agonists thrombin and collagen, together with secretion of soluble APP (sAPP). A comparison between serum and plasma shows a 1.6-fold increase in Abeta levels and a 2.4-fold increase in sAPP levels in serum. This is consistent with the view that platelets are the primary source of circulating Abeta and APP. The release of platelet Abeta by physiologic stimuli suggests that it may play a role in platelet aggregation and coagulation or in the repair mechanisms associated with injury.

Relative increase in Alzheimer's disease of soluble forms of cerebral Abeta amyloid protein precursor containing the Kunitz protease inhibitory domain

Although a number of studies have examined amyloid precursor protein (APP) mRNA levels in Alzheimer's disease (AD), no clear consensus has emerged as to whether the levels of transcripts for isoforms containing a Kunitz protease inhibitory (KPI)-encoded region are increased or decreased in AD. Here we compare AD and control brain for the relative amounts of APP protein containing KPI to APP protein lacking this domain. APP protein was purified from the soluble subcellular fraction and Triton X-100 membrane pellet extract of one hemisphere of AD (n = 10), normal (n = 7), and neurological control (n = 5) brains. The amount of KPI-containing APP in the purified protein samples was determined using two independent assay methods. The first assay exploited the inhibitory action of KPI-containing APP on trypsin. The second assay employed reflectance analysis of Western blots. The proportion of KPI-containing forms of APP in the soluble subcellular fraction of AD brains is significantly elevated (p < 0.01) compared with controls. Species containing a KPI domain comprise 32-41 and 76-77% of purified soluble APP from control and AD brains, respectively. For purified membrane-associated APP, 72-77 and 65-82% of control and AD samples, respectively, contain a KPI domain. Since KPI-containing species of APP may be more amyloidogenic (Ho, L., Fukuchi, K., and Yonkin, S. G. (1996) J. Biol. Chem. 271, 30929-30934), our findings support an imbalance of isoforms as one possible mechanism for amyloid deposition in sporadic AD.

Collection and normal levels of the amyloid precursor protein in plasma

The amyloid precursor protein is contained in platelet alpha granules and released with degranulation. Methods are described to control for amyloid precursor protein release from platelets during blood collection and processing. In normal subjects (n = 97; age range, 44-84 years), the average plasma level of amyloid precursor protein was 6.5 +/- 1.8 ng/ml.

An abnormality of plasma amyloid protein precursor in Alzheimer's disease

beta A4 amyloid deposition in the brain, which is characteristic of Alzheimer's disease (AD), may result from either overexpression of the amyloid protein precursor (APP) or failure of APP to be correctly processed. A blood marker reflecting this abnormal metabolism would be of diagnostic value and would provide a means of monitoring the efficacy of therapeutic interventions. We analyzed immunoblots of plasma APP enriched by heparin-Sepharose chromatography from patients with moderate to severe AD dementia (n = 34) and control subjects (n = 77) and found an approximately 50% increase in the proportion of 130-kd APP species in patients with AD (p less than 0.001), no difference in the 110-kd form, a 15 to 30% decrease in the 65-kd form (p less than 0.001), and a 20 to 35% decrease in the proportion of 42-kd APP (p less than 0.001). These species of APP were soluble, lacked the carboxyl terminus, and the 110- and 42-kd species were shown to be consistent with degradation products derived from the 130-kd species. A comparison of levels of 130-kd plasma APP from moderately to severely demented patients with AD and control subjects distinguished the two groups with a specificity of 87.0% and a sensitivity of 79.4%.

A rare heteromorphism of chromosome 20 and reproductive loss

A rare centromeric heterochromatic variant of chromosome 20 was encountered during investigations in a couple with repeated miscarriages. The enlarged segment was G and C band positive and stained positively by Giemsa II. In situ hybridisation of the biotinylated alphoid probe D20Z1 specific for the centromere of chromosome 20 to metaphase cells confirmed the presence of amplified sequences adjacent to the centromere. The variant was found to be familial and was evaluated as having no clinical significance.

Familial paracentric inversion of 1p

We report a paracentric inversion of 1p in a boy with mild mental retardation. The chromosome aberration was identified by high resolution chromosome banding, and was also present in his phenotypically normal mother and other relatives. The boy's karyotype was considered to be 46,XY,inv(1) (p31,2p36.22) ISCN (1981).