A 10-week intergenerational program bringing together community-living older adults and preschool children (INTERACTION): a pilot feasibility non-randomised clinical trial

BACKGROUND

Social isolation and low levels of physical activity are strong drivers for frailty, which is linked to poor health outcomes and transition to long-term care. Frailty is multifactorial, and thus an integrated approach is needed to maintain older adults' health and well-being. Intergenerational programs represent a novel multifactorial approach to target frailty, social isolation and physical decline but these have not yet been rigorously tested in Australia. Here, we present the results of our pilot study which aimed to test the feasibility of a 10-week intergenerational program between older adults and preschool children.

METHODS

A non-randomised wait-listed controlled trial was conducted. Participants were allocated to either the intervention or wait-list control group. The intervention group received 10 weekly 2-h intergenerational sessions led by trained child educators; the control group continued with their usual routine and received their intergenerational program after the 10-week control period. All participants were assessed at baseline and 10 weeks. The primary outcome was the feasibility and acceptability of the program including measures of recruitment eligibility, adherence and effective data collection across the multiple domains important for frailty, including functional mobility and balance, grip strength, cognitive function, mood, social engagement, quality of life and concerns about falling.

RESULTS

Nineteen adults were included, with nine in the intervention and ten in the control group. A total of 42% of older adults screened were eligible, 75% of participants were present at each intervention session and the overall attrition rate was 21% (n = 4). The reasons for participant absence were primarily health-related. Missing data was minimal for the majority of assessments but more apparent for the cognitive testing where completion rates ranged from 53 to 79% for baseline tests and 73 to 100% for those who received follow-up testing.

CONCLUSIONS

The high program compliance and low attrition show that a 10-week intergenerational program embedded in the local community, designed for community-living older adults and preschool children, is feasible and acceptable to older adults. Our next trial will test the efficacy of intergenerational programs in this setting.

Risk-Stratification using the 40-Gene Expression Profile (40-GEP) Test Identifies Patients with Node Negative Cutaneous Squamous Cell Carcinoma (cSCC) at Higher Risk of Metastasis Who May Benefit from Adjuvant Radiation Therapy (ART)

PURPOSE/OBJECTIVE(S)

ART is a standard treatment used to reduce the risk of metastasis and recurrence in moderate‒to‒high-risk cSCC patients. Indications for ART have been largely based on pathologic risk factors and informed by staging systems, and while radiation oncologists generally designate a >10% risk threshold for usage of ART, there is no consensus on which groups of tumors may benefit from ART. The 40-GEP test has been independently validated to predict a cSCC patient's risk for regional/distant metastasis in patients with one or more high-risk clinicopathologic factors and reports three biologic risk groups: Class 1 (low, ∼7%), Class 2A (moderate, 20-25%), and Class 2B (high risk, >50%) for metastasis. This study aims to evaluate whether a biomarker informed risk stratification approach using a 40-GEP result could refine the ability to select patients with node negative cSCC at higher risk of metastasis who are most likely to benefit from ART.

MATERIALS/METHODS

In this retrospective study, all patients had primary cSCC tissue with verified clinicopathologic information of tumors with one or more high-risk factors, met clinical testing criteria, were comprehensively staged, and had outcomes data (n = 954). Patients with node positive disease, or those with nodal failure within 3 months of diagnosis were excluded (n = 19). From the n = 935, an intermediate risk population wherein ART is often considered was defined as Brigham and Women's Hospital (BWH) ≥T2a (n = 489). Kaplan-Meier survival analysis and log-rank test were used to assess metastasis free survival (MFS). Univariate Cox regression compared metastasis rates between 40-GEP results.

RESULTS

The 3-year MFS rate for this eligible for ART cohort was 82.4% The 40-GEP demonstrated statistically significant risk stratification with MFS rates of 92.4%, 76.1% and 59.4% for Class 1, Class 2A and Class 2B, respectively (p<0.0001). Cox regression was significant for Class 2A and 2B compared to Class 1, with a 3.2-fold and 6.4-fold increase in metastasis, respectively (p<0.0001). 64% (59/92) of all metastases received a Class 2A result, and 44% (14/32) of Class 2B patients metastasized. 46% (223/489) of the cohort received a Class 1 result. Of patients staged BWH T1 (n = 446), those with a Class 2A and 2B had an 88.7% and 66.7% MFS rate, respectively.

CONCLUSION

Within this eligible for ART population, patients with Class 2A or 2B 40-GEP results have inferior rates of MFS, while Class 1 patients have <10% risk of metastasis. Nearly half of this population received a 40-GEP Class 1 result and could be considered for treatment de-intensification trials. Conversely, patients with low-risk BWH T1 stage, who are traditionally not considered for ART, that received a Class 2A or 2B (>10% risk of metastasis) could be considered for adjuvant therapy.

208 Blunt Splenic Trauma, Retrospective Study 2008–2013, the Canberra Hospital

Aim

To evaluate the management of Blunt Splenic Trauma (BST) management in multi-injured trauma patients at The Canberra Hospital (TCH). Non operative management (NOM) for hemodynamically stable patients & operative management (OM) for unstable patients. The aim was how to further reduce failed NOM.

Method

Retrospective data collected from of all multi trauma patients with BST from June 2008 - June 2013 at TCH. Data review included patients’ admission notes, CT results, management technique, and clinical outcome.

Results

A total of 161 patients included in the study. All paediatric patients treated with NOM with success rate of 100%. Seventy-three per cent of adults managed NOM with success rate of 97.8%. Twenty-six per cent managed operatively. ICU admissions were 54.4 % and splenic angioembolisation 2.9%. Mortality was 3.7 % with multiple injury patients zero with isolated splenic injury

Conclusions

As per our study NOM is the standard of care for all hemodynamically stable patients with success rate of 97.8% acceptable rate as per evidence more than 96%. All hemodynamically unstable patients with diffuse peritonitis require urgent laparotomy. The query to answer that AE should be considered for all patients with (AAST) grade 4–5 who are hemodynamically stable as adjunct to NOM to reduce rate of fail NOM. Further randomised controlled studies are needed.

In Search of A Contemporary Definition of Meaningful Engagement: A systematic literature review

Consumer engagement is emerging as an important trend in a contemporary health care environment. Yet, a universal definition of meaningful consumer engagement has not been determined. This paper presents our systematic literature review findings, which intended to consolidate the definition of consumer engagement (or related terms) in the context of health care to date to arrive at a definition for meaningful consumer engagement in healthcare. Literature searches were performed in MEDLINE, CINAHL, Embase and PsychINFO in June 2021. Using a combination of medical subject headings (MeSH) terms, Emtree search headings and free text words, a total of 82 records were identified. After reviewing in line with PRISMA methodology, 23 articles were considered relevant to the development of the definition of consumer engagement. The methodology of these papers was analysed using the revised Mixed Methods Appraisal Tool (MMAT) (2018). A total of 13 of these papers were then further analysed for a definition of meaningful consumer engagement or characteristics of consumer engagement. None of the definitions found comprehensively defined meaningful consumer engagement but instead, five described meaningful consumer engagement. Therefore, a new definition of meaningful consumer engagement is proposed, which is based upon the synthesis of the characteristics of meaningful consumer engagement and person-centred care. This new definition speaks to what is it means to be consumers of health care rather than patients and acknowledged the importance of the reciprocity of the exchange relationship of ‘consumers’, the importance of leadership, and the emerging evidence around diversity and inclusion trust and partnership which requires active involvement and participation.

Reading program research proposal

Introduction

There is a significant problem of unidentified and unaddressed reading disabilities leading to psychiatric problems in children and adolescents because of not having proper tools of assessments in schools. This research proposal can be a revolutionary paradigm in identifying, classifying, modeling, and benefitting children and adolescents with a specific learning disorder (SLD).

Objectives

The objective of the current research proposal is to provide a framework of our reading program and collect data over time as cohorts to reflect the positive outcomes of the reading program.

Sub-Objectives

1. To provide an intervention that is accessible and feasible for children and their parents that will improve their academic and socio-emotional aspects.

2. Educate parents regarding SLD.

3. To provide reading training to address SLD in reading and improve reading.

4. To provide Cognitive Behavioral Therapy (CBT) to target the anxiety and depression that results because of having a SLDin reading.

Methods

After a reading assessment, students with specific reading disabilities will be registered in the program for 10 weeks. Every student will have reading training and CBT on different days of the week via video conference. Data will be collected retrospectively from the initial cohort and subsequent cohorts will be added to the data collection process for a final analysis when 60 students have completed the program.

Results

Initial two weeks of reading training and CBT shows positive and promising results so far.

Conclusions

Children need to be screened at a young age for a reading disability before they struggle academically, and develop psychiatric issues later in life.

Conflict of interest

The aim of this research proposal is to help us understand, evaluate and benefit children with Specific Learning Disorder (SLD) with our newly setup reading program at RUSH University Medical Center, Department of Child and Adolescent Psychiatry.

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136 Readmissions to Hospital Following A Decision to Eat and Drink with Acknowledged Risk with Support From the Forward Care Bundle

Introduction

The FORWARD care bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) is used to support patients with dysphagia eating and drinking with acknowledged risk (EDAR) at our Trust. Key aims of FORWARD include improving advanced care planning (ACP) and avoiding unnecessary readmissions. This study aimed to determine the incidence of EDAR related readmissions (RR-EDAR) after FORWARD, and the effects of ACP and discharge location.

Methods

Retrospective review of all patients supported by FORWARD during admissions between January 2018 and December 2019. Data were collected on number and reasons for in-Trust hospital readmissions 6 months post-discharge, preferred place of care ACPs in event of EDAR related deterioration and discharge destination. Readmission reasons were classified as RR-EDAR (e.g. chest infection, reduced oral intake) and no relation to EDAR. Means (SD) and percentages are presented with comparisons using Fishers Exact Test.

Results

316 patients were included; mean (SD) age 81(12). 64% (n = 202) of patients were discharged alive, 36% (n = 114) were alive at 6 months. 38% of live discharges (n = 75) were readmitted and 52% (n = 39) of these patients were RR-EDAR. Mean (SD) RR-EDAR number was 11, and 18% (n = 7) of patients had RR-EDAR &gt;1 (range 1–5). RR-EDAR was only 7% (n = 4) in patients wishing to remain at home vs 25% (n = 33) in those without a documented place of care (p &lt; 0.01). RR-EDAR was 23% (n = 29) in patients discharged to a private home vs 10% (n = 6) discharged to nursing/care homes (p &lt; 0.05).

Conclusions

The majority of FORWARD patients are not readmitted. RR-EDAR comprises half of all readmitted patients and some have multiple admissions. Fewer patients with ACPs were RR-EDAR suggesting these are effective. Most patients RR-EDAR were from private homes, suggesting residential care may provide more support. Further work includes increasing ACPs, supporting patients with multiple RR-EDAR and those discharged to private homes.

Intergenerational Programmes bringing together community dwelling non-familial older adults and children: A Systematic Review

BACKGROUND

Social isolation is associated with an increased risk of adverse health outcomes, including functional decline, cognitive decline, and dementia. Intergenerational engagement, i.e. structured or semi structured interactions between non-familial older adults and younger generations is emerging as a tool to reduce social isolation in older adults and to benefit children and adults alike. This has great potential for our communities, however, the strength and breadth of the evidence for this is unclear. We undertook a systematic review to summarise the existing evidence for intergenerational interventions with community dwelling non-familial older adults and children, to identify the gaps and to make recommendations for the next steps.

METHODS

Medline, Embase and PsychInfo were searched from inception to the 28^th Sept 2020. Articles were included if they reported research studies evaluating the use of non-familial intergenerational interaction in community dwelling older adults. PROSPERO registration number CRD42020175927 RESULTS: Twenty articles reporting on 16 studies were included. Although all studies reported positive effects in general, numerical outcomes were not recorded in some cases, and outcomes and assessment tools varied and were administered un-blinded. Caution is needed when making interpretations about the efficacy of intergenerational programmes for improving social, health and cognitive outcomes.

DISCUSSION

Overall, there is neither strong evidence for nor against community based intergenerational interventions. The increase in popularity of intergenerational programmes alongside the strong perception of potential benefit underscores the urgent need for evidence-based research.

Balancing Yin and Yang: the development of a framework using Participatory Action Research for the Translation and Implementation (Part 1) of new practices

Context: Despite the demonstrable benefits of many healthcare innovations, embedding research findings into practice has been slow and sporadic. [1,2] Many implementation frameworks exist, however most havebeen criticised for not having a strong theoretical underpinning. This study addresses this gap by reviewing the current models to propose a new, theoretically driven framework for change management and translation. Methods: This study is reported in two parts. In part 1, a systematically-based literature review was undertaken. Following this, part 2 included conducting focus groups with academics to verify the model and provide feedback on the new framework. Findings: The gaps in current implementation frameworks identified include deficiencies in the areas of individual and social behaviour, participatory action, operationalisation and evaluation of the frameworks. The Quality Implementation Framework (QIF) [3] was used to provide the basis to develop a robust extended model, which addressed those areas that were identified as deficient in the current frameworks. By combining the best parts of extant models with a translation and implementation foci, we developed the PARTI model that is underpinned by commitment to change (Ying) and change fidelity (Yang) at each of its four stages, which included a behavioural questionnaire and implementation checklist. PARTI stands for Participatory Action Research, Translation and Implementation. Conclusions: The implementation of change in healthcare delivery is difficult and demanding, and healthcare managers look to change frameworks for guidance. The PARTI model has been developed to provide a systematic approach to implementing changed practices that is repeatable, reliable and scalable. Abbreviations: ISF – Interactive Systems Framework; PAR – Participatory Action Research; PARTI – Participatory Action Research for Translation and Implementation; QIF – Quality Implementation Framework; TDF – Theoretical Domains Framework.

Developing an evaluation framework for clinical redesign programs: lessons learnt

Purpose The purpose of this paper is to present lessons learnt through the development of an evaluation framework for a clinical redesign programme - the aim of which was to improve the patient journey through improved discharge practices within an Australian public hospital. Design/methodology/approach The development of the evaluation framework involved three stages - namely, the analysis of secondary data relating to the discharge planning pathway; the analysis of primary data including field-notes and interview transcripts on hospital processes; and the triangulation of these data sets to devise the framework. The evaluation framework ensured that resource use, process management, patient satisfaction, and staff well-being and productivity were each connected with measures, targets, and the aim of clinical redesign programme. Findings The application of business process management and a balanced scorecard enabled a different way of framing the evaluation, ensuring measurable outcomes were connected to inputs and outputs. Lessons learnt include: first, the importance of mixed-methods research to devise the framework and evaluate the redesigned processes; second, the need for appropriate tools and resources to adequately capture change across the different domains of the redesign programme; and third, the value of developing and applying an evaluative framework progressively. Research limitations/implications The evaluation framework is limited by its retrospective application to a clinical process redesign programme. Originality/value This research supports benchmarking with national and international practices in relation to best practice healthcare redesign processes. Additionally, it provides a theoretical contribution on evaluating health services improvement and redesign initiatives.

Finding brilliance using positive organizational scholarship in healthcare

PURPOSE

Positive organizational scholarship in healthcare (POSH) suggests that, to promote widespread improvement within health services, focusing on the good, the excellent, and the brilliant is as important as conventional approaches that focus on the negative, the problems, and the failures. POSH offers different opportunities to learn from and build resilient cultures of safety, innovation, and change. It is not separate from tried and tested approaches to health service improvement--but rather, it approaches this improvement differently. The paper aims to discuss these issues.

DESIGN/METHODOLOGY/APPROACH

POSH, appreciative inquiry (AI) and reflective practice were used to inform an exploratory investigation of what is good, excellent, or brilliant health service management.

FINDINGS

The researchers identified new characteristics of good healthcare and what it might take to have brilliant health service management, elucidated and refined POSH, and identified research opportunities that hold potential value for consumers, practitioners, and policymakers.

RESEARCH LIMITATIONS/IMPLICATIONS

The secondary data used in this study offered limited contextual information.

PRACTICAL IMPLICATIONS

This approach is a platform from which to: identify, investigate, and learn about brilliant health service management; and inform theory and practice.

SOCIAL IMPLICATIONS

POSH can help to reveal what consumers and practitioners value about health services and how they prefer to engage with these services.

ORIGINALITY/VALUE

Using POSH, this paper examines what consumers and practitioners value about health services; it also illustrates how brilliance can be theorized into health service management research and practice.

Beyond clinical priority: what matters when making operational decisions about emergency surgical queues?

Objective This paper describes the perceptions of operating theatre staff in Australia and The Netherlands regarding the influence of logistical or operational reasons that may affect the scheduling of unplanned surgical cases. It is proposed that logistical or operational issues can influence the priority determination of queue position of surgical cases on the emergency waiting list. Methods A questionnaire was developed and conducted in 15 hospitals across The Netherlands and Australia, targeting anaesthetists, managers, nurses and surgeons. Statistical analyses revolved around these four professional groups. Six hypotheses were then developed and tested based on the responses collected from the participants. Results There were significant differences in perceptions of logistics delay factors across different professional groups when patients were waiting for unplanned surgery. There were also significant differences among different groups when setting logistical priority factors for planning and scheduling unplanned cases. The hypotheses tests confirm these differences, and the findings concur with the paradigmatic differences mentioned in the literature. These paradigmatic differences among the four professional groups may explain some of the tensions encountered when making decisions about scheduling emergency surgical queues, and therefore should be taken into consideration for management of operating theatres. Conclusions Queue positions of patients waiting for unplanned surgery, or emergency surgery, are determined by medical clinicians according to clinicians' indication of clinical priority. However, operating theatre managers are important in facilitating smooth operations when planning for emergency surgeries. It is necessary for surgeons to understand the logistical challenges faced by managers when requesting logistical priorities for their operations. What is known about the topic? Tensions exist about the efficient use of operating theatres and negotiating individual surgeon's demands, especially between surgeons and managers, because in many countries surgeons only work in the hospital and not for the hospital. What does this paper add? The present study examined the logistical effects on functionality and purports the notion that, while recognising the importance of clinical precedence, logistical factors influence queue order to ensure efficient use of operating theatre resources. What are the implications for practitioners? The results indicate that there are differences in the perceptions of healthcare professionals regarding the sequencing of emergency patients. These differences may lead to conflicts in the decision making process about triaging emergency or unplanned surgical cases. A clear understanding of the different perceptions of different functional groups may help address the conflicts that often arise in practice.

Hospital employees’ perceptions of fairness and job satisfaction at a time of transformational change

Objective This study examines the relationships between job satisfaction and organisational justice during a time of transformational change. Methods Data collection occurred immediately before a major regional hospital’s move to a greenfield site. Existing measures of job satisfaction and organisational justice were used. Data were analysed (n = 316) using descriptive, correlation and regression methods together with interactions between predictor variables. Results Correlation coefficients for satisfaction and organisational justice variables were high and significant at the P < 0.001 level. Results of a robust regression model (adjusted R2 = 0.568) showed all three components of organisational justice contributed significantly to employee job satisfaction. Interactions between the predictor variables showed that job satisfaction increased as the interactions between the predictor variables increased. Conclusions The finding that even at a time of transformational change staff perceptions of fair treatment will in the main result in high job satisfaction extends the literature in this area. In addition, it was found that increasing rewards for staff who perceive low levels of organisational justice does not increase satisfaction as much as for staff who perceive high levels of fairness. If people feel negative about their role, but feel they are well paid, they probably still have negative feelings overall. What is known about the topic? Despite much research highlighting the importance of job satisfaction and organisational justice in healthcare, no research has examined the influence of transformational change, such as a healthcare organisational relocation, on these factors. What does this paper add? The research adds to academic literature relating to job satisfaction and organisational justice. It highlights the importance of organisational justice in influencing the job satisfaction of staff. What are the implications for practitioners? Financial rewards do not necessarily motivate staff but low rewards do demotivate. Shortages of health professionals are often linked to a lack of job satisfaction, and recruitment and retention strategies are often based on salary.

Health LEADS Australia and implications for medical leadership

Purpose

– The purpose of this paper is to call for strong medical co-leadership in transforming the Australian health system. The paper discusses how Health LEADS Australia, the Australian health leadership framework, offers an opportunity to engage medical clinicians and doctors in the leadership of health services.

Design/methodology/approach

– The paper first discusses the nature of medical leadership and its associated challenges. The paper argues that medical leaders have a key role in the design, implementation and evaluation of healthcare reforms, and in translating these reforms for their colleagues. Second, this paper describes the origins and nature of Health LEADS Australia. Third, this paper discusses the importance of the goal of Health LEADS Australia and suggests the evidence-base underpinning the five foci in shaping medical leadership education and professional development. This paper concludes with suggestions on how Health LEADS Australia might be evaluated.

Findings

– For the well-being of the Australian health system, doctors need to play an important role in the kind of leadership that makes measurable differences in the retention of clinical professions; improves organisational cultures; enhances the engagement of consumers and their careers; is associated with better patient and public health outcomes; effectively addresses health inequalities; balances cost effectiveness with improved quality and safety; and is sustainable.

Originality/value

– This is the first article addressing Health LEADS Australia and medical leadership. Australia is actively engaging in a national approach to health leadership. Discussions about the mechanisms and intentions of this are valuable in both national and global health leadership discourses.

Applying lean flows in pathology laboratory remodelling

PURPOSE

This purpose of this paper is to examine the application and outcomes of applying all of the seven lean flows to pathology laboratory remodelling as part of a lean rapid improvement event (RIE).

DESIGN/METHODOLOGY/APPROACH

Longitudinal case study of a lean RIE linking emergency and pathology departments focusing on the systematic application of lean's seven flows to the physical environment.

FINDINGS

Following the lean RIE, changes improving patient specimen, technician, supplies and information flows avoided 187 km and eight days of unnecessary walking each year.

RESEARCH LIMITATIONS/IMPLICATIONS

The difficulty of making accurate comparisons between time periods in a health care setting is acknowledged.

PRACTICAL IMPLICATIONS

This research provides evidence that applying lean design concepts in a laboratory can make substantial improvements, particularly if the expertise of the people working in the laboratory is trusted to determine the most appropriate changes. Significant amounts of time and motion were saved by just one, easily quantifiable change.

SOCIAL IMPLICATIONS

The laboratory staff is processing increased numbers of time-critical tests, yet report a calmer working environment, without any increase in the pace of work. Laboratory personnel also experienced satisfaction in exercising control over their work environment.

ORIGINALITY/VALUE

To the best of the authors' knowledge this is the first comprehensive report applying lean flows to pathology laboratory remodelling and one of the few applications of Lean Systems Thinking between departments and between separate health services organisations.

Combining patient journey modelling and visual multi-agent computer simulation: a framework to improving knowledge translation in a healthcare environment

This article focuses on a framework that will investigate the integration of two disparate methodologies: patient journey modelling and visual multi-agent simulation, and its impact on the speed and quality of knowledge translation to healthcare stakeholders. Literature describes patient journey modelling and visual simulation as discrete activities. This paper suggests that their combination and their impact on translating knowledge to practitioners are greater than the sum of the two technologies. The test-bed is ambulatory care and the goal is to determine if this approach can improve health services delivery, workflow, and patient outcomes and satisfaction. The multidisciplinary research team is comprised of expertise in patient journey modelling, simulation, and knowledge translation.

Is Clostridium difficile infection a particular problem after reversal of ileostomy?

AIM

Clostridium difficile infection (CDI) is a cause of morbidity and mortality in hospitals. Various independent risk factors have been identified, including age and antibiotic exposure. This study attempted to determine whether surgery and associated antibiotic use influence the development of CDI.

METHOD

A retrospective review of all patients with a diagnosis of CDI diagnosed during admission to a colorectal unit was conducted over a 20-month period. Patient records were cross-referenced with a microbiology database to identify previous episodes of infection and cases of recurrence.

RESULTS

There were 38 CDI episodes in 29 patients, including nine with recurrence. In 33, the use of antibiotics prior to the onset of CDI was documented, but in 14 (37%) patients this was limited to perioperative prophylaxis. The incidence of CDI after various procedures was as follows: ileostomy closure (4.2%), right hemicolectomy (2.1%) and anterior resection (1%).

CONCLUSION

Ileostomy closure may carry a higher risk of CDI.

Diagnostic performance of urine dipstick testing in children with suspected UTI: a systematic review of relationship with age and comparison with microscopy

BACKGROUND

Prompt diagnosis of urinary tract infection (UTI) in children is needed to initiate treatment but is difficult to establish without urine testing, and reliance on culture leads to delay. Urine dipsticks are often used as an alternative to microscopy, although the diagnostic performance of dipsticks at different ages has not been established systematically.

METHOD

Studies comparing urine dipstick testing in infants versus older children and urine dipstick versus microscopy were systematically searched and reviewed. Meta-analysis of available studies was conducted.

RESULTS

Six studies addressed these questions. The results of meta-analysis showed that the performance of urine dipstick testing was significantly less in the younger children when compared with older children (p < 0.01). Positive likelihood ratio (LR) of both nitrite and leucocyte positive 38.54 [95% confidence interval (CI) 22.49-65.31], negative LR for both negative 0.13 (95% CI 0.07-0.25) are reasonably good, and those for young infants are less reliable [positive LR 7.62 (95% CI 0.95-51.85) and negative LR 0.34 (95% CI 0.66-0.15)]. Comparing microscopy and urine dipstick testing, using bacterial colony count on urine culture showed no significant difference between the two methods.

CONCLUSION

Urine dipstick testing is more effective for diagnosis of UTI in children over 2 years than for younger children.

Organisational professional conflict and hybrid clinician managers: the effects of dual roles in Australian health care organizations

PURPOSE

This article aims to examine tensions between hybrid clinician managers' professional values and health care organisations' management objectives.

DESIGN/METHODOLOGY/APPROACH

Data are from interviews conducted with, and observation of, 14 managerial participants in a Cancer Therapy Unit set in a large teaching hospital in New South Wales, Australia, who participated in a Clinical Leadership Development Program.

FINDINGS

The data indicate that there are tensions experienced by members of the health care organisation when a hybrid clinician manager appears to abandon the managerial role for the clinical role. The data also indicate that when a hybrid clinician manager takes on a managerial role other members of the health care organisation are required concomitantly to increase their clinical roles.

RESEARCH LIMITATIONS/IMPLICATIONS

Although the research was represented by a small sample and was limited to one department of a health care organisation, it is possible that other members of health care organisations experience similar situations when they work with hybrid clinician managers. Other research supports the findings. Also, this paper reports on data that emerged from a research project that was evaluating a Clinical Leadership Development Program. The research was not specifically focused on organisational professional conflict in health care organisations.

PRACTICAL IMPLICATIONS

This paper shows that the role of the hybrid clinician manager may not bring with it the organisational effectiveness that the role was perceived to have. Hybrid clinician managers abandoning their managerial role for their clinical role may mean that some managerial work is not done. Increasing the workload of other clinical members of the health care organisation may not be optimal for the health care organisation.

ORIGINALITY/VALUE

Organisational professional conflict, as a result of hybridity and divergent managerial and clinical objectives, can cause conflict which affects other organisational members and this conflict may have implications for the efficiency of the health care organisation. The extension or duality of organisational professional conflict that causes interpersonal or group conflict in other members of the organisation, to the authors' knowledge, has not yet been researched.

Self-renewal and differentiation of mouse embryonic stem cells as measured by Oct4 expression: the role of the cAMP/PKA pathway

In this study we examined the role of the cAMP/protein kinase A (PKA) pathway in affecting IOUD2 ES cell self-renewal and differentiation, Oct4 expression, and cell proliferation. Forskolin, the adenylate cyclase agonist, alone had no effect on ES cell self-renewal. However, when cells were treated with the differentiation-inducing agent retinoic acid, forskolin significantly promoted ES cell self-renewal. Effectively, forskolin rescued cells from a pathway of differentiation. Culturing ES cells in the presence of the phosphodiesterase inhibitor IBMX had no effect on ES cell self-renewal but did increase cell proliferation. In the presence of 100 muM IBMX without LIF, 10 muM forskolin significantly increased ES cell self-renewal. The cell permeable cAMP analog 8-Br-cAMP (1 and 5 mM) promoted ES cell differentiation in the presence of LIF, while in the absence of LIF, it promoted ES cell self-renewal. The effect of the PKA specific inhibitors H89 and KT5720 on Oct4 expression was, again, LIF-dependent. In the presence of LIF, these inhibitors decreased Oct4 expression, while they increased Oct4 expression in the absence of LIF. In general, ES cells maintained on a self-renewal pathway through the presence of LIF show little effect from altered cAMP signaling except at higher levels. However, in strict contrast, when ES cell are on a differentiation pathway through exposure to retinoic acid or the removal of LIF, altering cAMP levels can rescue the self-renewal process promoting Oct4 expression. This study clearly shows that the cAMP/PKA pathway plays a role in ES cell self-renewal pathways.

Norovirus outbreak associated with a hotel in the west of Ireland, 2006

An outbreak of gastrointestinal disease (nausea, vomiting or diarrhoea) occurred among a party of wedding guests, staff and other guests in a hotel in the west of Ireland, in October 2006. Upon notification, a multi-disciplinary outbreak control team was convened to investigate and control the outbreak. In all, 98 people were ascertained ill. The median duration of illness was 48 hours. The attack rate ranged between 48 and 85%. The hotel voluntarily notified health authorities and co-operated fully with investigation and control measures. Strict prevention and control measures were instituted promptly, including air ventilation, enhanced hand hygiene, isolation of cases, temporary "cooked food only", temporary alternative accommodation and specialised cleaning. Three cases of norovirus infection were laboratory-confirmed. There was no evidence of food- or water-borne transmission. Clinical and epidemiological findings indicated person-to-person transmission of norovirus. This report highlights the potential for large social gatherings to facilitate the spread of viral gastroenteritis by person-to-person transmission and via contaminated environment. Effective community management of this outbreak appears to have prevented its having an impact on local acute hospital services. The authors conclude that in addition to the existing national guidelines on the management of outbreaks of norovirus in healthcare settings, agreed guidelines for the management of norovirus outbreaks in the hotel and tourism industry are needed in Ireland.

Effects of Financial Incentives on the Intention to Consent to Organ Donation: A Questionnaire Survey

INTRODUCTION

Shortage of donor organs is a serious problem for transplantation medicine. One controversial suggestion to increase the number of organ donors is financial incentives for consent. The aim of this study was to test whether different forms and amounts of financial incentives were apt to increase the consent to organ donation.

MATERIALS AND METHODS

Data were collected via questionnaires in urban and rural regions of Austria and randomly assigned to settings with three different amounts of financial incentives. The questionnaire was designed by using the theory of planned behaviour of Ajzen. Parents 69 mothers and 35 fathers; ages 25 to 65 years were evaluated for intention to consent to organ donation, perceived social norm, and positive/ negative aspects of organ donation without and with various financial incentives.

RESULTS

The intention to consent to organ donation dropped highly significantly (Z = -7.556 P = .000) from the basic condition (M = 1.13; confidence interval [CIs] 0.78 to 1.51) to the condition with financial incentives (M = -1.58; CI, 1.96 to -1.15). No influence of the amount of financial incentive was observed. Highly significant differences were measured between both conditions for the social norm (Z = -5.638; P < .000) and the attitude toward organ donation (Z = -1.962; P < .05; Z = -2.104; P < .035).

CONCLUSIONS

Financial incentives led to decreased consents and elicited strong rejections and negative reactions of the participants. Taking money for consent to organ donation seems to be a strict taboo for most people in Austrian society.

HGS-ETR2—A fully human monoclonal antibody to TRAIL-R2: Results of a phase I trial in patients with advanced solid tumors

3012

Background: HGS-ETR2 is a fully-human high-affinity monoclonal antibody that is agonistic to the Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor 2 (TRAIL-R2, DR5). TRAIL-R2 is expressed more widely on the surface of tumor cells than normal cells; binding of HGS-ETR2 to TRAIL-R2 leads to activation of the extrinsic apoptosis pathway. HGS-ETR2 shows anti-tumor activity at doses ≥ 0.3 mg/kg in xenograft models, both as a single agent and in combination with chemotherapeutic agents. Methods: This phase 1, dose-escalation study assessed the safety, tolerability, pharmacokinetics and immunogenicity of HGS-ETR2 administered IV every 14 days in patients with advanced solid tumors. Patients received HGS-ETR2 until disease progression or unacceptable toxicity. Tumor measurements were repeated every 2 months. Results: To date, 31 patients have received 167 courses of HGS-ETR2 over 5 dose levels: 0.1, 0.3, 1.0, 3.0 and 10.0 mg/kg q14 days. The majority (26 of 31) received at least 4 courses. One patient experienced a dose-limiting toxicity of grade 3 hyperamylasemia at the 10 mg/kg dose level. The event was determined to be possibly related to HGS-ETR2 and also possibly related to a nutritional supplement. Stable disease was achieved in 10 patients for 4 to 16 cycles. One patient with chemotherapy-refractive Hodgkin’s disease had a tumor regression of abdominal disease. HGS-ETR2 pharmacokinetics were linear up to 10 mg/kg. At the 10 mg/kg dose, the pharmacokinetics were characterized by a mean (SD) t1/2β of 11 (4) days, CL of 6.0 (0.7) mL/day, and V1 of 47 (8) mL/kg, slightly larger than the plasma volume. The 1.8-fold larger Vss of 85 (27) mL/kg indicates that HGS-ETR2 distributes outside the plasma compartment. Human anti-human antibody formation has not been detected. Conclusions: HGS-ETR2 can be safely administered every 14 days at doses up to and including 10 mg/kg. Further evaluation of HGS-ETR2 is planned, including studies of HGS-ETR2 in combination with chemotherapeutic agents.

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A phase I study of the VEGF receptor tyrosine kinase inhibitor vatalanib (PTK787/ZK 222584) and gemcitabine in patients with advanced pancreatic cancer

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Background: The VEGF pathway is the predominant mediator of angiogenesis in pancreatic cancer. Vatalanib (PTK787/ZK 222584) is a small molecule tyrosine kinase inhibitor of all known VEGF receptors. We initiated a phase I study of vatalanib and gemcitabine for advanced pancreatic cancer. Methods: Patients with newly diagnosed unresectable or metastatic pancreatic adenocarcinoma were enrolled. Previous adjuvant chemoradiotherapy with fluorouracil was allowed. Gemcitabine was given by fixed-dose rate infusion weekly x 3 in a 28-day cycle, and vatalanib was given orally daily. Dose-limiting toxicities (DLT) are defined as any grade 3/4 toxicity during the first cycle. The dose levels are as follows: Results: To date, 11 patients are evaluable for toxicity (5M/6F; median age 62 years, range 40–82 years; median KPS 90%). Thus far, 42 cycles have been given, with a median of four cycles per patient. Two patients have experienced DLT. The first patient (cohort 1) experienced grade 3 diarrhea and hypokalemia and grade 4 neutropenia occurring simultaneously and treated without sequelae. The second patient (cohort 3) developed grade 3 deep vein thrombosis. Beyond the first cycle, grade 3 toxicities included neutropenia (1), anemia (3), thrombocytopenia (1), hypertension (2), diarrhea (1), hypokalemia (1), thrombosis (1), and proteinuria (1). Three of eleven patients (27%) did not complete treatment to the first evaluation timepoint (2 cycles); two discontinued due to toxicity and one discontinued due to disease progression. Two of eleven patients (18%) had a partial response by RECIST. Six of eleven patients (55%) had stable disease as the best response ranging from 2–6 months. Conclusions: The combination of gemcitabine and vatalanib is generally well-tolerated with most grade 3/4 toxicities occurring late in the treatment course. Antitumor responses have been observed at initial dose levels and accrual to the final cohort with BID dosing of vatalanib continues.

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No significant financial relationships to disclose.

Gastroprotective effects of oral nucleotide administration

BACKGROUND AND AIMS

Nucleotides form the building blocks of DNA and are marketed as dietary supplements, alone or in combination with other ingredients, to promote general health. However, there has been only limited scientific study regarding the true biological activity of orally administered nucleotides. We therefore tested their efficacy in a variety of models of epithelial injury and repair.

METHODS

Effects on proliferation ([3H] thymidine incorporation) and restitution (cell migration of wounded monolayers) were analysed using HT29 and IEC6 cells. The ability of a nucleotide mixture to influence gastric injury when administered orally and subcutaneously was analysed using a rat indomethacin (20 mg/kg) restraint model.

RESULTS

In both cell lines, cell migration was increased by approximately twofold when added at 1 mg/ml (p<0.01); synergistic responses were seen when a mixture of nucleotides was used. Cell proliferation was stimulated by adenosine monophosphate (AMP) in HT29, but not in IEC6, cells. Gastric injury was reduced by approximately 60% when gavaged at 4-16 mg/ml (p<0.05), concentrations similar to those likely to be found in consumers taking nucleotide supplements. Systemic administration of nucleotides was unhelpful.

CONCLUSIONS

Nucleotides possess biological activity when analysed in a variety of models of injury and repair and could provide a novel inexpensive approach for the prevention and treatment of the injurious effects of non steroidal anti-inflammatory drugs and other ulcerative conditions of the bowel. Further studies on their potential benefits (and risks) appear justified.

Genetic segregation of spontaneous erosive arthritis and generalized autoimmune disease in the BXD2 recombinant inbred strain of mice

The BXD2 strain of mice is one of approximately 80 BXD recombinant inbred (RI) mouse strains derived from an intercross between C57BL/6J (B6) and DBA/2J (D2) strains. We have discovered that adult BXD2 mice spontaneously develop generalized autoimmune disease, including glomerulonephritis (GN), increased serum titres of rheumatoid factor (RF) and anti-DNA antibody, and a spontaneous erosive arthritis characterized by mononuclear cell infiltration, synovial hyperplasia, and bone and cartilage erosion. The features of lupus and arthritis developed by the BXD2 mice segregate in F2 mice generated by crossing BXD2 mice with the parental B6 and D2 strains. Genetic linkage analysis of the serum levels of anti-DNA and RF by using the BXD RI strains shows that the serum titers of anti-DNA and RF were influenced by a genetic locus on mouse chromosome (Chr) 2 near the marker D2Mit412 (78 cm, 163 Mb) and on Chr 4 near D4Mit146 (53.6 cm, 109 Mb), respectively. Both loci are close to the B-cell hyperactivity, lupus or GN susceptibility loci that have been identified previously. The results of our study suggest that the BXD2 strain of mice is a novel model for complex autoimmune disease that will be useful in identifying the mechanisms critical for the immunopathogenesis and genetic segregation of lupus and erosive arthritis.

Health reform, professional identity and occupational sub-cultures: the changing interprofessional relations between doctors and nurses

Recent literature on health reform describes advantages of a collaborative approach to the management of health organizations. However, it is important for the managers of health organizations, including nurse managers, to understand that occupational groups adapt to organizational change and policy reform in different ways. These differences to change may have an effect on health reform initiatives, in particular, by potentially limiting the development of collaboration, team work and inter-professional practice. This paper presents fieldwork from a study on health reform and professional identities. Data from focus group discussions are used to discuss the dynamics of reform, the tensions between occupational subcultures and the organization, and changing relations within and between diverse occupational and professional groups. As opposed to much of the literature on professional identity, data for this research suggests that professional identities are changing under the strain of environmental changes to the health system, and associated cultural changes. Professions are not static. In addition, this research found that cultural differences are not limited to occupational groups of doctors, nurses and others, and include differentiation within the medical profession that is based upon specialization, generation, educational background, employment status and feelings of [non]association with the organization. These differences have resulted in cultural ambiguity of sustained and non-sustained fragmentation of occupational and professional groupings that, if not fully understood, are potentially complicating the implementation of change.

Posterior interosseous nerve palsy due to parosteal lipoma

Lipomas are extremely common benign soft tissue tumours that are usually subcutaneous and asymptomatic. Occasionally, lipomas can occur in deeper soft tissue planes and when adjacent to the neck of the radius they can cause compression of the posterior interosseous nerve. Five such cases are described. An anterior approach to excision of the lipoma is recommended.