Noninvasive drug adherence monitoring of antipsychotic patients via finger sweat testing

Collection of finger sweat is explored here as a rapid and convenient way of monitoring patient adherence to antipsychotic drugs. Finger sweat samples (n = 426) collected from patients receiving treatment with clozapine, quetiapine and olanzapine were analysed by liquid chromatography mass spectrometry, including a subgroup of patients with paired plasma samples. Finger sweat samples were also analysed from a negative control group and patients who had handled antipsychotic medication only. The finger sweat test (based on the detection of parent drug in one donated sample) was 100% effective in monitoring adherence within commonly prescribed dosing ranges. In comparison to participants who handled the medication only, the test could distinguish between contact and administration through monitoring of the drug metabolite, or the level of parent drug. Additionally, in a subgroup of patients prescribed clozapine, a statistically significant correlation was observed between the mass of parent drug in finger sweat and plasma concentration. The finger sweat technology shows promise as a dignified, noninvasive method to monitor treatment adherence in patients taking antipsychotics.

396 Rotator Cuff Assessment Following Traumatic Anterior Shoulder Dislocation

Aim

Glenohumeral joint dislocation is the most common traumatic joint dislocation with a high recurrence rate correlating with age at first dislocation. There is an associated increased incidence in concurrent rotator cuff tears with increasing age affecting 40% aged 40–60. Patient care was assessed against BESS/BOA standard: These patients should have rotator cuff assessment and those aged 40–60 should undergo routine MRI/Ultrasound imaging.

Method

All patients admitted to the emergency departments of the 3 Lanarkshire hospitals undergoing first time traumatic anterior dislocation of the shoulder in February 2021 were included. This was the third cycle of this audit. Previous interventions were presentation at a CPD meeting after cycle one and an NHS Lanarkshire regional meeting after cycle two.

Results

Cycle one (2018)-14 patients. 3/14 underwent rotator cuff assessment. 5/14 aged 40–60. 1/5 underwent rotator cuff imaging.

Cycle two (2020)-11 patients. 0/9 underwent rotator cuff assessment (Two excluded as managed operatively). 4/11 aged 40–60. 0/4 underwent rotator cuff imaging.

Cycle three (2021)-13 patients. 3/11 underwent rotator cuff assessment (Two excluded as managed operatively). 3/13 aged 40–60. 0/3 underwent rotator cuff imaging.

Conclusions

Although a slight improvement has been made over the 3 cycles with rotator cuff assessment the BOA standard is not being met. There has been no improvement in the additional imaging required in traumatic anterior shoulder dislocations in those aged 40–60 over the 3 cycles. These patients may develop pain, reduced function, and rotator cuff arthropathy. There is now an aim to introduce a pathway for these patients across the health board.

Measuring therapeutic engagement in acute mental health inpatient environments: the perspectives of service users and mental health nurses

BACKGROUND

A key component of caring for service users (SUs) in acute mental health inpatient environments is Therapeutic Engagement (TE). To that end, the Therapeutic Engagement Questionnaire (TEQ) was developed and validated. The TEQ measures TE between SUs and registered mental health nurses (RMHNs) from the perspective of both parties and can quantify and recognise how nurses engage with SUs and monitor this activity as well as its enhancement of SU care and recovery. The aim of this study was to explore the views of SUs and RMHNs in relation to the TEQ and how it could be adopted into clinical practice within an acute inpatient environment.

METHODS

As part of the validation stage of the development of the TEQ, the views of 628 SUs and 543 RMHNs were collected using a qualitative approach by way of free text at the end of the questionnaire. Two questions required free text response: - 'what do you think of the TEQ?', and 'how can it be utilised?'

RESULTS

Following thematic analysis, it was found that both sets of participants stated that such a tool could be utilised to improve the service, could help nurses with reflective practice, be utilised as part of clinical supervision and to aid nurses' professional development. The nurse participants also stated that such a tool would help track SU participation and enablement in their care. Furthermore, the nurses noted that the tool would help to reinforce the core 'caring' value of nursing and the overall goal of recovery. The SUs added that the TEQ would recognise the work of mental health nurses and provide them with a clear opportunity to express their views in relation to nursing staff.

CONCLUSIONS

Therapeutic engagement (TE) has been identified as part of the repertoire of mental health nursing and both groups of participants identified how a tool to assess this construct may be utilised in day-to-day clinical practice to the benefit of each group.

Measuring therapeutic engagement in finnish adult acute psychiatric in-patient care units using the finnish version of therapeutic engagement questionnaire (TEQ)

Introduction

The Therapeutic Engagement Questionnaire (TEQ) has been developed and validated in partnership with service users (SUs), registered mental health nurses (RMHNs) and nurse academics in the UK in accordance with psychometric theory. The TEQ is highly relevant and useful to clinical practice. The TEQ measures therapeutic engagement (TE) in two contexts - 1-1 interactions between SUs and RMHNs, as well as the overall environment and atmosphere of the units - from the perspective of both SUs and RMHNs. The TEQ has been translated into Finnish by two expert panels and was pre-tested and validated in ten adult acute psychiatric in-patient units in two hospitals in Finland.

Objectives

To measure TE in Finnish adult acute in-patient psychiatric settings from the perspectives of both SUs and RMHNs.

Methods

The Finnish version of the TEQ (Hoidollinen yhteistyö) will be completed by RMHNs and SUs in 15 adult acute psychiatric in-patient units. Nine of the units are within the University Hospital and six in a municipal psychiatric hospital. The data will be collected within a 3-month period (October - December 2020). The coordinating nurse of each unit will organise the operational side of the study including obtaining consent from SUs. The nurses will participate in the survey via Webropol which includes nurses’ consent. Sociodemographic information will be collected from the SUs and nurses.

Results

The results of the measurement study will be reported at the 29th European Congress of Psychiatry.

Conclusions

The conclusions of the measurement study will be reported at the 29th European Congress of Psychiatry.

Conflict of interest

This study is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London).

Topical wound anaesthesia: efficacy to mitigate piglet castration pain

OBJECTIVE

There is a critical need for safe and effective analgesic treatments to address pain resulting from surgical husbandry procedures in livestock. Piglet castration results in acute pain and stress to the animal; however, it is performed globally on millions of piglets annually, often without any analgesia what-so-ever. Tri-Solfen® (Animal Ethics Pty Ltd, Yarra Glen, Victoria, Australia) is a combination local anaesthetic and antiseptic formulation which, applied topically to wounds, has proven effective, and is registered for use to alleviate pain associated with castration (and other wounds) in lambs and calves in Australia and New Zealand. It is also reported to be effective to reduce pain in piglets following castration.

DESIGN

This randomised, blinded, placebo-controlled study examined the safety and efficacy of the formulation, administered via an adapted wound instillation method, to control pain both during and following piglet castration.

METHOD

Piglets received Tri-Solfen or placebo, instilled to the wound immediately following skin incision. A 30 s wait period was then observed prior to completing castration. Pain mitigation was assessed by grading nociceptive resistance movements and piglet vocal response during castration, as well as by grading response to mechanical sensory stimulation of the wound (von Frey and needlestick) following castration.

RESULTS

There was a significant reduction in nociceptive motor and vocal response during castration and in response to mechanical sensory wound stimulation up to and including 2 h following castration. There were no adverse events.

CONCLUSION

Administered via this method, Tri-Solfen is effective to mitigate acute peri-operative castration pain in piglets.

Qualitative and Quantitative Scintigraphic Imaging to Predict Fracture Healing

Purpose: Evaluate the value of 24- hour postoperative quantitative bone scintigraphy to identify devascularized fragments and predict delayed fracture bridging in canine clinical patients; to determine the effect of fracture type, fixation type, age, sex, and weight on fracture bridging and the quantitative scintigraphic ratios; and to evaluate the relationship between qualitative scintigraphic assessment and quantitative scintigraphic ratios. Methods: Forty-two adult dogs, with diaphyseal long bone fractures treated with minimally invasive biological or invasive surgical techniques, were evaluated with 24-hour postoperative bone scintigraphy and six and 12 week postoperative radiographs. Fractured bones were classified as simple, moderately multiple, or severely multiple. Bone scintigrams were qualitatively and quantitatively analyzed. Radiographs were made at six and 12 weeks after the operation and graded as fracture gap(s) bridged or not bridged with bone opacity material. The data was evaluated statistically to determine the relationship between age, sex, and weight of the dogs, fracture type, fixation type, and results of scintigram analysis to fracture bridging at six and 12 weeks. Results: Fourteen of the 42 fractures were bridged at six weeks after the operation and 33 at 12 weeks. Prediction of fracture healing was not possible. There was not any statistical relationship of fracture type, fixation, sex, nor weight to bridged fractures or non-bridged fractures at six and 12 weeks. There was a trend toward more of the fractures with multiple fragments treated with minimally invasive biological techniques to be bridged by 12 weeks when compared to similar fractures treated with invasive techniques. The mean age of dogs with bridged fractures at six and 12 weeks was significantly lower than the mean age of dogs with non-bridged fractures at six and 12 weeks. Qualitative scintigraphic assessment scores were not significantly related to the quantitative scintigraphic ratios or to fracture bridging. Conclusions: Neither qualitative nor quantitative assessment of bone scintigrams 24 hours after the operation could be used to predict fracture bridging at six or 12 weeks postoperatively.

The value of 24-hour postoperative qualitative and quantitative bone scintigraphy to predict fracture bridging by 12 weeks in canine clinical patients with diaphyseal long bone fractures was evaluated. Neither qualitative nor quantitative assessment of bone scintigrams 24 hours after the operation could be used to predict fracture bridging by 12 weeks.

Supported in part by a grant from the AO Vet Centre, Zurich, Switzerland.

User acceptance of a multi-media software application to increase preparedness for caring problems

This paper presents verification data for a multimedia software application intended to enhance carers’ ability to respond to everyday difficulties and emergency situations. The program provides educational information about first aid, how to deal with everyday problems and a number of emergency situations such as bleeding, falling and choking. An evaluation plan was developed, including instruments for measuring and assessing usability. These included a questionnaire, scenarios and a pro-forma for user trials; a questionnaire for evaluation of the program; log diaries, field notes and technical diaries. User trials were carried out with both healthcare professionals and family carers. Casual users were encouraged to test the programs at the professional sites. Users’ views on usability were utilized for the development of further prototype of the software application.

Managing and caring for distressed and disturbed service users: the thoughts and feelings experienced by a sample of English mental health nurses

This paper reports the thoughts and feelings experienced by registered mental health nurses caring for distressed and/or disturbed service users in acute inpatient psychiatric settings in England. The prevailing thoughts of nurses were of cognitive dissonance and the conflict between benevolence and malevolence if coercive measures were seen as negative rather than positive; prevailing feelings experienced by nurses were fear, anxiety and vulnerability. To enhance care quality, nurses expressed the need for better communication with service users, and preventing the use of coercive measures and promotion of alternative methods of care and management. The nurses considered that debriefing dialogues following untoward incidents, practice development initiatives, education and training together with clinical supervision could be the way forward. The paper builds on the existing literature in offering clear explanations of nurses' thoughts and feelings when caring for distressed and/or disturbed service users in an English acute, inpatient psychiatric setting. Despite the small sample size and the limitations that it generates, the study findings will be of interest to the wider mental health nursing community. The findings will link to other national and international studies and therefore be valuable for future research studies of this kind. Collectively, they are building up a general picture of the distress, cognitive and emotional dissonance experienced by mental health nurses when using coercive interventions. The findings will help to develop mental health nurse education and enhance practice. High levels of distress and disturbance among service users experiencing acute mental illness is a major problem for mental health nurses (MHNs). The thoughts and feelings experienced by these nurses when caring for service users are of paramount importance as they influence clinical practice and caregiving. Similarly to research by other countries, this paper reports national, qualitative data regarding the thoughts and feelings of English MHNs who care for these service users within acute inpatient psychiatric settings. Data were collected from focus groups in which MHNs working in acute inpatient settings in England participated and analysed using inductive content analysis. Findings highlighted three broad themes: (1) emotional and cognitive dissonance; (2) therapeutic engagement; and (3) organizational management and support. The prevailing thoughts of nurses were of cognitive dissonance and the conflict between benevolence and malevolence if coercive measures were seen as negative rather than positive; the prevailing feelings experienced by nurses were fear, anxiety and vulnerability. Nurses would like better communication with service users, prevention of coercive measures and the use of alternative methods of care and/or management to ensure enhanced care. Participants considered practice development initiatives, education, training, staff and managerial support including debriefing and clinical supervision as the way forward. Despite the small sample size and its limitations, these national data add to the existing literature, and the study findings link to those of other studies both nationally and internationally. Collectively, these studies are building up a general picture of the distress, cognitive and emotional dissonance experienced by MHNs when using coercive interventions. The findings will help to develop MHN education and enhance practice.

Abstract P1-14-06: Everolimus effect on hematologic parameters in a phase II clinical trial for metastatic estrogen receptor (ER) positive breast cancer

Background: Everolimus (RAD001) is increasingly used in combination with endocrine therapy for treatment of metastatic ER-positive breast cancer. Its beneficial effect notwithstanding, familiarity with its associated toxicities is critical for the treating oncologist. Here we present hematologic changes on everolimus from a phase II trial using a combination of everolimus and fulvestrant in metastatic ER-positive breast cancer after aromatase inhibitor failure (NCT00570921).

Methods: Complete Blood Counts (CBCs) were collected at baseline, 2 weeks, 4 weeks, and every 4 weeks thereafter while on treatment, as well as one month after discontinuation. Adverse events (AEs) were defined on protocol using Common Toxicity Criteria (CTC) version 3. Linear mixed modeling with random intercepts and slopes were used to study trends of studied parameters during treatment and comparisons were conducted using paired t-test. All p-values were two sided.

Results: There were 31 evaluable patients on trial. Anemia was reported in 22 patients (71%), thrombocytopenia in 17 (55%), and leukopenia in 14 (45%). All toxicities were grade 1 or 2 except for one grade 3 anemia deemed unrelated to study drug. To further analyze the observed changes and trends, we next studied red blood cell indices, including mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC), as well as differential white blood cell percent distribution. Both MCV and MCH decreased significantly over time (p<0.0001) starting as early as the first 2 weeks of therapy. Not unexpectedly, there was no significant change observed in MCHC (p = 0.104). Interestingly, both MCV and MCH increased one month after discontinuation of treatment (p values <0.0001 and 0.0003, respectively). Using the same linear mixed model, lymphocyte percentage decreased significantly over time while on therapy (p = 0.0408) but with no significant increase one month after discontinuation (p = 0.1476). There were no significant changes observed in either monocyte or neutrophil percentage.

Conclusion: Anemia, leukopenia, and thrombocytopenia are commonly observed on everolimus, albeit predominantly mild in nature. Changes in red blood cell indices start very early after treatment and appear readily reversible upon discontinuation, suggesting that these changes may not solely be due to suppression of hematopoiesis. The etiology for these changes is currently unclear. While leukopenia is relatively common, lymphopenia in particular is consistently observed and does not appear to be readily reversible in the first month after treatment discontinuation. This may be related to the risk of infection encountered while on everolimus. Regular monitoring and familiarity with the spectrum of CBC changes observed on everolimus is prudent with its increased use.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-14-06.

Evaluation of an educational practice development programme for staff working in mental health inpatient environments

This paper describes key components of a mental health practice development training programme, which aimed to translate into practice a deeper, more evidence-based understanding of the lived experience of service users detained under the Mental Health Act (1983/2007), using action research as the underpinning paradigm. The programme explored the myriad applications of the six categories of intervention initially proposed by Heron and the widespread applicability of solution-focused brief therapy. The programme evaluation used open-ended questionnaires in order to obtain participants' views on facilitation and workshop content, in addition to two focus groups. The aim of the evaluation was to provide insight into participants' experience of the programme. Feedback from participants reflected a high degree of skill acquisition and enhancement and a noticeable change in ward culture after completing the programme. Service user researchers were intimately involved during all stages of the design, implementation and analysis including service user interviews for Phase 1 and the education intervention element of the practice development programme. Implications for evidence-based mental health nursing practice, service user involvement in research and directions for future research are discussed.

Evaluation of a method to detect Mycobacterium bovis in air samples from infected Eurasian badgers (Meles meles) and their setts

Environmental air sampling was evaluated as a method to detect the presence of M. bovis in the vicinity of infected badgers and their setts. Airborne particles were collected on gelatine filters using a commercially available air sampling instrument and tested for the presence of M. bovis using bacteriological culture and real-time PCR. The sensitivity of bacteriological culture was broadly similar to that of real-time PCR when testing samples artificially spiked with M. bovis. Sampling was undertaken from directly under the muzzles of badgers which had been experimentally infected with M. bovis (37 samples), within enclosures housing the experimentally infected animals (50 samples), and in the vicinity of setts with resident infected wild badgers (52 samples). The methods employed did not detect M. bovis from either infected badgers or artificial or natural setts known to contain infected animals. However, samples taken at four of the six natural setts were positive for Mycobacterium gordonae.

Abstract P2-14-05: A phase II study of combined fulvestrant and RAD001 (everolimus) in metastatic estrogen receptor (ER) positive breast cancer after aromatase inhibitor (AI) failure

Background: Fulvestrant is used to treat women with metastatic ER-positive breast cancer after AI failure, but has a short duration of benefit. Pi3K/mTOR signaling has been implicated in preclinical models of fulvestrant resistance and recent trials suggest that everolimus, an oral inhibitor of mTOR, can overcome resistance to other forms of endocrine therapy. We hypothesized that everolimus may delay resistance to fulvestrant and prolong time to progression (TTP).

Methods: We designed a phase II clinical trial of combined fulvestrant and everolimus in postmenopausal women with ER-positive breast cancer who relapsed or experienced metastatic disease progression within 6 months of AI use. Fulvestrant was given at 500 mg IM on day1, 250 mg d14, 250 mg d28, and monthly thereafter. Everolimus was given at 10 mg po daily. Patients were required to have measurable or evaluable disease with preserved performance status and adequate organ function. Primary endpoint is TTP, and secondary endpoints are safety, response rate, clinical benefit rate, and biomarker analysis. A sample size of 40 patients was calculated to meet a median TTP of 7.0 vs. 3.7 months for fulvestrant alone as reported in the EFECT trial. Patients were followed monthly for clinical and toxicity assessment and imaging was obtained every 2 months. Tumor blocks were collected when available and biopsies were offered if disease was accessible.

Results: To date, 30 patients enrolled on study with a median age of 56 years (range 39–85). Most common metastatic disease sites were bone in 26 patients (87%), liver in 19 (63%), and lung in 16 (53%). Prior therapy included tamoxifen in 21 patients (70%), and chemotherapy in 20 (67%), of those 17 were in the adjuvant/neoadjuvant setting. 6 patients (20%) received more than one AI. 2 patients were ruled ineligible immediately after enrollment and starting study treatment, one because of a creatinine level outside the reference range and one because of the need for palliative radiation. Of the remaining 28 patients, 18 discontinued therapy because of disease progression, 3 because of toxicity, 2 upon patient request, and 1 because of unrelated intercurrent illness, with 4 patients currently on therapy. Most common adverse events reported were mucositis in 13 patients (43%) and rash in 11 (36%). Most common laboratory abnormalities were elevated ALT/AST in 18 patients (60%), elevated cholesterol in 13 (43%), and hypokalemia in 13 (43%). The majority of toxicities were grade I/II. Most common grade III toxicities, regardless of attribution, were infection requiring hospitalization in 3 patients (10%), hypokalemia in 3 (10%) and mucositis in 2 (7.4%). There was one grade 4 toxicity reported-hypokalemia. Overall, treatment was reasonably tolerated and toxicities manageable. Efficacy findings, including the primary endpoint of TTP, will be analyzed and presented at the meeting.

Conclusions: Combined everolimus with fulvestrant is feasible and has manageable toxicities in this cohort of women with metastatic ER-positive breast cancer. Detailed efficacy analysis along with updated toxicity data will be presented at the meeting.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-14-05.

Managing distressed and disturbed patients: the thoughts and feelings experienced by Italian nurses

This paper reports on a qualitative study to identify Italian nurses' feelings and emotions towards the management of distressed and disturbed psychiatric patients in acute inpatient settings. Four focus groups were carried out involving 33 nurses from seven acute psychiatric services in a region of Italy. Data were analysed using content analysis. Findings highlight that fear is the prevailing feeling experienced by nurses in the management of distressed patients. This includes both fear of being physically harmed and concerns about doing harm or damage to patients. The unpredictability of aggressive behaviour from unknown patients was described as especially frightening. Known patients, namely those previously admitted to the unit, induced less fear, as their behaviour was considered more predictable. Patients with dual diagnosis were also a worry for many nurses, who considered themselves lacking in the personal relational skills needed to manage an individual in crisis. Nurses reported that they try to understand the reasons for a patient's aggressive behaviour and are empathetic to his or her suffering. When such empathy is lacking, nurses experience conflicting feelings of counter-aggressiveness. The paper concludes by emphasizing the need to increase availability of education related to patient management, in particular team working and its internal relationships.

Method for assessing IFN-γ responses in guinea pigs during TB vaccine trials

AIMS

We sought to develop a new method that enables the assessment of the immune response of guinea pigs during TB vaccine evaluation studies, without the need to cull or anaesthetize animals.

METHOD AND RESULTS

Guinea pigs were vaccinated with five different formulations of oral BCG. One week prior to challenge with Mycobacterium bovis, blood (50-200 μl) was taken from the ears of vaccinated subjects. Host RNA was isolated and amplified following antigenic restimulation of PBMCs for 24 h with 30 μg of bovine PPD. The up- or down-regulation of γ-interferon (IFN-γ), a key cytokine involved in protection against tuberculosis, was assessed using real-time PCR. The relative expression of prechallenge IFN-γ mRNA in the vaccinated groups (n=5) correlated (P<0·001) with protection against M. bovis challenge.

CONCLUSION

We have demonstrated that it is possible to take blood samples and track IFN-γ responses in guinea pigs that then go on to be exposed to M. bovis, thus providing prechallenge vaccine uptake information.

SIGNIFICANCE AND IMPACT OF THE STUDY

This methodology will also be applicable for tracking the immune responses of vaccinated guinea pigs over time that then go on to be challenged with M. tuberculosis during human TB vaccine evaluation studies.

What can virtual patient simulation offer mental health nursing education?

This paper discusses the use of simulation in nursing education and training, including potential benefits and barriers associated with its use. In particular, it addresses the hitherto scant application of diverse simulation devices and dedicated simulation scenarios in psychiatric and mental health nursing. It goes on to describe a low-cost, narrative-based virtual patient simulation technique which has the potential for wide application within health and social care education. An example of the implementation of this technology in a web-based pilot course for acute mental health nurses is given. This particular virtual patient technique is a simulation type ideally suited to promoting essential mental health nursing skills such as critical thinking, communication and decision making. Furthermore, it is argued that it is particularly amenable to e-learning and blended learning environments, as well as being an apt tool where multilingual simulations are required. The continued development, implementation and evaluation of narrative virtual patient simulations across a variety of health and social care programmes would help ascertain their success as an educational tool.

Section 136 of the Mental Health Act: a new literature review

Section 136 of the Mental Health Act 1983 (amended) provides police officers in the United Kingdom with the authority to remove individuals who appear to be suffering from a mental illness from any public place to a designated 'place of safety' for appropriate assessment. A considerable amount of research has been dedicated to investigate who is detained under this section and how it is implemented. A review of the literature revealed a high prevalence of schizophrenia, personality disorders and mania in individuals detained under Section 136 and an over-representation of black detainees. Several studies also reported poor communication between different agencies and poor levels of knowledge regarding the implementation of the section. There is a lack of qualitative research exploring detainee and professional experience of Section 136 and in particular the patient pathway to mental health care via Section 136 experienced by black detainees. Implications for clinical practice, multi-agency collaboration and future research are discussed.

Efficacy against Fasciola hepatica and the pharmacokinetics of triclabendazole administered by oral and topical routes

OBJECTIVE

To determine the efficacy of triclabendazole (TCBZ) against 28-day-old, early immature liver fluke in cattle and its pharmacokinetics following administration by the oral or topical (pour-on) route.

PROCEDURES

Cattle (n = 18) were infected with 500 TCBZ-susceptible liver fluke metacercariae and randomly allocated to three groups. At 28 days after infection, the groups were: (1) untreated controls; (2) treated with oral TCBZ at 12 mg/kg in combination with oxfendazole and selenium (TOS); (3) treated with pour-on TCBZ at 30 mg/kg in combination with abamectin (TA). Blood samples were taken immediately prior to treatment and serially after treatment to assess the plasma profile of TCBZ metabolites. Ten weeks after treatment all animals were slaughtered and total liver fluke counts, fluke egg counts and liver pathology were assessed.

RESULTS

Both the TOS and TA treatments resulted in significant reductions of 28-day-old liver fluke, as assessed by fluke counts and fluke egg counts at slaughter, and the reductions following TOS treatment were significantly greater than those following TA treatment. The blood profile of TCBZ metabolites in TOS-treated animals showed a significantly greater area under the plasma concentration time curve and a higher maximum observed concentration than those treated with TA. There was significantly less liver pathology in TOS-treated animals than in the TA-treated animals.

CONCLUSION

TCBZ administered orally at 12 mg/kg resulted in greater efficacy against 28-day-old, early immature liver fluke than was achieved by topical administration at 30 mg/kg. Plasma metabolites of TCBZ were higher and liver pathology was less in TOS-treated animals than in TA-treated animals.

Flexible trainees in Scotland

INTRODUCTION

Demand for flexible training is increasing. The contribution of such trainees to the trained medical workforce is not clear.

METHODS

All full time and flexible trainees in Scotland were 'tracked' at the completion of training.

RESULTS

80% of flexible trainees took up a consultant post of which 93% were in Scotland. 82% of full time trainees took up a consultant post of which 80% were in Scotland.

DISCUSSION

Flexible trainees become consultants at the same rate as their full time counterparts. They are commonly geographically tied and are therefore more likely to remain in Scotland and contribute to retention of doctors in this country.

An evaluation of a combined education and multi-project practice development programme in mental health

This paper describes a unique mental health practice development programme, which aims to integrate education, research, clinical practice and culture change, and promote collaboration between academics, researchers and healthcare practitioners to meet current government policy needs. The programme combines academic qualifications within the context of practice development and aims to produce practitioners who are dynamic leaders, capable of critical thinking, influencing culture change and challenging the nature of conventional practice. The aim of the evaluation was to give insight into participants' experience of the programme using a qualitative approach. Open-ended questionnaires obtained participant's views on facilitation and module content. Focus groups discovered the views and experiences of participants of the programme. The findings showed that the programme was well-received and impacted positively on both patient care and the personal and professional development of participants. The findings were used to modify the programme for the next intake of participants. The research complements the existing body of knowledge on practice development and highlights the benefits for staff, nurses and service users, and the challenges of implementation. The framework and design has the potential to be applied to other areas of practice beyond mental health.

Outcomes of electrically stimulated gracilis neosphincter surgery

OBJECTIVES

To examine patient quality of life (QoL) and long-term costs of electrically stimulated gracilis neosphincter surgery (ESGNS).

DESIGN

Independently conducted prospective case-comparison study of patients at the Royal London Hospital (RLH), plus a cross-sectional study of outcomes of ESGNS performed at three other UK centres.

PARTICIPANTS

Cases were patients who underwent ESGNS at the participating hospitals during a 5-year period from 1977. Comparisons were made with two groups of people with similar bowel disorders who did not undergo ESGNS.

INTERVENTION

ESGNS is a procedure designed to improve bowel function for people living with severe faecal incontinence or stomas. It involves transposition of the gracilis muscle to form a neo-anal sphincter. The transposed muscle is electrically stimulated via an electronic pulse generator implanted beneath the skin of the abdomen.

MAIN OUTCOME MEASURES

Clinical success and symptomatic outcomes of surgery. Generic, domain and condition specific measures of QoL. Comparative costs to the NHS of ESGNS and conventional alternatives.

RESULTS

At 3 years after surgery approximately three-quarters of patients still had functioning neosphincters. At this stage, bowel-related QoL and continence improved by more than 20% for nearly two-thirds of RLH patients. However, ongoing bowel evacuation difficulties occurred in half of those with good continence outcomes. QoL improvements were maintained in the smaller group of RLH patients who had reached 4 and 5 years of follow-up, although at this stage the proportion with failed neosphincters had increased. The RLH findings were supported by those from the three other UK centres. No significant changes in QoL were observed in the comparison groups during the follow-up period. The mean cost of patient care at RLH, was 23,253 pounds. In the other three centres, the estimated mean cost of the intervention per patient was 11,731 pounds, reflecting fewer planned operations and repeat admissions. Costs of patient care for those with stomas who did not undergo ESGNS were estimated at 2125 pounds per patient-year and for those who remained with severe faecal incontinence, 442 pounds per patient-year. For patients with prior faecal incontinence, a decision to refer to ESGNS resulted in a cost-effectiveness ratio, estimated over 25 years of follow-up, of between 30,000 pounds and 40,000 pounds per quality-adjusted life-year (QALY) gained, depending on centre. The choice of stoma for these patients resulted in a slightly higher cost than ESGNS. For those with prior stoma, referral to ESGNS resulted in a cost-effectiveness ratio of between 5000 pounds and 15,000 pounds per QALY gained, depending on the centre. Cost-effectiveness ratios of around 30,000 pounds per QALY gained are generally regarded to be reasonably attractive in the UK NHS context.

CONCLUSIONS

Although ESGNS is a major procedure associated with a high rate of long-term failure and bowel evacuation difficulty, it could be considered as an option at the extreme end of the treatment spectrum for refractory faecal incontinence. A strategy to refer patients for ESGNS would be regarded as cost-effective for patients already with stoma, whilst on the margin of cost-effectiveness for patients initially being managed conservatively.

Substance use and young people: the potential of technology

There is widespread concern about alcohol and drug use and abuse among young people in the United Kingdom, Europe and the United States. Evaluations of current drug and alcohol education approaches have mixed findings and some methodological difficulties. This paper reports on exploratory research to explore the potential of technology to provide information and support to young people regarding substance use and abuse. Eight focus groups were conducted with young people (n = 78) and three with key informants (n = 22). The findings revealed that technology has potential to provide information on this topic, and that young people are critical of some of the more traditional methods of provision. The young people were prepared to experiment with technology, felt competent to do so, and made suggestions of information they would like. These findings are discussed and recommendations made for future research in the area.

Usability of multimedia technology to help caregivers prepare for a crisis

The objective of the research was to evaluate the usability of a multimedia software application that provides information on coping with difficult situations, dealing with everyday caring problems, and first aid for emergency situations. Casual users (family caregivers, professional caregivers, and older people) were invited to use the software application and complete a questionnaire measuring quality and efficiency in utility and usability. Quantitative data were analyzed using the Statistical Package for the Social Sciences (SPSS) and qualitative data were analyzed by content analysis. Findings indicated the software application to have high global usability, correspond to user expectations, respond quickly, and be visually pleasant and easily understood. The authors conclude that software applications of this type have the potential to increase the quality of life of family caregivers, enhance their coping capacity, and enable them to continue for a longer period in their caring role.

Supporting family carers through the use of information and communication technology--the EU project ACTION

Assisting Carers Using Telematics Interventions to meet Older persons' Needs (ACTION) is an EU project designed to improve the quality of life of frail older and disabled people and their family carers by the use of information and communication technology. It involved Sweden, England, Northern Ireland, the Republic of Ireland and Portugal. This article provides an overview of the research and development process of the ACTION system and services. The focus is upon the evaluation results with regard to the quality of life of older people and their family carers, the usability of ACTION and cost considerations. Recommendations are made regarding user-focused technology such as ACTION.

Technology as an aid to coping with caring: a usability evaluation of a telematics intervention

This paper presents evaluation data for an interactive software program designed to provide family carers with information, advice and psychological support by way of feedback of their coping capacity. The multimedia program consists of an information-based package that provides carers with advice on health promotion and relaxation and offers them a range of coping strategies (for example, positive self-talk, assertiveness training and relaxation tapes and videos). The program also includes a carer's self-assessment instrument, designed to provide both family and professional carers with information to assess how family carers are coping with their care-giving role. As part of the usability evaluation, casual users (family carers, professional carers and older people) were invited to test the program and were administered a program evaluation questionnaire measuring quality and efficiency in utility and usability. Quantitative data were analysed by using the Statistical Package for the Social Sciences (SPSS) and qualitative data were analysed by content analysis. Findings indicated that the program is visually pleasant, easily understood, responds quickly and corresponds with user expectations. A number of recommendations are made for improvement of the navigation of the program.

The dynamics and processes of 'ending' in clinical supervision

While there is a growing number of papers in academic and professional nursing journals that focus on clinical supervision, there remain unanswered questions and unresolved issues. One such issue where there is a distinct paucity of theoretical or empirical work is that of 'ending' within clinical supervision. Accordingly, this article examines key issues and dynamics of ending within clinical supervision. These key issues are summarized as: ending when the supervisor is reluctant to let go; parallel processes in ending in clinical supervision and ending in clinical relationships; the different ending dynamics of different approaches to clinical supervision; endings in group supervision; ending as a form of bereavement; healthy endings in clinical supervision; and endings as a opportunity for growth and celebration. The authors posit that an understanding of these processes can help facilitate a 'healthy' ending in clinical supervision. Furthermore, there may be particular merit in considering dynamics that, when present, create the best chance of all parties experiencing a health ending, namely: the ending is negotiated; the ending is gradual rather than sudden and all parties work towards the ending; the supervisee retains (wherever possible) a degree of control over the timing of the ending; and both supervisor and supervisee achieve a sense of closure.