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Paradigm lost? Reflections on the effectiveness of NHS approaches to improving employment relations. BMJ LEADER 2023:leader-2022-000729. [PMID: 37192121 DOI: 10.1136/leader-2022-000729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/11/2023] [Indexed: 05/18/2023]
Abstract
The National Health Service in England has largely relied on a human resources trilogy of policies, procedures and training to improve organisational culture. Evidence from four interventions using this paradigm-disciplinary action, bullying, whistleblowing and recruitment and career progression-confirms research findings that this approach, in isolation, was never likely to be effective. An alternative methodology is proposed, elements of which are beginning to be adopted, which is more likely to be effective.
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Abstract
Root cause analyses were intended to search for system vulnerabilities rather than individual errors, using a human factors engineering approach. In practice, root cause analyses done in the NHS may generally fail to identify components where there are organisational failures, as there may be an inherent desire to protect institutional reputation. A human factors approach to root cause analysis looks at system vulnerabilities, considering the entirety of the environment in which an individual works and taking into account factors such as the physical environment and individual mental characteristics. Other human factors include group dynamics, task complexity and concurrent tasks. It is time that the growing evidence of the potential shortcomings of root cause analysis, especially as frequently applied within the NHS, is heeded. At present, rather than assisting learning it may be an impediment to patient safety. The authors propose that root cause analyses should be performed by a group of people who are not managing the service. External organisations such as the General Medical Council, Nursing and Midwifery Council, Care Quality Commission and Practitioner Performance Assessment are heavily reliant on this tool when concerns are raised. If the flaws in root cause analysis can be eliminated, drawing on the available evidence, cases such as those of Dr Hadiza Bawa-Garba and Mr David Sellu might be avoided.
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Postoperative Outcomes in Gynecologic Oncology Patients using a Multimodal Analgesia Regimen with Liposomal Bupivicaine. Gynecol Oncol 2017. [DOI: 10.1016/j.ygyno.2017.07.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Peri-Operative Inflammatory Cytokines in Plasma of the Elderly Correlate in Prospective Study with Postoperative Changes in Cognitive Test Scores. ACTA ACUST UNITED AC 2016; 4:313-321. [PMID: 28317003 DOI: 10.19070/2332-2780-1600065] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Increasingly, postoperative cognitive dysfunction (POCD) is recognized as a complication after surgery in the elderly; but it's etiology remains unclear. Here we examine changes in cytokine levels during both the pre-operative and postoperative period, comparing them with long term variation in cognitive test scores. Forty-one patients aged 65 and older undergoing major surgery with general anesthesia were recruited after written consent in this IRB approved study. Thirty went on to complete this prospective, non-interven-tional and non-randomized study. Plasma levels of cytokines Il-6, Il-8, Il-10, and TNF were determined using ELISA with MILLIPLEX Multi-Analyte Profiling (Billerica, MA). All subjects had neurocognitive tests pre-operatively and 6 months post-surgery, including Paragraph Recall Immediate and Delayed, Digit Span Forward (DSF) and Backward (DSB), and Trail Making A and B. Spearman's Rho and repeated measure rank analysis were used to examine the dependence of z score changes in cognitive tests (baseline versus 6 months) as a function of 3 cytokine time points (presurgical, post anesthesia care unit (PACU), and post-operative day one (POD1)). A greater increase in PACU inflammatory burden correlated with a greater decline in performance on the DSB (IL6, IL8; r>-0.560; p<= 0.008). DSF changes correlated slightly better with pre-surgical cytokines, declining more with higher cytokines (IL6, r= -0.551, p=0.002; IL8, -0.468, 0.009). TNF, examining all 3 values, changed only slightly postoperatively, but still correlated with a decline in DSB (p=0.014). Thus, cognitive performance, over 6 months post surgery, declines with elevated perioperative inflammation. Specific cytokines at specific perioperative times may impact specific cognitive functions, serving as diagnostics as well as contributing causation.
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WORKFORCE. Rule out the menace of bullying. THE HEALTH SERVICE JOURNAL 2015; 125:26-27. [PMID: 26753372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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NHS interview panels must do more to encourage would-be BME leaders. Nurs Stand 2015; 30:30. [PMID: 26443167 DOI: 10.7748/ns.30.6.30.s35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Abstract
NHS organisations are now being judged on indicators of ethnic diversity. Naomi Priest and colleagues look at the international evidence on how they should tackle discrimination
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NHS England chief executive: welcome back, Simon. Here's your to-do list. THE HEALTH SERVICE JOURNAL 2014; 124:16-19. [PMID: 24956712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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10
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"Nursing schools should back speak out safely to support students". NURSING TIMES 2014; 110:7. [PMID: 24669465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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11
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Coumarins with Xanthine Oxidase Inhibiting and Radical Scavenging Properties: Tools to Combat Oxidative Stress in Cells. ACTA ACUST UNITED AC 2014. [DOI: 10.7763/ijbbb.2014.v4.346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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12
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Denying race bias exists in the NHS is damaging to everyone. NURSING TIMES 2013; 109:7. [PMID: 24380181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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A Randomized, Double Blind Study to Evaluate the Efficacy of Palonosetron with Dexamethasone Versus Palonosetron Alone for Prevention of Post-Operative Nausea and Vomiting in Subjects Undergoing Bariatric Surgeries with High Emetogenic Risk. ACTA ACUST UNITED AC 2013. [DOI: 10.2174/1874321801307010030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction:
Postoperative (PONV) and postdischarge (PDNV) nausea and vomiting are common (60-70%) after bariatric surgery. Palonosetron (Pal), a novel 5-HT3 antagonist, is an effective antiemetic with a prolonged duration of action in the setting of PDNV. We hypothesized that combination therapy with Palonosetron (Pal) and dexamethasone (Dex) would improve treatment in comparison to Palonosetron alone in patients at high risk for PONV.
Methods:
In this study, patients undergoing bariatric laparoscopic surgery under general anesthesia, a subgroup of a larger Phase IV clinical trial of patients who had laparoscopic surgery, were randomized to 8 mg Dex + 0.075mg Pal or saline + 0.075mg Pal. Data was collected postoperatively at 2, 6, 24 and 72 hrs. A Functional Living Index-Emesis (QOL-FLIE) test was administered at 96 hrs.
Results:
We enrolled 76 ASA 1-2 patients with at least 3 PONV risk factors. Both randomization groups had a low incidence of vomiting in the PACU (Pal, 0.0%; Pal + Dex, 5.4%) as well as at 72 hours (0.0% both groups). Complete response (no vomiting, no rescue medication) was not different between treatment groups at any time intervals. Cumulative success rates over the entire 72 hrs were 60.4% (Pal alone) vs. 60.0% (Pal + Dex). Nausea scores (4 point ordinal scale) were not different between groups for any time intervals. Cumulative success scores for nausea (score = “none”; 0-72 hrs) were 41.9% for the Pal group, and 55.2% for the Pal+ Dex group. The Pal + Dex group showed a trend toward greater satisfaction on the QOL-FLIE scores with the greatest differences in the “nausea domain”.
Discussion:
The combination therapy (Pal + Dex) did not significantly reduce the incidence of PONV or PDNV when compared with Pal alone although a trend was observed indicating the possible increased efficacy of multi-drug therapy. There was no change in comparative efficacy over 72 hrs, possibly due to the low incidence of PDNV in both groups.
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Equality and safety are linked. THE HEALTH SERVICE JOURNAL 2013; 123:20. [PMID: 24383239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Whistleblowing. A farewell to arms for the NHS bullies. THE HEALTH SERVICE JOURNAL 2013; 123:30-31. [PMID: 24371901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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"With Francis' main concerns ignored, expect more scandals". NURSING TIMES 2013; 109:7. [PMID: 23798157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Mind the workplace hazards. Nurs Stand 2013; 27:23. [PMID: 23556214 DOI: 10.7748/ns2013.03.27.28.23.s11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Expecting nursing staff to work in an unsafe environment puts employees and patients at risk of harm. Employers are required by law to protect everyone on their premises, but some still fail to comply. This article provides a guide to the rights and responsibilities of employers, managers and employees.
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Stop the bullies. Nurs Stand 2013; 27:19. [PMID: 23556302 DOI: 10.7748/ns2013.03.27.27.19.s9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This article offers guidance on how to speak out if you are the victim of bullying or harassment, or you see a colleague being abused. The problem is widespread, with one in seven respondents to the 2011 NHS staff survey saying they had experienced bullying, harassment or abuse.
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Safe to delegate? Nurs Stand 2013; 27:19. [PMID: 23540060 DOI: 10.7748/ns2013.02.27.26.19.s10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Some employers are delegating tasks to less qualified staff. This can present problems for nurses, who are accountable for work they pass on, and who may be asked to perform tasks without adequate training. This article sets out what to do in such circumstances.
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Whistleblowing duties. Nurs Stand 2013; 27:21. [PMID: 23520961 DOI: 10.7748/ns2013.02.27.25.21.s10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Nurses and midwives have a legal obligation to raise concerns when patient care is compromised, but doing so is problematic. This article explains how to speak out when nursing staff are being spread too thinly or the skill mix is too weak.
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Stand up and be an agent for change. Nurs Stand 2013; 27:16-17. [PMID: 23505891 DOI: 10.7748/ns2013.02.27.24.16.s6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Why did so few nurses raise concerns about Stafford Hospital? The Francis inquiry reminds individual nurses and their managers of their duties. Nursing Standard begins a series of articles that will help nurses challenge those in charge.
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Patient Safety. Whistle while you work--if you dare. THE HEALTH SERVICE JOURNAL 2012; 122:22-23. [PMID: 23323508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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23
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Prediction of flammability speciation for the lower alkanes, carboxylic acids, and esters. PROCESS SAFETY PROGRESS 2007. [DOI: 10.1002/prs.10148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Radiation Therapy Oncology Group. Research Plan 2002-2006. Medical Physics Committee. Int J Radiat Oncol Biol Phys 2002; 51:96-102. [PMID: 11641023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Abnormal calcium and protein kinase C-epsilon signaling in hypertrophied atrial tumor myocytes (AT-1 cells). Am J Physiol Heart Circ Physiol 2001; 280:H2761-9. [PMID: 11356634 DOI: 10.1152/ajpheart.2001.280.6.h2761] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cardiac hypertrophy leads to contractile dysfunction and altered hormone responsiveness through incompletely understood mechanisms. Atrial tumor (AT-1) myocytes (AT-1 cells) are a cardiomyocyte lineage that proliferates but hypertrophies when proliferation is prevented with mitomycin C. Because both states maintain a highly differentiated phenotype, AT-1 cells were used to explore the signaling pathways that accompany and/or contribute to hypertrophic cardiomyocyte growth. Mitomycin C-induced AT-1 cell enlargement is associated with a pronounced increase in the amplitude and the duration of both electrically stimulated calcium transients and endothelin receptor-dependent calcium responses. Studies with caffeine indicate that the intracellular pool of releasable calcium is similar in control and hypertrophied AT-1 cells. This agrees with the results of Northern analyses that show similar steady-state levels of transcripts encoding the sarcoplasmic reticulum Ca-ATPase (and higher levels of transcripts encoding the Na+/Ca2+ exchanger) in hypertrophied AT-1 cells, relative to proliferating control cultures. However, immunoblot analyses reveal a marked increase in the expression of protein kinase C (PKC)-epsilon (a critical intermediate in the signaling pathway for endothelin receptor-dependent modulation of intracellular calcium) during AT-1 cell hypertrophy; the abundance of other PKC isoforms is not changed. Collectively, these results identify reciprocal regulation between calcium/PKC signaling and hypertrophic growth. The evidence that AT-1 cell hypertrophy leads to abnormalities in calcium regulation and specific changes in PKC-epsilon expression that alter endothelin receptor responsiveness supports the notion that pathophysiological changes in PKC-epsilon abundance lead to functionally important changes in hormonal modulation of cardiomyocyte function.
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Abstract
PURPOSE Management of the carotid artery involved with metastatic squamous cell carcinoma continues to be a topic of much discussion. Early reports, for the most part, focused on the sequel of ligation and the development of various tests to predict patient tolerance for the procedure. More recent alternatives have described resection reconstruction in multistage procedures. By using immediate reconstruction with autogenous arterial grafting, carotid artery resection can be accomplished in patients with radiation failure in a single stage. This technique can be used without the addition of myocutaneous flaps, controlled fistulas, or intracranial surgery advocated for usage with alternative techniques. PATIENTS AND METHODS Immediate reconstruction after resection of the carotid artery with superficial femoral arterial graft is described. RESULTS In a series of 18 high-risk patients with radiation failure, the artery was successfully resected and reconstructed in 1 stage without any neurologic or vascular complications. The technique has been associated with prolonged survival in selected patients. CONCLUSION Carotid artery resection and immediate reconstruction can be performed in high-risk radiation failure patients with acceptable complications, and is associated with prolonged survival in selected cases.
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Feasibility of pooling sera for HIV-1 viral RNA to diagnose acute primary HIV-1 infection and estimate HIV incidence. AIDS 2000; 14:2751-7. [PMID: 11125894 DOI: 10.1097/00002030-200012010-00015] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To develop a pooling method for detection of viral RNA for diagnosis of acute HIV infection and estimation of HIV-1 incidence. METHODS Sera from 700 consecutive seronegative patients attending sexually transmitted disease clinics in Pune, India, were screened individually for p24 antigen, and pooled into seven pools of 100 for detection of HIV-1 RNA by reverse transcriptase-polymerase chain reaction. HIV-1 incidence was calculated by the traditional cohort method, the p24 antigen method, and a multistage pooling method in which RNA-positive pools were re-analyzed in smaller pools. RESULTS Sera from 700 individuals were grouped into seven pools of 100, of which four were positive. These four positive pools were subdivided into eight pools of 50, of which seven were positive. The seven positive pools were subdivided into 35 pools of 10, of which 10 were positive. Based on the 10 RNA-positive pools, the point estimate of HIV-1 incidence was 19.9% per year [95% confidence interval (CI), 7.3-31.8%]. Of the 700 samples analyzed for p24 antigen, eight were positive, resulting in a point estimate of incidence of 18.5%/year (8.0-36.5%). In contrast, the incidence rate based on the traditional cohort method of follow-up was lower at 9.4%/year (4.8-16.4%) due to a low follow-up rate. Testing of individual samples from the 10 RNA-positive pools identified 10 individuals with acute primary HIV-1. CONCLUSION The multistage pooling method for detection of HIV-1 RNA was more sensitive than the p24 antigen method, and was five-fold less expensive than the p24 antigen assays. Pooling samples for RNA detection was effective in estimating current incidence rates with cost savings that would be practical for use in developing countries.
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Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: final report of RTOG protocol 90-05. Int J Radiat Oncol Biol Phys 2000; 47:291-8. [PMID: 10802351 DOI: 10.1016/s0360-3016(99)00507-6] [Citation(s) in RCA: 1070] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To determine the maximum tolerated dose of single fraction radiosurgery in patients with recurrent previously irradiated primary brain tumors and brain metastases. METHODS AND MATERIALS Adults with cerebral or cerebellar solitary non-brainstem tumors </= 40 mm in maximum diameter were eligible. Initial radiosurgical doses were 18 Gy for tumors </= 20 mm, 15 Gy for those 21-30 mm, and 12 Gy for those 31-40 mm in maximum diameter. Dose was prescribed to the 50-90% isodose line. Doses were escalated in 3 Gy increments providing the incidence of irreversible grade 3 (severe) or any grade 4 (life threatening) or grade 5 (fatal) Radiation Therapy Oncology Group (RTOG) central nervous system (CNS) toxicity (unacceptable CNS toxicity) was < 20% within 3 months of radiosurgery. Chronic CNS toxicity was also assessed. RESULTS Between 1990-1994, 156 analyzable patients were entered, 36% of whom had recurrent primary brain tumors (median prior dose 60 Gy) and 64% recurrent brain metastases (median prior dose 30 Gy). The maximum tolerated doses were 24 Gy, 18 Gy, and 15 Gy for tumors </= 20 mm, 21-30 mm, and 31-40 mm in maximum diameter, respectively. However, for tumors < 20 mm, investigators' reluctance to escalate to 27 Gy, rather than excessive toxicity, determined the maximum tolerated dose. In a multivariate analysis, maximum tumor diameter was one variable associated with a significantly increased risk of grade 3, 4, or 5 neurotoxicity. Tumors 21-40 mm were 7.3 to 16 times more likely to develop grade 3-5 neurotoxicity compared to tumors < 20 mm. Other variables significantly associated with grade 3-5 neurotoxicity were tumor dose and Karnofsky Performance Status. The actuarial incidence of radionecrosis was 5%, 8%, 9%, and 11% at 6, 12, 18, and 24 months following radiosurgery, respectively. Forty-eight percent of patients developed tumor progression within the radiosurgical target volume. A multivariate analysis revealed two variables that were significantly associated with an increased risk of local progression, i.e. progression in the radiosurgical target volume. Patients with primary brain tumors (versus brain metastases) had a 2.85 greater risk of local progression. Those treated on a linear accelerator (versus the Gamma Knife) had a 2.84 greater risk of local progression. Of note, 61 % of Gamma Knife treated patients had recurrent primary brain tumors compared to 30% of patients treated with a linear accelerator. CONCLUSIONS The maximum tolerated doses of single fraction radiosurgery were defined for this population of patients as 24 Gy, 18 Gy, and 15 Gy for tumors </= 20 mm, 21-30 mm, and 31-40 mm in maximum diameter. Unacceptable CNS toxicity was more likely in patients with larger tumors, whereas local tumor control was most dependent on the type of recurrent tumor and the treatment unit.
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Extended hemipelvectomy in a Jehovah's Witness with erythropoietin support. Am Surg 1998; 64:1074-6. [PMID: 9798772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The care of patients refusing blood transfusion who require major ablative surgery for malignancy is a continuing challenge. The use of recombinant human erythropoietin is clearly efficacious in patients with renal disease and may be useful in anemic patients who refuse transfusion. Herein, we report a successful extended hemipelvectomy in a Jehovah's Witness using recombinant human erythropoietin support.
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Opportunity knocks. NURSING TIMES 1998; 94:37. [PMID: 10026509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
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Sex discrimination. NURSING TIMES 1998; 94:15. [PMID: 9752166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Wishing well. Nursing leaders share their hopes for the future of the NHS. Nurs Stand 1998; 12:16. [PMID: 9776891 DOI: 10.7748/ns.12.41.16.s27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Now is the time to harness the future. NURSING TIMES 1998; 94:19. [PMID: 9687745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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"Take Care of Yourself" project can avoid frivolous office visits. QRC ADVISOR 1998; 14:5-8. [PMID: 10179234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Update of radiation therapy oncology group (RTOG) protocol 9005: Single dose radiosurgical treatment of recurrent brain tumors. Int J Radiat Oncol Biol Phys 1998. [DOI: 10.1016/s0360-3016(98)80244-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Chest wall resection for extrapulmonary tumor. THE JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY : OFFICIAL ORGAN OF THE LOUISIANA STATE MEDICAL SOCIETY 1997; 149:323-7. [PMID: 9316348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Despite progress in early detection of breast cancer, a minority of women continue to present with extensive disease which may necessitate chest wall resection. Between 1992 and 1996, 14 patients were treated by surgical resection of the chest wall and reconstruction by the LSU Sections of Surgical Oncology and Plastic Surgery. Indications included resection of primary tumor, resection of recurrent tumor, and resection of radiation therapy induced damage to the chest wall. We report chest wall excision and reconstruction with no operative mortality and minor surgical morbidity in 21% of cases. Local control was achieved in 13 of 14 cases. Additionally we report uniform success in the palliation of ulcerating, painful, or infected chest wall lesions. Approximately 25% of patients treated for breast cancer and followed up for more than 6 months have remained free of disease. Chest wall resection is a useful modality in selected patients with extensive disease.
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Nonoperative therapy for postcatheterization femoral artery pseudoaneurysms. Am Surg 1997; 63:199-204. [PMID: 9012437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Since November 1992, 160 patients were referred to the Vascular Surgery Laboratory for duplex scanning to assess whether a femoral artery pseudoaneurysm was present. Of these patients, 33 per cent (n = 53) had femoral artery pseudoaneurysms with maximal diameters ranging from 1.5 to 8.1 cm. Most pseudoaneurysms (79%; 42 of 53) followed diagnostic or therapeutic cardiac catheterization procedures. Pseudoaneurysms were treated by external compression using an ultrasound probe in 33 of these 53 patients, and thrombosis of the aneurysm was successfully induced in 76 per cent (n = 25) of those in whom nonoperative external compression therapy was attempted. Of the eight patients in whom compression was unsuccessful, three had severe pain that required cessation of compression, and femoral nerve involvement by the pseudoaneurysm was noted at surgery in two of the three. One additional patient refused a second attempt at compression due to discomfort. Of the other four failures of compression, four (50% overall) received anticoagulants during or prior to compression. In 25 patients with successful pseudoaneurysm thrombosis after external compression, none had severe pain from compression, and 40 per cent (n = 10) were on anticoagulants until or during compression. Four of the 53 (7.5%) pseudoaneurysms diagnosed in the vascular laboratory subsequently thrombosed spontaneously, and two patients (3.8%) experienced pseudoaneurysm rupture. Thrombosis of postcatheterization pseudoaneurysms can be achieved by nonoperative compression therapy in most patients. Severe pain during external compression suggests possible femoral nerve involvement by the pseudoaneurysm and is an indication for surgical therapy.
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Abstract
PURPOSE Venacavograms are routinely obtained before vena cava filter placement to evaluate cava size, patency, and the presence of thrombus or venous anomalies. The objective of this study was to determine the ability of duplex ultrasonography to adequately evaluate the inferior vena cava (IVC) for size, patency, and the presence of thrombus before Greenfield filter (GF) insertion. METHODS Duplex ultrasonographic scans were performed in 40 patients who had documented lower-extremity deep venous thrombosis diagnosed by duplex scan before GF placement. The infrarenal transverse and anteroposterior diameters of the IVC were measured, and the entire IVC was imaged for patency and the presence of thrombus or anomalies. Preoperative venacavograms were not obtained in any patients who had GFs placed in the operating room, but was performed during surgery during filter insertion. An additional 26 patients who had deep venous thrombosis and did not have caval interruption underwent IVC duplex to determine the patency and proximal extent of venous thrombosis. RESULTS The indications for GF placement were contraindication to anticoagulation in 72.5% (29 patients); five filters were placed prophylactically; three for failure of anticoagulation; two after a complication of anticoagulation; and one before pulmonary embolectomy. The filters were placed in the operating room by surgeons in 82.5% of patients, with the remainder inserted in an angiography suite by an interventional radiologist. The ability of duplex to measure a transverse diameter of 26 mm or less had a sensitivity of 97.5%, positive predictive value of 100%, and overall accuracy of 97.5% using venacavography as the standard. Measurements of IVC diameter by duplex correlated with those based on venacavograms (r = 0.766; p < 0.001). Of the entire group of 66 IVC duplex examinations, one (1.5%) was incomplete because of technical limitations. IVC thrombus was noted by duplex in two patients who underwent GF insertion, which was confirmed with venacavography. No IVC anomalies were noted by duplex scans or venacavograms. CONCLUSION Duplex ultrasonography is a useful and accurate method for assessment of the IVC before vena cava filter placement.
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Radiosurgery for the treatment of previously irradiated recurrent primary brain tumors and brain metastases: initial report of radiation therapy oncology group protocol (90-05). Int J Radiat Oncol Biol Phys 1996; 34:647-54. [PMID: 8621289 DOI: 10.1016/0360-3016(95)02106-x] [Citation(s) in RCA: 207] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE To determine the maximum acutely tolerable dose of single fraction radiosurgery in patients with recurrent previously irradiated primary brain tumors or brain metastases. METHODS AND MATERIALS Between August 1990 and September 1993, 102 analyzable patients were entered on Radiation Therapy Oncology Group (RTOG) protocol 90-05, 38 of whom had recurrent primary brain tumors (median prior dose 60 Gy), and 64 of whom had recurrent brain metastases (median prior dose 30 Gy) < or = 40 mm in maximum diameter. Unacceptable toxicity was defined as irreversible Grade 3, any Grade 4, or Grade 5 central nervous system (CNS) toxicity according to the RTOG CNS criteria, occurring in > 20% of patients per treatment arm within 3 months of radiosurgery. RESULTS Patients were initially entered onto one of three treatment arms according to the maximum diameter of the recurrent lesion. Twelve to 22 patients were entered on each arm. The dose levels were: arm 1, < or = 20 mm, 18 Gy; arm 2, 21-30 mm, 15 Gy; and arm 3, 31-40 mm, 12 Gy. Subsequently, doses were escalated as follows: arm 4, < or = 20mm, 21 Gy; arm 5, 21-30 mm 18 Gy; and arm 6, 31-40 mm, 15 Gy. Unacceptable acute toxicity secondary to cerebral edema occurred in 0, 7 and 5% of patients on Arms 1, 2 and 3, respectively, and in no patients on arms 4, 5, or 6. Multivariate analysis revealed that tumor volume > or = 8200 mm(3) and a ratio of maximum dose to prescription dose (MD/PD) > or = 2 were significantly associated unacceptable toxicity. Of 15 patients with both tumor volume > or = 8200 mm(3) and MD/PD > or = 2, unacceptable toxicity occurred in 2 of 4 treated with a single isocenter and 1 of 11 treated with multiple isocenters. Subsequently, operation for symptomatic radionecrosis was required in 6% of patients. CONCLUSION We found that the incidence of acute toxicity was acceptable at 0-7% in patients with recurrent, previously irradiated primary brain tumors or brain metastases < or = 40 mm in maximum diameter treated according to the protocol described.
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Mosaic loss of 15q11q13 in a patient with hypomelanosis of Ito: is there a role for the P gene? Hum Genet 1995; 96:485-9. [PMID: 7557977 DOI: 10.1007/bf00191813] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report a patient with mental retardation, behavioral disturbances, and pigmentary anomalies, consistent with the phenotype of hypomelanosis of Ito (HMI), and in whom cytogenetic analysis revealed mosaicism for an unbalanced translocation. His karyotype is 45, XY,-7,-15,+der(7)(7:15)t(q34:q13)/46,XY. He is therefore monosomic for 7q34 to qter and 15pter to q13 in the cells containing the translocation. The human homolog (P) of the p gene (the product of the mouse pink-eyed dilution locus) maps to 15q11q13. Loss of this locus is believed to be associated with abnormalities of pigmentation, such as the hypopigmentation seen in patients with deletions of 15q11q13, and the Prader-Willi and Angelman syndromes. Mutations within the P gene have also been associated with tyrosinase-positive (type II) oculocutaneous albinism. Using fluorescence in situ hybridization, we confirmed that our patient is deleted for one copy of a P gene probe in the cells with the unbalanced translocation, and for loci within the region critical for the Prader-Willi/Angelman syndromes. Although hypomelanosis of Ito is a heterogeneous disorder, we postulate that, in our case and potentially in others, this phenotype may result directly from the loss of specific pigmentation genes.
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Occupational health. In sickness and in health. HEALTH VISITOR 1995; 68:205. [PMID: 7751152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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The lateralized processing of affect in emotionally labile extraverts and introverts: central and autonomic effects. Biol Psychol 1995; 39:143-57. [PMID: 7734627 DOI: 10.1016/0301-0511(94)00968-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The purpose of the present study was to better understand both the lateralized hemispheric processing of emotion and the differential neural processing of arousal in extraverts and introverts. We preselected right-handed male and female extraverts and introverts who were high in emotional lability. Each subject was exposed to two positive and two negative emotional stimuli under each of three counterbalanced conditions, including affective, cognitive, and neutral, while EEG and electrodermal activity (EDA) were recorded. Results showed that introverts are more aroused and that extraversion interacts with gender to produce differentiated patterns of lateralized neural activity. In addition, affective conditions produced higher levels of arousal than did cognitive or neutral conditions, particularly in the left hemisphere and under negative as opposed to positive stimuli. Finally, the hemispherically differentiated processing of positive and negative stimuli was affected by the contextual conditions under which they were experienced.
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Clients come first. HEALTH VISITOR 1995; 68:37. [PMID: 7829366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Professional accountability is central to all nursing and health visiting practice. Roger Kline explains how this operates in the context of skill mix and challenging excessive workloads.
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9 Radiosurgical treatment of previously irradiated primary brain tumors and brain metastasis: Final report of radiation therapy oncology group (RTOG) protocol 90-05. Int J Radiat Oncol Biol Phys 1995. [DOI: 10.1016/0360-3016(03)06301-b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Immunisation. At the sharp end. HEALTH VISITOR 1994; 67:398. [PMID: 7995726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Asking why and saying no. HEALTH VISITOR 1994; 67:359. [PMID: 7829336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
A change of atmosphere in the NHS has left many staff less prepared to challenge management decisions. This is partly reflected in reports of increased bullying at work and of the risks of being a whistleblower. Yet much grief in the NHS (and elsewhere) would be avoided if staff were a little more assertive when decisions affecting them are being taken. Often simple steps can help avoid more difficult situations later on. Roger Kline looks at some common situations and how to negotiate your way through them.
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Knowledge can be power. HEALTH VISITOR 1994; 67:313. [PMID: 7960850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Despite the erosion of many employment rights during the past 15 years, there has been some improvement in the right to information about individual contracts of employment, or for the purposes of collective bargaining. Roger Kline considers how local representatives may obtain some of the information.
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Discrimination. Right on your side. HEALTH VISITOR 1994; 67:278. [PMID: 7960835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The NHS is Europe's largest employer of women. It is also the largest employer of black and ethnic minority people in the UK. Yet race and sex discrimination are rife. Roger Kline describes how trade union representatives can use official guidance and the law to challenge discriminatory employment practices.
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Twice as nice. HEALTH VISITOR 1994; 67:215. [PMID: 7960807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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