Hippocampal vulnerability following traumatic brain injury: a potential role for neurotrophin-4/5 in pyramidal cell neuroprotection.

Traumatic brain injury (TBI) causes selective hippocampal cell death, which is believed to be associated with cognitive impairment observed both in clinical and experimental settings. Although neurotrophin administration has been tested as a strategy to prevent cell death following TBI, the potential neuroprotective role of neurotrophin-4/5 (NT-4/5) in TBI remains unknown. We hypothesized that NT-4/5 would offer neuroprotection for selectively vulnerable hippocampal neurons following TBI. Measurements of NT-4/5 in rats subjected to lateral fluid percussion (LFP) TBI revealed two-threefold increases in the injured cortex and hippocampus in the acute period (1-3 days) following brain injury. Subsequently, the response of NT-4/5 knockout (NT-4/5(-/-)) mice to controlled-cortical impact TBI was investigated. NT-4/5(-/-) mice were more susceptible to selective pyramidal cell loss in Ahmon's corn (CA) subfields of the hippocampus following TBI, and showed impaired motor recovery when compared with their brain-injured wild-type controls (NT-4/5(wt)). Additionally, we show that acute, prolonged administration of recombinant NT-4/5 (5 microg/kg/day) prevented up to 50% of the hippocampal CA pyramidal cell death following LFP TBI in rats. These results suggest that post-traumatic increases in endogenous NT-4/5 may be part of an adaptive neuroprotective response in the injured brain, and that administration of this neurotrophic factor may be useful as a therapeutic strategy following TBI.

Redesigning postnatal care: a randomised controlled trial of protocol-based midwifery-led care focused on individual women's physical and psychological health needs.

OBJECTIVES: To develop, implement and test the cost-effectiveness of redesigned postnatal care compared with current care on women's physical and psychological health. DESIGN: A cluster randomised controlled trial, with general practice as the unit of randomisation. Recruited women were followed up by postal questionnaire at 4 and 12 months postpartum and further data collected from midwife and general practice sources. SETTING: Thirty-six randomly selected general practice clusters in the West Midlands Health Region, UK. PARTICIPANTS: All women expected to be resident within recruited practices for postnatal care were eligible for inclusion. Attached midwives recruited 1087 women in the intervention and 977 in the control practice clusters. INTERVENTIONS: The systematic identification and management of women's health problems, led by midwives with general practitioner contact only when required. Symptom checklists and the Edinburgh Postnatal Depression Scale (EPDS) were used at various times to maximise the identification of problems, and individual care and visit plans based on needs. Evidence-based guidelines were used to manage needs. Care was delivered over a longer period. MAIN OUTCOME MEASURES: Women's health at 4 and 12 months, assessed by the Physical and Mental Component Scores (PCS and MCS) of the Short-Form 36 (SF-36) and the EPDS. Women's views about care, reported morbidity at 12 months, health service usage during the year, 'good practice' indicators and health professionals' views about care were secondary outcomes. RESULTS: At 4 and 12 months postpartum the mean MCS and EPDS scores were significantly better in the intervention group and the proportion of women with an EPDS score of 13+ (indicative of probable depression) was significantly lower relative to controls. The physical health score (PCS) did not differ. Health service usage was significantly less in the intervention group as well as reported psychological morbidity at 12 months. Women's views about care were either more positive or did not differ. Intervention midwives were more satisfied with redesigned care than control midwives were with standard care. Intervention care was cost-effective since outcomes were better and costs did not differ substantially. CONCLUSIONS: The redesigned community postnatal care led by midwives and delivered over a longer period, resulted in an improvement in women's mental health at 4 months postpartum, which persisted at 12 months and at equivalent overall cost. It is suggested that further research should focus on: the identification of postnatal depression through screening; whether fewer adverse longer term effects might be demonstrated among the children of the women who had the intervention care relative to the controls; testing interventions to reduce physical morbidity, including studies to validate measures of physical health in postpartum women. Further research is also required to investigate appropriate postnatal care for ethnic minority groups.

Participation of UK dentists in continuing professional development.

INTRODUCTION: This paper reports participation of dentists in continuing professional development (CPD) and factors affecting participation. METHOD: All general dental practitioners (GDPs) in three deaneries in England were surveyed. The overall response rate was 54% (n = 2082); by deanery it was 68% West Midlands, 45% South West and 44% Anglia. Findings across deaneries were remarkably similar. Comparisons with national data show no notable bias in the sample for gender, owners/partners and age/experience. RESULTS: Most frequent forms of CPD were journal reading and courses in which almost all engaged. A score based on individual participation in CPD over the 12-month period was calculated. The mean score (hours) for participation in verifiable CPD was 31 (median 25) and for general, 29 (median 29). In terms of the GDC's Lifelong Learning Scheme, 57% were already undertaking 50 hours. Net of other effects, those less likely to be doing 50 hours are those with more years in practice and single-handed practitioners. Greater access to courses and media-based CPD is desired. CONCLUSION: Certain groups of dentists will need support to meet the requirements of the GDC's Lifelong Learning Scheme. Statutory peer review or clinical audit will significantly alter the CPD profile of most dentists. This has implications for facilitators.

The benefits and costs of continuing professional development (CPD) for general dental practice: a discussion.

This paper sets out the benefits and costs of continuing professional development (CPD) for general dental practice. These considerations are important in evaluating CPD yet they are rarely formally assessed. This paper draws on literature specifically on dentistry but also from across the medical profession and the economics of education and training. First, the costs of CPD are itemised with some suggestions as to how costs may be reduced. Second, the benefits are identified and the (limited) evidence on the value of CPD is surveyed. Finally, reasons why some GDPs might not undertake sufficient or appropriate CPD are explored and the need for guidance for dental practitioners is identified.

Assessment in postgraduate dental education: an evaluation of strengths and weaknesses.

UNLABELLED: This paper describes a study designed to evaluate assessment in postgraduate dental education in England, identifying strengths and weaknesses and focusing specifically on its relevance, consistency and cost-effectiveness. METHODS: A four-phase qualitative method was used: a mapping of current career paths, assessment policy, and issues (phase 1); more detailed studies of the practice of assessment for a range of courses, and the systemic/management perspective of assessment (i.e. quality assurance) (phases 2 and 3), and analysis and reporting (phase 4). Data were analysed from documents, interviews, group consultations and observations. RESULTS AND DISCUSSION: Five key issues may be distilled from the findings: (i) lack of formal assessment of general professional training; (ii) trainer variation in assessment; (iii) the extent to which assessments are appropriate indicators of later success; (iv) the relationship between assessment and patient care, and (v) data to assess the costs of assessment. CONCLUSION: Current assessment procedures might be improved if consideration is given to: assessment which supports an integrated period of general professional training; training for trainers and inspection procedures to address variation; more authentic assessments, based directly on clinical work and grading cases and posts, and better data on allocation of resources, in particular clinicians' time given to assessment.

A role for clinical audit and peer review in the identification of continuing professional development needs for general dental practitioners: a discussion.

The purpose of this paper is to discuss how the role of peer review and clinical audit may be used in the identification of the continuing professional development (CPD) needs of general dental practitioners (GDPs). Clinical audit and peer review are intrinsically valuable in terms of the continued professional development of GDPs. Collaborative clinical audit, in particular, can provide a framework for short course input and there are particular benefits to this combination of activities which might usefully be more widely encouraged. If open to analysis in a way which retains individual anonymity, peer review and clinical audit resumes, these could be used to inform the provision of CPD and, linked to the knowledge of audit facilitators, short courses might more closely match the CPD needs of local dentists.

Continuing education courses in dentistry: assessing impact on practice.

INTRODUCTION: In the context of movement towards mandatory continuing dental education, this paper describes how a delayed postal questionnaire can be used in course evaluation. Specifically, the value of the questionnaire as a tool for assessing the impact of short course attendance on general dental practice is examined. METHOD: Questionnaires were distributed to all those attending three courses, ranging in size, in the West Midlands region. As well as reflecting on the course, respondents were asked their views on the usefulness of the questionnaire, the length of time between course attendance and assessment of impact, and types of courses likely to have greatest impact. RESULTS: Respondents thought the questionnaire an appropriate tool for assessing impact on practice, that an appropriate interval of time between the course and the delayed questionnaire is about six weeks, and that courses most likely to impact on practice are those which offer updates on common clinical topics and are hands-on in nature. DISCUSSION: A delayed questionnaire could be a useful mechanism for evaluating the impact on practice of some types of courses. Response rates from those attending large lecture courses might be low. Course evaluation is also limited by resources and time. Criteria for identifying which courses should be subject to such evaluation might include high cost per participant and links with review cycles. CONCLUSION: There is scope for more structured evaluation of continuing dental education, including the assessment of impact on practice. The questionnaire described is a useful component of an evaluation framework.

A framework for the evaluation of continuing education short courses in dentistry.

The objective of this paper is to propose an evaluation framework for short courses in continuing education for general dental practitioners (GDPs) (so called, Section 63 courses). Existing monitoring and evaluation procedures in the West Midlands deanery were examined and an improved evaluation framework was then devised, piloted and revised. A 5 phase method was used incorporating the examination of existing practice (Phases 1 and 2), development of a new framework (Phase 3), piloting (Phase 4) and revision of the evaluation framework in the light of the pilot. This approach will be implemented in the West Midlands and may be adapted for national use (Phase 5). It was found that existing monitoring and evaluation was inconsistent in prevalence and scope. Those involved in short courses were in favour of a more consistent and visible evaluation, including some assessment of impact-on-practice and cost-effectiveness. In conclusion, meaningful evaluation needs to include four key processes: data gathering; data analysis; dissemination and, action planning (reviewing provision in the light of the data analysis). Thus, this evaluation framework feeds into a quality development cycle designed to ensure high quality and relevant short course provision for general dental practitioners.