Physical activity and mental health in an Irish population.

BACKGROUND: Physical activity represents a modifiable behaviour which may be associated with increased likelihood of experiencing positive mental health. AIMS: The aim of this study was to examine the association between self-rated physical activity and subjective indicators of both positive and negative mental health in an Irish adult population. METHODS: Based on data from a population-based, observational, cross-sectional study, participants were categorised using the International Physical Activity Questionnaire (IPAQ) into those who reported that they did and did not meet recommended physical activity requirements. Self-reported positive and negative mental health indicators were assessed using the Energy and Vitality Index (EVI) and the Mental Health Index-5 (MHI-5) from the SF-36 Health Survey Instrument, respectively. Binary logistic regression was used to identify variables independently associated with self-reported positive and negative mental health. RESULTS: A total of 7539 respondents were included in analysis. Overall, 32% reported that they met recommended minimal physical activity requirements. Self-reported positive and negative mental health were reported by 16 and 9% of respondents, respectively. Compared with those who reported meeting-recommended physical activity requirements, those performing no physical activity were three times less likely to report positive mental health (adjusted odds ratio (OR) 0.39, 95% confidence interval (CI) 0.28-0.55) and three times more likely to report negative mental health (OR 3.27, 95% CI 2.38-4.50). CONCLUSION: Compared with those who do not, those who report meeting-recommended physical activity requirements are more and less likely to report experiencing positive and negative mental health, respectively. Future policy development around physical activity should take cognisance of the impact of this activity on both physical and mental health outcomes.

A systematic review of the clinical effectiveness of emergency endovascular therapy using mechanical thrombectomy in acute ischaemic stroke: implications for service delivery.

BACKGROUND: Twelve randomised controlled trials (RCTs) comparing mechanical thrombectomy against traditional treatment options for patients experiencing acute ischaemic stroke (AIS) have been published. AIMS: To evaluate whether this technology is more effective and/or safer than traditional treatment options and to assess the potential for implementation of this technology as a treatment strategy for acute ischaemic stroke in Ireland. METHODS: RCTs published up to February 2017 were included. Meta-analysis was performed for two primary (mortality at 90 days, mRS at 90 days) and four secondary outcomes. Cumulative meta-analysis was used to investigate the point at which a consistent treatment effect was observed for outcomes that had a statistically significant pooled effect. RESULTS: Mechanical thrombectomy was associated with higher likelihood of being independent (mRS, p < 0.01; Barthel index, p < 0.01) at 90 days post-AIS (p < 0.001). Cumulative meta-analysis demonstrated a consistent treatment effect in favour of mechanical thrombectomy after each trial was added to the analysis. There was no evidence of a difference in mortality rates (p = 0.21) or rates of SICH (p = 0.71) between patients randomised to intervention and control arms. Although the intervention appears to be associated with higher rates of any cerebral haemorrhage (p < 0.01) and recurrent ischaemic stroke (p = 0.03), considerable uncertainty remains as to these treatment effects. CONCLUSIONS: The trials published most recently have acted as a 'watershed' for mechanical thrombectomy, and while there are significant caveats, the data suggests that mechanical thrombectomy needs to be factored into the planning and delivery of services for the management of patients with acute ischaemic stroke in Ireland.

Acute ischaemic stroke: a systematic review of the cost-effectiveness of emergency endovascular therapy using mechanical thrombectomy.

PURPOSE: Although good evidence exists regarding the clinical effectiveness of mechanical thrombectomy for people with acute ischaemic stroke, cost-effectiveness should also be considered. The aim of this study was to systematically review the evidence of cost-effectiveness of emergency endovascular therapy using mechanical thrombectomy in the management of acute ischaemic stroke. METHODS: The search was carried out in PubMed, EMBASE, Cochrane Library, and a grey literature search. Studies were included if they compared the costs and consequences of mechanical thrombectomy added to usual medical care compared to usual care alone for people with acute ischaemic stroke in the anterior and/or posterior region. Study quality was assessed using two appraisal tools tailored to economic evaluations. FINDINGS: Thirteen studies were identified including twelve cost-utility analyses and one cost-benefit analysis. Studies could be dichotomised into those that evaluated first-generation (n = 4) and second-generation (n = 9) mechanical thrombectomy devices. Six studies had low applicability, six had moderate applicability, and one had high applicability to other settings. All cost-utility studies reported incremental cost-effectiveness ratios that would be considered cost-effective under typical willingness-to-pay thresholds. CONCLUSIONS: If the outcomes of the trials underpinning the evidence of clinical effectiveness can be replicated, then mechanical thrombectomy is likely to be cost-effective by typical willingness-to-pay thresholds. This finding holds under the assumption that no investment is required to develop stroke centres to the standard required to provide a safe emergency endovascular service and that additional expenditure on timely patient transport is not required.

Chemsex, risk behaviours and sexually transmitted infections among men who have sex with men in Dublin, Ireland.

BACKGROUND: Drug use for or during sex ('chemsex') among MSM has caused concern, because of the direct effects of the drugs themselves, and because of an increased risk of transmission of sexually transmitted infections (STIs). This study aimed to assess the prevalence of chemsex, associated behaviours and STIs among attendees at Ireland's only MSM-specific sexual health clinic in Dublin over a six week period in 2016. METHODS: The questionnaire collected demographic data, information on sexuality and sexual practice, self-reported history of treatment for STIs, and chemsex use. Key variables independently associated with treatment for STIs over the previous 12 months were identified using multivariable logistic regression. RESULTS: The response rate was 90% (510/568). One in four (27%) reported engaging in chemsex within the previous 12 months. Half had taken ≥2 drugs on his last chemsex occasion. One in five (23%) reported that they/their partners had lost consciousness as a result of chemsex. Those engaging in chemsex were more likely to have had more sexual partners(p<0.001), more partners for anal intercourse (p<0.001) and to have had condomless anal intercourse(p=0.041). They were also more likely to report having been treated for gonorrhoea over the previous 12 months (adjusted OR 2.03, 95% CI 1.19-3.46, p=0.009). One in four (25%) reported that chemsex was impacting negatively on their lives and almost one third (31%) reported that they would like help or advice about chemsex. CONCLUSION: These results support international evidence of a chemsex culture among a subset of MSM. They will be used to develop an effective response which simultaneously addresses addiction and sexual ill-health among MSM who experience harm/seek help as a consequence of engagement in chemsex.

Public knowledge and understanding of dementia-evidence from a national survey in Ireland.

Background: there is growing consensus around the importance of population level approaches which seek to improve public knowledge and awareness of dementia. Aim: to assess knowledge of the relationship between dementia and ageing, and of the risk and protective factors associated with it, among the general public in Ireland. Design: cross-sectional survey. Participants selected using quota sampling based on Census data. Methods: the final sample of 1,217 respondents provided estimates of dementia knowledge in the Irish population. Logistic regression was used to assess the impact of potential predictor variables on knowledge of dementia. Results: a majority (52%) reported that they knew someone living with dementia. Just 39% were confident that they could tell the difference between the early signs of dementia and normal ageing. Less than half (46%) believed that there were things they could do to reduce their risk of developing dementia, and knowledge of risk and protective factors for dementia was very poor. Although significant differences were seen according to area of residence, social class and experience of dementia, even those groups with 'better' understanding demonstrated substantial knowledge deficits regarding risk and protective factors. Conclusions: the general public in Ireland are confused about the relationship between dementia and ageing, and knowledge of risk and protective factors for dementia is very poor. While not dissimilar to those reported internationally, the findings present a challenge to those tasked with promoting behaviour change and interventions to delay or prevent the onset of dementia.

Type 2 Diabetes Research Yield, 1951-2012: Bibliometrics Analysis and Density-Equalizing Mapping.

The objective of this paper is to provide a detailed evaluation of type 2 diabetes mellitus research output from 1951-2012, using large-scale data analysis, bibliometric indicators and density-equalizing mapping. Data were retrieved from the Science Citation Index Expanded database, one of the seven curated databases within Web of Science. Using Boolean operators "OR", "AND" and "NOT", a search strategy was developed to estimate the total number of published items. Only studies with an English abstract were eligible. Type 1 diabetes and gestational diabetes items were excluded. Specific software developed for the database analysed the data. Information including titles, authors' affiliations and publication years were extracted from all files and exported to excel. Density-equalizing mapping was conducted as described by Groenberg-Kloft et al, 2008. A total of 24,783 items were published and cited 476,002 times. The greatest number of outputs were published in 2010 (n=2,139). The United States contributed 28.8% to the overall output, followed by the United Kingdom (8.2%) and Japan (7.7%). Bilateral cooperation was most common between the United States and United Kingdom (n=237). Harvard University produced 2% of all publications, followed by the University of California (1.1%). The leading journals were Diabetes, Diabetologia and Diabetes Care and they contributed 9.3%, 7.3% and 4.0% of the research yield, respectively. In conclusion, the volume of research is rising in parallel with the increasing global burden of disease due to type 2 diabetes mellitus. Bibliometrics analysis provides useful information to scientists and funding agencies involved in the development and implementation of research strategies to address global health issues.

Prophylactic total thyroidectomy using the minimally invasive video-assisted approach in children with multiple endocrine neoplasia type 2.

BACKGROUND: There have been few reports of prophylactic thyroidectomy using the minimally invasive video-assisted thyroidectomy (MIVAT) approach in children with multiple endocrine neoplasia 2 (MEN2). METHODS: We conducted a retrospective review of a prospectively maintained database of patients who underwent MIVAT for total thyroidectomy. RESULTS: Six children underwent MIVAT; RET codon mutations identified were 634, 620, 611, and 918. Mean operative time was 93 minutes (range, 68-105 minutes). Five patients were discharged on the first postoperative day; however, 1 patient had a postoperative hematoma and was discharged 2 days postoperatively. There were no cases of laryngeal nerve palsy or postoperative hypoparathyroidism. High levels of satisfaction with postoperative cosmesis were reported. Calcitonin levels have been undetectable at follow-up thus far (mean follow-up, 42.8 months). CONCLUSION: Although our outcomes are similar to those reported using the traditional approach, it is important to note that MIVAT is essentially the same operation, just performed through a smaller incision, with resulting benefits in terms of pain, cosmesis and, perhaps, morbidity.

Publication patterns on neonatal surgery over 65 years.

BACKGROUND/PURPOSE: Staying abreast of the literature in a given speciality is difficult. The aim of this study is to analyze the publication patterns of the neonatal surgical literature over the last six decades. MATERIALS: A search strategy for the Web of Science database was designed using MeSH defined terms for 10 index neonatal surgical conditions, with output analyzed over two time-periods. RESULTS: There were 6215 and 6144 publications for periods 1 (1945-1994) and 2 (1995-2010), respectively. There were 24 and 546 articles published in 1945 and 2010, respectively. The mean citation counts of the top 50 publications are 228 and 156 for periods 1 and 2, respectively. There were 6 and 11 authors with two or more publications in the top 50 list in periods 1 and 2, respectively. Three of the pediatric surgery journals cumulatively have published 30.9% of the total articles. CONCLUSIONS: Publication patterns for neonatal surgical conditions have changed significantly over time. The majority of articles are published outside of pediatric surgical journals. Pediatric surgeons should not limit their reading to these journals.

Patterns of Internet and smartphone use by parents of children attending a pediatric otolaryngology service.

OBJECTIVES: To assess Internet use and the influence of smartphones on health-information seeking by parents and carers of children with ENT conditions. METHODS: A paper-based questionnaire was circulated to parents attending otolaryngology services in both the out-patient and day-case settings at a tertiary referral centre. RESULTS: 79.5% of questionnaires were returned. 29.9% had consulted the Internet for ENT-related information. Factors associated with increased rates of ENT-related online activity included younger age, university education, and access to a smartphone (all p ≤ 0.001). 65.7% and 57.7% had found the information which they had found online to be understandable and helpful, respectively; however, just 25.5% felt that it had influenced the medical decisions they had made for their child. 50.3% had previously or intended to discuss information found online with their surgeon. 9.2% had searched online for information regarding their child's surgeon; 19.6% of these said that this had been a factor in choosing that particular surgeon. On ranking 8 information sources in terms of importance (scale 0-5), the ENT Surgeon ranked as most important (mean=4.63), whilst the Internet ranked lowest (3.10). 48.6% of respondents or their partners had an Internet-enabled smartphone; 45.2% said they would definitely use an iPhone app regarding their child's condition if one was available. 36.1% reported they would definitely use the Internet in the future. CONCLUSIONS: Whilst online sources must increasingly be considered in the dialogue with parents, it is clear that parents still rate the clinical team as most important for information gathering. Clinician-provided websites and smartphone applications may be the key to ensuring the provision of quality information into the future.

Surgical mentors and role models: prevalence, importance and associated traits.

BACKGROUND: Role models and mentors play an important part in attracting undergraduates into various medical specialties. However, little is known about the part played by role models and mentors in the context of surgery. The aim of this survey was to elucidate medical students' and surgical trainees' experiences of role models and to determine how mentoring works in practice. We also set out to identify traits associated with successful role models and mentors. METHODS: A questionnaire was distributed to senior undergraduate medical students in 1 medical school, and postgraduate surgical trainees (members of the Association of Surgeons in Training (ASIT) in the UK and Ireland. The survey included questions about the availability of mentors and role models and explored mentorship process. RESULTS: A total of 163 medical students and 216 surgical trainees completed the questionnaire. While most medical students did not have a mentor, 52% (n = 104) of trainees reported having a surgical mentor. In both cases, mentoring was ill-structured and informal. While most medical students expressed a preference for a formal mentoring program, only 38% of surgical trainees expressed a preference for a more formal approach. Experiences of negative surgical role models were a pervasive feature for both medical student and surgical trainee respondents. DISCUSSION: This survey highlights a lack of a deliberate approach to mentoring in surgery and the presence of an excess of negative role models. It is, therefore, time for surgeons to pay much more attention to their roles as professional exemplars and mentors.

Laryngeal cancer: quantitative and qualitative assessment of research output, 1945-2010.

OBJECTIVES/HYPOTHESIS: To provide an in-depth evaluation of research yield in laryngeal cancer from 1945 to 2010, using large-scale data analysis, employment of bibliometric indicators of production and quality, and density equalizing mapping. STUDY DESIGN: Bibliometic analysis incorporating the Web of Science Database. METHODS: The search strategy employed was as follows; "TS = ((Laryngeal Neoplasm$) OR (Larynx Neoplasm$) OR (Larynx Cancer$) OR (Laryngeal Cancer$))." Author and journal data and cooperation networks were computed following analysis of combinations of countries and institutions that registered cooperation during the study period. Mapping was performed as described by Groneberg-Kloft in 2004. RESULTS: A total of 8,658 items relating to laryngeal cancer were published over the study period, accounting for 139,700 citations. The United States was the most prolific country, accounting for 28.83% (n = 2,496) of total output. Other prolific nations included Italy (n = 794) and Germany (n = 792). There were 973 items published as a consequence of international cooperation; this practice increased steadily over time and accounted for 15.58% (88 of 565) of output in 2010. There were 1,073 different journals publishing articles on laryngeal cancer, although the top 20 (1.8%) most prolific titles were together responsible for more than 43% of the total output; these were led by Laryngoscope (n = 368) and Head and Neck, Journal of the Scientific Specialties (n = 364). A total of 24,682 authors contributed to the literature on laryngeal cancer; the leading author by output was Alfio Ferlito (n = 120); Carlo La Vecchia recorded the highest h-index (h = 32). CONCLUSIONS: This work represents the first attempt to provide quantitative and qualitative analysis of laryngeal cancer research output, whilst in tandem identifying the key bibliometric benchmarks to which those involved in the production of that output might aspire.

Expression levels of HER2/neu and those of collocated genes at 17q12-21, in breast cancer.

HER2/neu is associated with poorer clinical outcome in breast cancer. Expression patterns of co-localised cancer-associated genes at 17q12-21 were examined using RT-PCR. The study group consisted of a 96-patient cohort. Relative quantity of mRNA expression was calculated using the comparative cycle threshold method and Qbase software. Results were analysed to detect expression patterns among the genes, and to identify associations between expression levels and clinical data. Levels of HER2/neu correlated with those of GRB7 (r=0.551, p<0.001), RARA (r=0.391, p<0.001), RPL19 (r=0.549, p<0.001) and LASP1 (r=0.399, p<0.001). GRB7 was significantly inversely associated with improved DFS at 60 months (p=0.036). RARA levels were greater in HER2/neu-positive as opposed to HER2/neu-negative patients (p=0.021); levels were significantly higher in ER-positive patients, relative to those who were ER-negative (p=0.003). Levels of RPL19 were significantly higher in the HER2/neu-overexpressing (p=0.010) and luminal B subtypes (p=0.007). LASP1 levels were higher in those patients who had been classified clinically as HER2/neu-positive (p=0.004). This study reaffirms the correlation between HER2/neu and the co-localised LASP1 and GRB7; the latter target may hold additional significance in addition to being a surrogate marker for HER2/neu expression. The relationship identified between RARA and ER-positivity may herald an avenue for targeted therapy of these tumours.

Supraclavicular scalenectomy for thoracic outlet syndrome--functional outcomes assessed using the DASH scoring system.

INTRODUCTION: To evaluate supraclavicular scalenectomy ± cervical rib excision for thoracic outlet syndrome (TOS), employing Disability of Arm, Shoulder, and Hand (DASH) scoring for functional assessment post-decompression. METHODS: A QuickDASH score was calculated for each patient using the algorithm: ([sum of responses/n] - 1) × 25, where n = number of completed responses. Nonparametric analysis was employed, with significance defined as P ≤ .05. RESULTS: Twenty-one patients were treated for TOS by the same surgeon; with 5 bilateral procedures (total = 26 procedures). Median DASH scores pre- and postoperatively were 68.5 and 36.0, respectively (P = .002). Just one reported worsening of symptoms postoperatively. Antecedent trauma and smoking were inversely associated with DASH score postoperatively (P = .005 and P = .005). Postoperative scores were less for patients with vascular symptoms (P = .011); scores did not change significantly for those with neurologic (P = .066) or mixed symptoms (P = .345). CONCLUSIONS: This study reconfirmed the value of supraclavicular approach for TOS, with the vast majority reporting subjective improvement.

Locoregional recurrence after breast cancer surgery: a systematic review by receptor phenotype.

Molecular subtyping confirms that breast cancer comprises at least four genetically distinct entities based on the expression of specific genes including estrogen receptor (ER), progesterone receptor (PR), and HER2/neu receptor. The quantitative influence of subtype on ipsilateral locoregional recurrence (LRR) is unknown. The aim of this study was to systematically appraise the influence of breast cancer subtype on LRR following breast conserving therapy (BCT) and mastectomy. A comprehensive search for studies examining outcomes after BCT and/or mastectomy according to breast cancer subtype was performed using Medline and cross-referencing available data. Reviews of each study were conducted and data extracted to perform meta-analysis. Primary outcome was LRR related to breast cancer subtype. A total of 12,592 breast cancer patients who underwent either BCT (n = 7,174) or mastectomy (n = 5,418) were identified from 15 studies. Patients with luminal subtype tumors (ER/PR +ve) had a lower risk of LRR than both triple-negative (RR 0.38; 95% CI 0.23-0.61); and HER2/neu-overexpressing (RR 0.34; 95% CI 0.26-0.45) tumors following BCT. Luminal tumors were also less likely to develop LRR than HER2/neu-overexpressing (OR 0.69; 95% CI 0.54-0.89) or triple-negative tumors (OR 0.61; 95% CI 0.46-0.79) after mastectomy. HER2/neu-overexpressing tumors have increased risk of LRR compared to triple-negative tumors (RR 1.44; 95% CI 1.06-1.95) following BCT but there was no difference in LRR between HER2/neu-overexpressing and triple-negative tumors following mastectomy (RR 0.91; 95% CI 0.68-1.22). Luminal tumors exhibit the lowest rates of LRR. Patients with triple-negative and HER2/neu-overexpressing breast tumors are at increased risk of developing LRR following BCT or mastectomy. Breast cancer subtype should be taken into account when considering local control and identifies those at increased risk of LRR, who may benefit from more aggressive local treatment.

The effect of breast cancer awareness month on internet search activity--a comparison with awareness campaigns for lung and prostate cancer.

BACKGROUND: This work aimed to assess the effects of the annual breast cancer awareness campaign on internet search activity, and to compare these effects with those of similar campaigns in prostate and lung cancer. We further aimed to assess overall levels of online activity relating to all three neoplasms between 2004 and 2009. METHODS: Google Insights for Search was employed to examine search trends for the term "breast cancer", across all Google domains between January 2004 and December 2009 (6 years). Search trends for both "prostate cancer" and "lung cancer" across all domains were also analysed for the same period, and these trends were compared with those for "breast cancer". Repeated measures ANOVA and Tukey post-hoc analyses were performed to assess for significant differences in activity. RESULTS: Increased levels of online activity relating to breast cancer are consistently generated each October. There is a significantly higher level of background activity in breast cancer compared with that in lung or prostate cancer (p < 0.001), and the October campaign stimulates online activity more effectively than equivalent campaigns for these other malignancies (p < 0.001). CONCLUSIONS: The annual breast cancer awareness campaign is proving effective in stimulating online activity and may hold useful lessons for other cancer awareness initiatives.

Younger age as a prognostic indicator in breast cancer: a cohort study.

BACKGROUND: The debate continues as to whether younger women who present with breast cancer have a more aggressive form of disease and a worse prognosis. The objectives of this study were to determine the incidence of breast cancer in women under 40 years old and to analyse the clinicopathological characteristics and outcome compared to an older patient cohort. METHODS: Data was acquired from a review of charts and the prospectively reviewed GUH Department of Surgery database. Included in the study were 276 women diagnosed with breast cancer under the age of forty and 2869 women over forty. For survival analysis each women less than 40 was matched with two women over forty for both disease stage and grade. RESULTS: The proportion of women diagnosed with breast cancer under the age of forty in our cohort was 8.8%. In comparison to their older counterparts, those under forty had a higher tumour grade (p = 0.044) and stage (p = 0.046), a lower incidence of lobular tumours (p < 0.001), higher estrogen receptor negativity (p < 0.001) and higher HER2 over-expression (p = 0.002); there was no statistical difference as regards tumour size (p = 0.477). There was no significant difference in overall survival (OS) for both groups; and factors like tumour size (p = 0.026), invasion (p = 0.026) and histological type (p = 0.027), PR (p = 0.031) and HER2 (p = 0.002) status and treatment received were independent predictors of OS CONCLUSION: Breast cancer in younger women has distinct histopathological characteristics; however, this does not result in a reduced survival in this population.

TOP2A amplification in the absence of that of HER-2/neu: toward individualization of chemotherapeutic practice in breast cancer.

PRIMARY OBJECTIVE: To investigate the relationship between human epidermal growth factor receptor (HER)-2/neu and the gene encoding topoisomerase IIα (TOP2A) in breast cancer, while elucidating their association with clinicopathological variables. METHODS: Real-time quantitative polymerase chain reaction (RQ-PCR) was performed on a 96-patient study group to assess gene amplification, and levels were determined using the comparative cycle threshold approach and Taqman assays. An immunohistochemistry (IHC) microarray (n = 76) was then employed to check for correlation between gene amplification and protein expression levels. RESULTS: Amplification levels of TOP2A did not differ significantly according to HER-2/neu status by either RQ-PCR or IHC microarray. Of the HER-2/neu(-) patients, 29.1% demonstrated levels of TOP2A above the third quartile, whereas 22.9% of the HER-2/neu(+) patients had values in the first quartile (log TOP2A <0.62), thereby indicating low-level amplification. Of the 60 patients characterized as HER-2/neu(-) using IHC and fluorescence in situ hybridization (FISH), 22.9% were classified as TOP2A(+) on the IHC microarray. Of the 14 patients deemed HER-2/neu(+) using IHC and FISH, meanwhile, the majority (n = 10) were classified as TOP2A(+). CONCLUSIONS: Our results indicate that amplification of TOP2A in breast cancer is not confined to those who are concomitantly HER-2/neu(+), and suggest that a significant proportion of HER-2/neu(-) patients exhibit high levels of TOP2A.

Interns' attitudes to IV cannulation: a KAP study.

UNLABELLED: One of the most common procedures for junior medical doctors is peripheral intravenous cannulation (PIVC). Considering this, an understanding of the peripheral intravenous cannulation procedure is paramount. AIM: The objective of this study was to identify the level of understanding of interns regarding intravenous cannulation. METHOD: An anonymized structured questionnaire using a knowledge attitude and practices (KAP) format was distributed to 60 interns affiliated to a university college hospital in Ireland. FINDINGS: This study suggests that interns are poorly prepared for one of the most common clinical skills they will perform. They showed poor understanding of whether peripheral cannulation is a clean or aseptic technique, and lacked knowledge of the potential side effects of peripheral cannulation and IV therapy. RECOMMENDATIONS: A structured learning module on peripheral intravenous cannulation is required. A rigid, evidence-based, Objective Structured Clinical Examination (OSCE) on peripheral cannulation is recommended. The reduction of junior doctors' weekly working hours to 48 under the European Working Time Directive offers the potential for nurses to take ownership of IV cannulation. This will allow junior doctors to focus on other clinical skills and assessments, which can only be to the advantage of the patient.

Breast cancer research output, 1945-2008: a bibliometric and density-equalizing analysis.

NTRODUCTION: Breast cancer is the most common form of cancer among women, with an estimated 194,280 new cases diagnosed in the United States in 2009 alone. The primary aim of this work was to provide an in-depth evaluation of research yield in breast cancer from 1945 to 2008, using large-scale data analysis, the employment of bibliometric indicators of production and quality, and density-equalizing mapping. METHODS: Data were retrieved from the Web of Science (WOS) Science Citation Expanded database; this was searched using the Boolean operator, 'OR', with different terms related to breast cancer, including "breast cancer", "mammary ductal carcinoma" and "breast tumour". Data were then extracted from each file, transferred to Excel charts and visualised as diagrams. Mapping was performed as described by Groneberg-Kloft et al. in 2008. RESULTS: A total of 180,126 breast cancer-associated items were produced over the study period; these had been cited 4,136,224 times. The United States returned the greatest level of output (n = 77,101), followed by the UK (n = 18,357) and Germany (n = 12,529). International cooperation peaked in 2008, with 3,127 entries produced as a result; relationships between the United States and other countries formed the basis for the 10 most common forms of bilateral cooperation. Publications from nations with high levels of international cooperation were associated with greater average citation rates. A total of 4,096 journals published at least one item on breast cancer, although the top 50 most prolific titles together accounted for over 43% (77,517/180,126) of the total output. CONCLUSIONS: Breast cancer-associated research output continues to increase annually. In an era when bibliometric indicators are increasingly being employed in performance assessment, these findings should provide useful information for those tasked with improving that performance.