ECG interpretation skill acquisition: A review of learning, teaching and assessment.

The recording of 12 lead electrocardiograms (ECG) is one of the most useful and commonly performed medical procedures. ECGs are used in diagnosis, risk-stratification management decision-making, and assessment in response to therapy. The correct interpretation of 12 lead ECG recordings is complex and clinically challenging with misinterpretation having the potential to result in poor outcomes or even patient fatality. Despite its widespread use, several studies have highlighted deficiencies in ECG interpretation skills among health professionals. The literature suggests that up to 33% of ECG interpretations have some error when compared to the expert reference and up to 11% resulted in inappropriate management. The pedagogy of ECG interpretation lacks universal establishment; time allocation, faculty training and teaching format vary considerably within the literature. This review of the literature reports how a lack of established ECG reporting methods may contribute to the variation in reported ECG interpretation competence across many healthcare professionals. The ubiquity of the ECG in clinical practice and an over reliance on computer assisted ECG interpretation are additionally explored as factors affecting acquisition and retention of this clinical skill.

An RCT to determine the effect of a heel elevation device in pressure ulcer prevention post-hip fracture.

OBJECTIVE: A randomised controlled trial set out to determine whether there are differences between complete offloading and standard care in terms of the number of new pressure ulcers (PUs) developing on the heels of older patients with fractured hips and the number or severity of new PUs on other areas of their bodies. METHOD: Patients aged over 65 years in a fracture trauma unit with fractured hips were randomly allocated to receive heel elevation (DM Systems, Evanston, Illinois) plus pressure-redistributing support surface or standard care (pressure-redistributing support surface alone). Exclusion criteria included existing heel damage. Patients were assessed on pre- and postoperative days for the occurrence of new pressure damage. Patients completed a satisfaction questionnaire at discharge. RESULTS: 119 patients were recruited into the control group and 120 into the intervention group. Independent t-tests and chi-squared analysis showed both groups were comparable at baseline. Thirty-one subjects (26%) in the control group developed PUs compared with eight in the intervention group (7%, p<0.001). No subjects in the intervention group developed a PU on their ankles, feet or heels, whereas 29 subjects in the control group did (p<0.001). Kaplan-Meier survival curves indicated that subjects in the control group were more likely than those in the intervention group to suffer pressure damage at all time points (p=0.001). A sensitivity analysis showed that when subjects lost to follow-up were assigned the worse outcome (PU positive) those in the intervention group were still less likely to develop PUs than the control group (p=0.001). The offloading device was rated as comfortable overall by 59% of subjects. CONCLUSION: The findings suggest that offloading reduces the incidence of heel ulcers.

Professionals delivering palliative care to people with COPD: qualitative study.

This article describes health and social care professionals' perceptions of palliative care and facilitators and barriers to the delivery of such care for patients with advanced chronic obstructive pulmonary disease. Health professionals participated in semi structured interviews and focus groups which were analysed using content analysis. According to participants, care of patients with chronic obstructive pulmonary disease is focused upon the management of symptoms, with emphasis focused predominately on an acute model of care. Key barriers towards the delivery of palliative care included the reluctance to negotiatie end-of-life decisions and a perceived lack of understanding among patients and carers regarding the illness trajectory. Consequently the delivery of palliative care was viewed as a specialist role rather than an integral component of care. There is a need for education and training for health and social care professions to plan and provide high quality end-of-life care.

Evaluating education in palliative care with link nurses in nursing homes.

BACKGROUND: Palliative care is recognized as an important component of care for everyone with advanced illness. Historically, it has been provided in specialist settings, but it has been suggested that best practice in palliative care should be transferred to non-specialist settings, including care homes. Care homes require particular support for this and link nurses have been recruited to develop palliative care in these settings. AIM: To assess the palliative care education received and consequently cascaded by designated nursing home staff. METHOD: Questionnaire administered to private nursing home nurses who attended a palliative care training programme in one UK region. FINDINGS: Thirty questionnaires were returned (response rate 77%). There was a high satisfaction with course content, facilitation and benefits accrued from participation. Many respondents (83%) had not commenced cascading training within their nursing homes due to lack of time and competing mandatory demands. CONCLUSION: Extending palliative care practice to non-specialist settings with the help of link nurses is possible and welcomed by nursing home staff. However, more substantive and on-going support is needed post-training from both nursing home management and training facilitator to enable and empower link nurses to undertake palliative care education with their peers.

Patients with head and neck cancer prefer individualized cognitive behavioural therapy.

Cognitive behaviour therapy (CBT) is a widely practiced and approved form of psychotherapy for many psychosocial difficulties. As the efficacy of CBT is recognized, its demand has increased and today exceeds the availability of qualified practitioners. Therefore, the effectiveness of delivering CBT using less labour-intensive modes than individualised therapy has been explored. These include group therapy, bibliotherapy and computer assisted therapy. Given the UK Government's impetus towards patient choice and involvement in the planning of healthcare, it was thought essential to ascertain the preferred delivery mode of patients with head and neck cancer for a CBT based intervention. Therefore, a small retrospective cohort (n= 28) of patients following treatment for head and neck cancer were sent postal questionnaires to ascertain their preferences on mode of CBT delivery. Simultaneously, the views of accredited cognitive behaviour therapists (n= 14) were determined on the optimal mode of CBT delivery to these patients. Findings indicated that patients preferred the more individualized mode of CBT delivery, namely one-to-one therapy, followed closely by bibliotherapy, with group format being the least preferred option. Professionals concurred with patients, in that one-to-one interaction was considered an optimal mode of CBT delivery, but professionals considered it equal to group therapy.

Bed occupancy and turnover interval as determinant factors in MRSA infections in acute settings in Northern Ireland: 1 April 2001 to 31 March 2003.

The following data were obtained from annual hospital statistics in Northern Ireland and from the Communicable Diseases Surveillance Centre (CDSC) Northern Ireland for 2001-2002 and 2002-2003: bed turnover interval (TI), percentage bed occupancy (PO) and methicillin-resistant Staphylococcus aureus rates per 1000 bed-days of patient episodes [MRSA (PE)]. A significant negative correlation was established (r=-0.854; P<0.01) between TI and MRSA (PE) in 2002-2003. A significant positive correlation for PO and MRSA (PE) (r=0.679; P<0.05) was also found for the same year. The correlation for TI and MRSA (PE) in 2001-2002 was r=0.621 (P<0.05), but no significant correlation was established for PO and MRSA (PE) in the same year. Partial correlation indicated that the influence on MRSA (PE) rates was greater for TI than for PO. These results infer that a rapid turnover of patients is an important factor influencing MRSA rates within acute hospitals.

A randomized controlled trial of intra-articular triamcinolone and/or physiotherapy in shoulder capsulitis.

OBJECTIVE: To assess the effectiveness of intra-articular triamcinolone injection and physiotherapy singly or combined in the treatment of adhesive capsulitis of the shoulder. METHODS: Eighty patients with adhesive capsulitis of less than 6 months duration were randomized to one of four groups: Group A, injection of triamcinolone 20 mg and eight sessions of standardized physiotherapy; Group B, injection of triamcinolone 20 mg alone; Group C, placebo injection and eight sessions of standardized physiotherapy; or Group D, placebo injection alone. All subjects were given an identical home exercise programme. Outcome measures were assessed at 6 weeks and 16 weeks. The primary outcome measure was Shoulder Disability Questionnaire (SDQ) score. Secondary outcomes were measurement of pain using a visual analogue scale (VAS), global disability using VAS and range of passive external rotation. A two-way analysis of variance was used to explore the effects of corticosteroid injection and physiotherapy. RESULTS: At 6 weeks, the SDQ had improved significantly more in the groups receiving corticosteroid injection (P = 0.004). Physiotherapy improved passive external rotation at 6 weeks (P = 0.02) and corticosteroid injection improved self-assessment of global disability at 6 weeks (P = 0.04). There was no interaction effect between injection and physiotherapy. At 16 weeks, all groups had improved to a similar degree with respect to all outcome measures. CONCLUSION: Corticosteroid injection is effective in improving shoulder-related disability, and physiotherapy is effective in improving the range of movement in external rotation 6 weeks after treatment.

Periprosthetic tibial fractures after cementless low contact stress total knee arthroplasty.

Periprosthetic fractures are a recognized complication of total knee arthroplasty. Fractures may occur intraoperatively or postoperatively, and risk factors have been identified that may predispose an individual to such a complication. We report 7 cases of periprosthetic tibial fractures after low contact stress total knee arthroplasty, a complication encountered by the senior author (D.E.B.) only after a change in practice from a cemented implant to a cementless one. In light of this previously unreported complication in our unit, we attempted to identify common features within this group of patients that may have contributed to fracture occurrence. Statistical analysis revealed a highly significant (P<.005) risk of periprosthetic tibial fracture in patients with a preoperative neutral or valgus knee. Age, gender, and diagnosis did not appear to increase the risk of fracture significantly. All patients displayed evidence of reduced bone mineral density in the lumbar spine and femoral neck regions on dual-energy x-ray absorptiometry scanning. Patients with a preoperative neutral or valgus knee and local evidence of osteopenia represent a high-risk group, in whom particular care in alignment should be taken. In this group, it may be preferable to have the tibial component inserted with cement fixation.

Numerical model of deep venous thrombosis detection using venous occlusion strain gauge plethysmography.

Strain gauge plethysmography (SGP) is a non-invasive method used in the detection of deep venous thrombosis (DVT). The technique is based on the measurement of calf volume changes in response to venous occlusion by a thigh cuff, the volume changes reflecting the rates of arterial inflow and venous outflow. A numerical model of the blood circulation within the limb and the response of this to a SGP test has been derived, based on treating the different parts of the circulatory system in the leg as resistance and capacitance elements. The simulation results were compared with clinical studies and support the ability of SGP to detect non-occlusive clots of more than 50-60% of the lumen, as well detecting calf vein occlusion. The non-linear behaviour of the venous compliance with intra-luminal pressure appears to be a particularly important factor within the model. In addition, increases in venous tone due to post-operative venospasm were shown to be a potential source of false positive results.

WWW as a teaching resource for introductory medical informatics in primary care.

This pro and contra report assesses the current state of the WWW as a teaching aid for Medical Informatics, using the experience gained from the delivery of a module to a heterogeneous group of health workers enrolled in an MSc/PgDip in Primary Care. The students were expected to act as both information consumers in a directed bibliographic retrieval task and information providers for Primary Care. The students' perceptions as to the usefulness and local relevance of current resources on the world wide web (WWW) are discussed.

Evaluation of a range of hospital replacement mattresses.

A combination of physical measurement and clinical testing was used to evaluate a range of pressure-reducing replacement mattresses, which had met tender specifications, in order to reduce the number available for selection in the purchasing process. Factors considered included mattress price and expected life-span. The results presented have supported a purchasing decision to replace mattresses but care should be taken in adopting these findings in a different context from that of a district general hospital. Optimum performance was found in one mattress replacement (Pentaflex).

They cannot sit properly or move around: seating and mobility during treatment for developmental dysplasia of the hip in children.

Children diagnosed with Developmental Dysplasia of the Hip (0.2% of live births) are often treated by splintage to hold the head of the femur in the acetabulum during early joint development. Whilst clinically effective, this can create difficulties for the parents in handling the child and affects the mobility of the family, which subsequently creates emotional and social difficulty resulting from the disruption of the family routine. To identify these problems and their order of priority, a survey of 113 recently affected families was carried out in England and Northern Ireland. Parents identified mobility, emotional and social problems. Splintage size and shape was the fundamental problem from which the other difficulties arose. Solutions to the basic difficulties of transporting and seating a child in splintage would largely alleviate the feelings of frustration felt by the families and enable more normal activities of daily living.

Towards computer assisted evaluation of plagiocephaly.

Plagiocephaly is a common asymmetry of the skull giving the impression that the subject, usually a neonate, has suffered a compressive force acting unilaterally. Normally innocuous, it is a postural deformity that can be suggestive of other significant abnormalities, e.g. joint dysplasia. Although intuitive measurements of plagiocephaly appear in the literature there is little evidence of analytical evaluation. This paper describes a measurement methodology based on black and white photography. A flat-bed scanner and a personal computer facilitated the transformation of the prepared photograph to standard tagged image file format at 256 grey scale. A utility was used to convert the file scan to a monochrome bitmap image which was displayed on the screen and subjected to an algorithm to compute the centroid of the cranial profile. Radials that emerge from the centroid to the cranial circumference at five degree intervals map to a signal display that represents the plagiocephaly.

High incidence of congenital dislocation of the hip in Northern Ireland.

To determine the incidence of congenital hip dislocation (CDH) a retrospective study was carried out of cases occurring in a defined population using multiple information sources. Of 138,600 children born in the period 1983-1987, a total of 243 were diagnosed with CDH, defined as those requiring splintage or surgery whose treatment extended beyond 6 months of age. Incidence and estimates of relative risks for pre-disposing factors were determined. The rate was 1.75 cases per 1000 livebirths. Major risk factors were female gender and breech presentation. The proportions of cases identified before 1, 3 and 6 months of age were 8, 14 and 35%, respectively. Despite using a restrictive definition, we have obtained an incidence rate among the highest reported in any United Kingdom population. Early detection is widely accepted as desirable, but neonatal screening has proved ineffective.

An evaluation of the adequacy of health visitor education for neonatal hip screening.

Congenital dislocation of the hip (CDH) affects two children per 1000, with potentially serious consequences. Student health visitors in Northern Ireland learn screening techniques for CDH at a half-day workshop at a regional hospital. In order to evaluate the adequacy of this preparation, 71 qualified health visitors were surveyed to assess their knowledge relating to CDH, their views on the adequacy of the training, and their opinions about referral of positive cases. Knowledge in some areas was poor and preparation was considered too short. Direct referrals of positive cases to orthopaedic clinics, without a general practitioner acting as an intermediary, was a frequently cited desire. Recommendations include extending the training for those involved in CDH screening while ensuring that experienced health visitors, from whom novices learn, are themselves using correct procedures.

Reliability of the Barlow and Ortolani tests for neonatal hip instability.

OBJECTIVE: To investigate if those responsible for screening for neonatal hip instability are using acceptable manual hip stress tests as described by Ortolani and Barlow. METHOD: A video camera was used to record the technique of 35 personnel who were responsible for screening. They examined both a baby and a simulator. The study comprised five groups, classified by experience and practice: senior orthopaedic surgeons, senior paediatric staff, junior paediatric staff, nurses, community staff. RESULTS: The seven authors together with six independent expert observers viewed the video and marked the performance with the aid of a specially designed proforma. Although there was some variation between these expert observers, the results showed differences in the scores obtained by the different groups of examiners over all aspects of the test procedure. CONCLUSION: Video recording for critical analysis and feedback is a useful technique in this situation. Overall, the results suggest that testing for neonatal hip instability was inadequate. A variety of hip stress manoeuvres were being performed. The ability of each subject to perform satisfactory tests seemed to depend on their experience and education. More "hands on" training and experience of testing might provide the necessary competency for screening.

Continuous passive motion in computer assisted auscultation of the knee.

A study of physiological patellofemoral crepitus (PPC) signal recorded from adolescent knees has yielded information which suggests that decay time of PPC amplitude due to continuous passive motion (CPM) activity is a consistent and useful signature variable for a given knee. The PPC vibrational signal was induced in each case by 1 min of static load on the patella and postural variables during the examination were carefully controlled. The speed of CPM has been noted as a factor directly influencing the rat of PPC amplitude decay; specifically, a higher CPM speed contributes to an increased decay constant at a cost of increased inter-subject variability. It is proposed that CPM might form an important basis for the ultimate development of a computer-based auscultation technique for diagnosis of patellofemoral joint disorders.

Measurement of the forces and movements involved in neonatal hip testing.

The screening for Developmental Dysplasia of the Hip in infants relies on the two manipulative tests developed by Ortolani and Barlow which are often poorly performed. This study investigated the forces applied and the sequences of physical manoeuvres underlying the tests in order to define a standard of safe practice. Eight subjects examined the hips of two training models that closely simulated the behaviour of a range of infant hip pathologies. The forces applied and the manoeuvres employed during each examination were recorded using a purpose-built force and displacement transducer system. The analysis concentrated on the peak forces and the biomechanical conditions necessary to detect an abnormality. The models' legs had to be abducted beyond certain critical angles in order to dislocate and relocate an unstable femoral head and the magnitude of the force required to dislocate the femoral head was significantly less than the peak force applied (12 N vs 33 N, p < 0.001). Also, the Palmen test, a less well known technique, provided the same level of diagnostic performance as the Barlow test but with a lower peak applied force (28 N vs 47 N, p < 0.001). Changes are therefore necessary to the training programmes for medical staff to ensure that the range of abduction during the manoeuvres is large enough to encompass the likely range of critical angles and that the forces applied are just sufficient so as not to overstress the joints.

Deep venous thrombosis in orthopaedic patients. Improving the specificity of diagnosis.

The diagnosis of deep vein thrombosis after total joint arthroplasty is difficult. The most widely used method of detection is physical examination and selective venography, which are unreliable and expensive even when symptoms and signs are prominent. This study employed computerized strain gauge plethysmography (CSGP) to select symptomatic patients for venography. The incidence of detection by CSGP was increased from 16% to 81.7%. Repeated CSGP also was investigated, but although specificity was further enhanced, it was at the expense of sensitivity. The negative predictive value of the CSGP screening was high and comparable to that of venography and indicates that CSGP is useful in the management of patients with symptoms suggestive of deep vein thrombosis. Computerized strain gauge plethysmography results emphasize the low specificity and poor feasibility of clinical examination and venography. Computerized strain gauge plethysmography is strongly advocated as a selection procedure for invasive venography in total joint arthroplasty patients.

A statistical analysis of hip scores.

Thirteen methods of hip scoring were applied in the postoperative assessment of 47 hip arthroplasties. Their results were found to be inconsistent, often giving contrary measures of success in the same patient. Ten variables were measured during the postoperative review of 256 hip arthroplasties and the data were submitted to multivariate factor analysis. This revealed that the ten variables could be reduced to three factors: pain, which correlated poorly with any other variable (Spearman correlation, r < 0.02); functional activity (distance walked, use of walking aids, stair climbing, use of public transport, limp, sitting and tying shoelaces); and deformity and range of movement. The range of hip flexion correlated closely with the sum of the arcs of movement and with Gade's index (Spearman correlation, r > 0.9). We suggest that, for outcome assessment, only three variables need to be recorded: pain, walking distance and range of hip flexion. The combination of these three measures into a single hip score is misleading.