Embedding collective leadership to foster collaborative inter-professional working in the care of older people (ECLECTIC): Study protocol.

Background: The National Integrated Care Programme for Older People (NICPOP), formerly NCPOP aims to support older people to live well in their homes by developing primary and secondary care services for older people, especially those with complex needs. The programme develops integrated intermediate care which traverses both hospital and community settings through multidisciplinary and interagency teams. This team-based approach to the integration of health services is a novel innovation in Irish health service delivery and will require, over time, a shift in cultures of care to allow for the development of competencies for inter-professional collaboration across the care continuum. The ECLECTIC project will develop an implementation framework for achieving, maintaining and monitoring competencies for interprofessional collaboration among multi-disciplinary teams charged with delivering care for older people across the continuum from acute to community settings. Design: The ECLECTIC research design has been developed in collaboration with the NICPOP. In phase one of the project, a co-design team will collaborate to define and shape competencies for interprofessional collaboration. Phase two will involve the delivery of a collective leadership intervention over a 10-month period with multidisciplinary professionals working with older people across two geographical regions (Mullingar/Midlands and Beaumont/Dublin North). Each group will comprise of members of two multidisciplinary teams charged with coordinating and delivering care to older people across the continuum of acute to community care. Observations of collaborative inter-professional working will take place before, during, and after intervention. In phase three of the study, analysis of the interview and observation data will be presented to the co-design team in order to develop an implementation framework for future teams. Discussion: The co-design process will develop core competencies and performance indicators for collaborative interprofessional working. The resulting implementation framework will be implemented nationally as part of the NICPOP.

Adaptation of adults to uncorrected hypospadias.

OBJECTIVES: Surgery has been advocated for children with hypospadias to improve the appearance of the penis, allow voiding in the standing position, and improve the chance of fertility. We undertook a survey of adults with hypospadias to determine their adaptation to this congenital anomaly without surgical correction. METHODS: In a 2-year prospective study, six urologists in the general practice of urology identified 56 adult patients from their practices with hypospadias. The urethral meatus was glanular in 21 patients, subcoronal in 23, distal penile in 7, mid-penile in 4, and proximal penile in 1. Nine patients had undergone failed or incomplete hypospadias repairs as children. Seven patients had mild to moderate chordee. RESULTS: Only 1 patient presented with a complaint referable to the hypospadias, and only 3 (5%) of the 56 patients expressed dissatisfaction with the appearance of their penis. Of the 56 patients, 18 (32%) stated that they were unaware that they had a congenital anomaly. The 2 patients who were known to be infertile were believed to be infertile on the basis of oligospermia. Although 20 (36%) of the 56 patients described angulation or spraying of the urinary stream, only 3 (5%) stated that they preferentially sat to void. No patient pursued an interest in corrective surgery. CONCLUSIONS: Of the adults we surveyed with hypospadias, most stated that they were satisfied with the appearance of the penis, voided in the standing position, and did not have infertility associated with the abnormal position of the urethral meatus.

In-depth analysis of molecular alterations within normal and tumour tissue from an entire bronchial tree.

Using laser capture microdissection (LCM), fluorescent microsatellite analysis and immunohistochemical analysis, we have constructed a detailed topographical molecular map of the entire bronchial tree surrounding a primary bronchial squamous carcinoma in order to establish the relationship between the molecular damage within the airway and that in the tumour itself. Allelic imbalance was analysed using markers on chromosomes 3, 9, 13 and 17. In addition, immunohistochemical analysis for p53 and cyclin D1 expression was performed. Analysis revealed allelic imbalance at several loci at the tumour site but also in 83% of the histologically normal airway specimens of the upper and lower lobes. The fractional allele loss (FAL) value was statistically higher (0.75+/-0.13) in the tumour site than in the distal site of the upper (0.42+/-0.09) and lower lobes (0.31+/-0.08). Immunohistochemical analysis revealed overexpression of p53 and cyclin D1 protein within histologically normal bronchial epithelium, thus confirming previous reports for their early involvement in lung tumour development. This is to date the largest in-depth study of allelic imbalance using LCM in a single individual. The patterns of allele-specific imbalance observed support a clonal or oligoclonal expansion model of outgrowths throughout the lung. The widespread incidence of genetic changes in the whole of lung most likely represents smoking-induced alterations and emphasize the complexity of the field cancerization concept. Our findings point to the need for in-depth studies of the whole bronchial tree tissue surrounding lung carcinomas, in order to identify the genetic changes that differentiate preneoplastic and neoplastic stages in lung carcinogenesis.

A T2517C polymorphism in the GSTM4 gene is associated with risk of developing lung cancer.

The human Mu class Glutathione S-Transferases is a family of genes encoding phase II detoxifying enzymes thus playing a significant role in the detoxification of potential carcinogens. While there are many contradicting reports on the association of GSTM1 polymorphisms and cancer development, no studies exist to date describing polymorphisms in GSTM4. We have identified a new C-T polymorphism in intron 6 of the GSTM4 gene (T2517C, Genebank sequence accession number X68677) and termed the allele carrying T at this position allele *A and the allele carrying C, allele *B. Screening a population sample in Merseyside, England, revealed 23 carriers of the *B allele out of 156 healthy control individuals but only 12 carriers of the *B allele out of 163 individuals with lung cancer (O.R.=2.23, Fisher's test P=0.026). The polymorphism did not demonstrate any associations with tumour type, gender, and age at presentation. This is the first report on the implication of a polymorphism in the GSTM4 gene in lung cancer risk. Further studies are required to investigate the relation of this polymorphism to cancer risk to substantiate these findings.