The role of dietitian clinical judgement in the nutrition care process within the acute care setting: a qualitative study.

BACKGROUND: Dietitian clinical decision making in the acute care setting likely incorporates a practitioner's clinical judgement to effectively support patient care. The term 'dietitian clinical judgement' is well used in clinical practice, yet is poorly defined and often used interchangeably with other concepts. The aim of this research was to describe the nature of dietitians' clinical judgement in the acute care setting. METHODS: A qualitative design within the interpretative paradigm was used guided by principles of philosophical hermeneutics. Dietitians with at least 3 years experience were invited to participate in two 60-min in-depth semi-structured interviews which were recorded, transcribed and interpreted using hermeneutic principles. A reference group was used to increase rigour and further interpretation of the findings. RESULTS: Ten dietitians participated in the interviews and five of these same participants in the reference focus group. The findings revealed clinical judgement to be a sophisticated practitioner dependent meta-reasoning process that helps the dietitian manage complexity, guide interpersonal interactions and individualise patient care. It is characterised by tacit and efficient use of various reasoning strategies reliant on the dietitian's clinical experience, used to synthesise and weigh up various types of information and knowledge with respect to delivering context-relevant care. CONCLUSIONS: Dietitian clinical judgement is a necessary part of clinical decision making that extends beyond logical or critical thinking. It facilitates a person-centredness to patient care and professional relationships that are key dimensions to dietitian clinical decision making. These findings provide training and professional development insights to managers, educators and supervisors.

A model of the multidimensional nature of experienced dietitian clinical decision-making in the acute care setting.

BACKGROUND: Clinical decision-making (CDM) is an essential component of dietetic practice that can significantly affect the quality of patient care. Research around CDM in clinical dietetics is scarce, with research in other healthcare professions offering limited insight into dietitian CDM in the specific setting of the acute care hospitals. The aim of this qualitative research was to deepen our understanding of the nature of the CDM of experienced dietitians in the acute care setting. METHODS: The present study employed philosophical hermeneutics to guide methods situated within the interpretative paradigm. This study invited dietitians currently practising in adult acute care hospitals with at least 3 years of experience to be involved two in-depth semi-structured interviews using the principles of hermeneutics. A reference focus group session was then used to provide rigour and further interpretation of the findings. RESULTS: Ten dietitians participated in the interviews and five of these same participants in the reference focus group. The findings have informed the development of A Model of the Multidimensional Nature of Dietitian CDM in the Acute Care Setting, which reflects the nature of making decisions for patient care through the synergistic relationship between five key dimensions: (i) tasks; (ii) interactions; (iii) reasoning; (iv) practitioner factors; and (v) context, all of which are managed and monitored by the higher- order reasoning process of the dietitian's clinical judgement. CONCLUSIONS: Because there is scarcity of research on the CDM of dietitians in acute care settings, the present study can provide training and professional development insights to managers, educators and supervisors.

Vitrectomy for primary symptomatic vitreous opacities: an evidence-based review.

Floaters are a common ocular condition which form as a consequence of aging changes in the vitreous. Although in most patients the symptoms are minimal, they can cause significant impairment in vision-related quality of life in a small population of patients. Recently there has been an increase in awareness of the visual disability caused by floaters, and the evidence-base for treatment of this condition using small-gauge vitrectomy has increased. In this review, we define the term 'floaters' as symptomatic vitreous opacities (SVO). We suggest a classification dependent on the presence or absence of posterior vitreous detachment and discuss their pathogenesis and natural history. We review their impact on patients' quality of life related to visual function. We review the psychological factors that may have a role in some patients who appear to be affected by SVO to the extent that they pursue all options including surgery with all its attendant risks. We summarise the available evidence-base of treatment options available for SVO with special emphasis on the safety and efficacy of vitrectomy for this condition.

Lymphopenia as a predictor of sarcoidosis in patients with uveitis.

AIMS: To investigate the hypothesis that lymphopenia is an independent predictor of sarcoidosis in new patients presenting with uveitis. PATIENTS AND METHODS: Retrospective case-control study of 112 patients with sarcoidosis-associated uveitis (SAU) against 398 controls with other forms of uveitis. RESULTS: Of the patients with SAU, 30/112 (26.8%) had significant lymphopenia (<1.0×10(9)/L), compared with 24/398 (6.0%) for other uveitis (p≤0.0001, OR 5.7 (95% CI 3.2 to 10.3)). The mean lymphocyte count for patients with SAU was 1.43 vs 2.04 for other uveitis (p≤0.0001). Logistic regression modelling using diagnosis of SAU as the independent variable identified age, ACE levels and lymphocyte count as independent predictors of SAU. A new patient with uveitis with significant lymphopenia has a risk of sarcoidosis (from this parameter alone) of 31.6%. CONCLUSIONS: Significant lymphopenia (<1.0×10(9)/L) is an independent predictor of sarcoidosis in new patients presenting with uveitis. We recommend that diagnostic criteria for SAU should be modified to include this phenomenon.

Microincision cataract surgery combined with vitrectomy: a case series.

AIM: The objective of this study was to present the results of combined phacovitrectomy using 1.8 mm microincision cataract surgery (MICS) with special emphasis on the anterior segment complications in this group. METHODS: Retrospective, single-centre case series involving consecutive patients undergoing phacovitrectomy in a single centre in the United Kingdom during a 6-month period. RESULTS: A total of 52 eyes underwent combined MICS and pars plana vitrectomy. Intraoperative complications included posterior capsule rupture (n=2), minor iris trauma during phacoemulsification (n=1), iatrogenic retinal tears (n=2), and entry site break (n=1). Postoperatively two cases had significant inflammation, one of which resulted in 360° posterior synaechiea, iris bombe, and raised intraocular pressure. Other complications included mild posterior synaechiae (n=2), posterior capsular opacification (n=3), cystoid macular oedema (n=1), and hyphaema (n=1), which spontaneously resolved. There were no cases of intraocular lens decentration. Two patients who underwent surgery for retinal detachment repair subsequently redetached. Among those having surgery for macular hole, non-closure was seen in one patient and one patient developed a retinal detachment. CONCLUSION: In conclusion, sub-2 mm MICS is a safe and effective technique in dealing with vitreoretinal disorders necessitating cataract surgery at the same time.

Association of retinal arteriolar dilatation with lower verbal memory: the Edinburgh Type 2 Diabetes Study.

AIMS/HYPOTHESIS: Retinal vascular calibre changes may reflect early subclinical microvascular disease in diabetes. Because of the considerable homology between retinal and cerebral microcirculation, we examined whether retinal vascular calibre, as a proxy of cerebral microvascular disease, was associated with cognitive function in older people with type 2 diabetes. METHODS: A cross-sectional analysis of 954 people aged 60-75 years with type 2 diabetes from the population-based Edinburgh Type 2 Diabetes Study was performed. Participants underwent standard seven-field binocular digital retinal photography and a battery of seven cognitive function tests. The Mill Hill Vocabulary Scale was used to estimate pre-morbid cognitive ability. Retinal vascular calibre was measured from an image field with the optic disc in the centre using a validated computer-based program. RESULTS: After age and sex adjustment, larger retinal arteriolar and venular calibres were significantly associated with lower scores for the Wechsler Logical Memory test, with standardised regression coefficients -0.119 and -0.084, respectively (p < 0.01), but not with other cognitive tests. There was a significant interaction between sex and retinal vascular calibre for logical memory. In male participants, the association of increased retinal arteriolar calibre with logical memory persisted (p < 0.05) when further adjusted for vocabulary, venular calibre, depression, cardiovascular risk factors and macrovascular disease. In female participants, this association was weaker and not significant. CONCLUSIONS/INTERPRETATION: Retinal arteriolar dilatation was associated with poorer memory, independent of estimated prior cognitive ability in older men with type 2 diabetes. The sex interaction with stronger findings in men requires confirmation. Nevertheless, these data suggest that impaired cerebral arteriolar autoregulation in smooth muscle cells, leading to arteriolar dilatation, may be a possible pathogenic mechanism in verbal declarative memory decrements in people with diabetes.

Pain responses of Pascal 20 ms multi-spot and 100 ms single-spot panretinal photocoagulation: Manchester Pascal Study, MAPASS report 2.

AIMS: To evaluate pain responses following Pascal 20 ms multi-spot and 100 ms single-spot panretinal photocoagulation (PRP). METHODS: Single-centre randomised clinical trial. 40 eyes of 24 patients with treatment-naive proliferative diabetic retinopathy randomised to 20 and 100 ms PRP under topical 0.4% oxybuprocaine. A masked grader used a pain questionnaire within 1 h (numerical pain score (NPS)) and 1 month after treatment (numerical headache score (NHS)). Primary outcome measure was NPS immediately post-PRP. Secondary outcome measures were mean NHS scores and levels of photophobia reported within 4 weeks of primary PRP. RESULTS: Mean laser fluence was significantly lower using 20 ms PRP (4.8 J/cm²) compared to 100 ms PRP (11.8 J/cm²); p < 0.001). Mean NPS scores for treatment were 2.4 (2.3) (mild) for 20 ms PRP group compared to 4.9 (3.3) (moderate) in 100 ms PRP group-a significant difference (95% CI 4.3 to 0.68; p = 0.006). Mean NHS score within 1 month was 1.5 (2.7) in 20 ms PRP group compared to 3.2 (3.5) in the 100 ms PRP group (p < 0.05). The median duration of photophobia after 20 ms PRP was 3 h, and significantly less compared to 100 ms PRP after which 72 h of photophobia was reported (p < 0.001). CONCLUSIONS: Multi-spot 20 ms PRP was associated with significantly lower levels of anxiety, headache, pain and photophobia compared to 100 ms single-spot PRP treatment. Possible reasons include lower fluence, shorter-pulse duration, and spatial summation of laser nociception with multi-spot Pascal technique.

Fractal analysis of retinal vessels suggests that a distinct vasculopathy causes lacunar stroke.

OBJECTIVES: Lacunar strokes account for 25% of all ischemic strokes and may represent the cerebral manifestation of a systemic small vessel vasculopathy of unknown etiology. Altered retinal vessel fractal dimensions may act as a surrogate marker for diseased cerebral vessels. We used a cross-sectional study to investigate fractal properties of retinal vessels in lacunar stroke. METHODS: We recruited patients presenting with lacunar stroke and patients with minor cortical stroke as controls. All patients were examined by a stroke expert and had MRI at presentation. Digital retinal photographs were taken of both eyes. Monofractal and multifractal analyses were performed with custom-written semiautomated software. RESULTS: We recruited 183 patients. Seventeen were excluded owing to poor photographic quality, leaving 166 patients (86 with lacunar and 80 with cortical stroke). The mean age was 67.3 years (SD 11.5 years). The patients with lacunar stroke were younger but the prevalence of diabetes, hypertension, and white matter hyperintensities did not differ between the groups. The mean Dbox (monofractal dimension) was 1.42 (SD 0.02), the mean D0 (multifractal dimension) 1.67 (SD 0.03). With multivariate analysis, decreased Dbox and D0 (both representing decreased branching complexity) were associated with increasing age and lacunar stroke subtype after correcting for hypertension, diabetes, stroke severity, and white matter hyperintensity scores. CONCLUSIONS: Lacunar stroke subtype and increasing age are associated with decreased fractal dimensions, suggesting a loss of branching complexity. Further studies should concentrate on longitudinal associations with other manifestations of cerebral small vessel disease.

Observational study of iron overload as assessed by magnetic resonance imaging in an adult population of transfusion-dependent patients with beta thalassaemia: significant association between low cardiac T2* < 10 ms and cardiac events.

BACKGROUND: Thalassaemia major patients usually die from cardiac haemosiderosis. Improved strategies are required to modify this risk. AIMS: To assess the significance of cardiac iron overload in patients with beta thalassaemia. METHOD: Observational study of cardiac iron overload as assessed by magnetic resonance imaging (MRI) cardiac T2* relaxometry in 30 adult patients with transfusion-dependent beta thalassaemia. RESULTS: 11/30 patients (37%) had cardiac T2* < 10 ms, 8/30 (27%) in range 10-20 ms and 11/30 (37%) > 20 ms. There was significant inverse correlation between T2* values and values for serum ferritin (SF) and liver iron concentration (LIC) and positive correlation with left ventricular ejection fraction (LVEF). Median LVEF values were 49% in patients with T2* < 10 ms and 58% in patients with T2* > 10 ms (P = 0.02). Very low T2* values <10 ms were strongly associated with the occurrence of cardiac events (congestive heart failure, arrhythmia, cardiac death): occurring in 5/11 patients with T2* < l0 ms and in 0/19 in patients with T2* > 10 ms (P = 0.003 Fisher's exact test; P = 0.002 log rank Kaplan-Meier time to event analysis). There was no significant association between T2* < 10 ms or cardiac events and traditional measures of iron overload, such as SF levels >2500 mg/L and LIC (evaluated at thresholds of >7 or >15 mg/g dry weight). CONCLUSION: Very low cardiac T2* values <10 ms are common in adults with beta thalassaemia and are significantly associated with risk of cardiac events. This permits the use of individually targeted chelation strategies which are more effective in removing cardiac iron.

Retinal microvascular abnormalities and cognitive dysfunction: a systematic review.

OBJECTIVE: To examine the evidence for an association between cognitive impairment or dementia and the presence of retinal microvascular abnormalities. METHODS: A systematic review of observational studies identified through searching five electronic databases and reference lists. Studies were required to have both a recognised cognitive function assessment (either a structured neuropsychological test or a clinical evaluation of dementia), and assessment of the retinal microvasculature (either characteristics associated with generalised retinopathy or changes specific to arterioles or venules). RESULTS: 6 studies were included. Studies were clinically and methodologically heterogeneous and of variable quality. Some degree of cognitive impairment was found to be associated with the presence of retinal microvascular abnormalities in all studies, although the extent of the association varied. The presence of retinal vascular signs was mostly associated with poorer verbal memory, mental speed and executive function in the general population, but not consistently associated with other cognitive modalities. CONCLUSIONS: There is some evidence suggesting a positive association between retinal microvascular abnormalities and cognitive impairment or dementia in elderly people and in patients with diabetes. Findings are inconclusive, and further better designed studies are required, with standardised and objective retinal vascular assessment and a range of sensitive cognitive tests.

Fractal analysis of the retinal vascular network in fundus images.

Complexity of the retinal vascular network is quantified through the measurement of fractal dimension. A computerized approach enhances and segments the retinal vasculature in digital fundus images with an accuracy of 94% in comparison to the gold standard of manual tracing. Fractal analysis was performed on skeletonized versions of the network in 40 images from a study of stroke. Mean fractal dimension was found to be 1.398 (with standard deviation 0.024) from 20 images of the hypertensives sub-group and 1.408 (with standard deviation 0.025) from 18 images of the non-hypertensives subgroup. No evidence of a significant difference in the results was found for this sample size. However, statistical analysis showed that to detect a significant difference at the level seen in the data would require a larger sample size of 88 per group.

The role of high-dose therapy and stem cell rescue in the management of T-cell malignant lymphomas: a BSBMT and ABMTRR study.

Peripheral T-cell lymphomas (PTCL) are a rare and heterogeneous subset of lymphomas with a poorer prognosis compared with B-cell lymphomas. We conducted a retrospective study of 82 patients who received high-dose therapy for PTCL (autologous SCT (ASCT) N=64; allogeneic SCT (Allo-SCT) N=18). With a median follow-up from ASCT of 37 months from transplant, 33 patients were alive; 20 died of progressive disease, 10 died from non-relapse mortality (NRM) with 1 unknown cause. Three-year overall survival (OS) and progression-free survival (PFS) were 53% (95% confidence interval (CI) 42, 67) and 50% (95% CI 39, 64), respectively. Factors significantly affecting OS and PFS on univariate analysis were histological subtype and chemotherapy sensitivity. In a multivariate analysis, the only factor with significant impact was chemotherapy sensitivity. After a median follow-up from Allo-SCT of 57 months, five patients were alive; five died of progressive disease and eight died from NRM. The 3-year OS and PFS were 39% (95% CI 22, 69) and 33% (95% CI 17, 64), respectively, and the 3-year relapse rate was 28% (95% CI 6, 50). These results demonstrate that high-dose chemotherapy with autologous stem cell rescue has a substantial role in the management of T-cell lymphoma. The use of full-intensity allogeneic transplantation is limited by high transplant-related mortality, and exploration of reduced intensity regimens is warranted.

Statistical strategies to assess reliability in ophthalmology.

Reliability of measurements and measurers is important so that we can trust the measurements we record. However, the statistical techniques used to assess reliability of measurements or measurers in the ophthalmic literature are often inappropriate, and not able to evaluate reliability between measurements/measurers. We review the techniques used in reliability studies for both continuous and categorical data, and describe appropriate statistical methods for particular study designs. We also highlight current techniques that are not appropriate in the analysis of reliability, but that are still commonly used in the ophthalmic literature. We hope that by highlighting these, we shall discourage their future use.

A reliability study of fractal analysis of the skeletonised vascular network using the "box-counting" technique.

Binary vascular networks of the human retina were obtained by computerized processing of digital fundus images. Fractal analysis was performed on skeletonised versions. The effect of three parameters in the vascular segmentation and skeletonization algorithm was quantified, with threshold level found to have the greatest influence. The results were compared to fractal analysis of skeletons derived by manual tracing. The mean difference in fractal dimension between 2 observers is 0.004 (0.3%) and the coefficient of repeatability is +/- 0.050 (3.4%). Between a single observer and the computerized approach the mean difference is 0.012 (0.8%) and the coefficient is +/- 0.038 (2.6%). The computerized approach demonstrated a superior reliability compared to manual segmentation.