The patient's experience of defaecating proctography: Comparing magnetic resonance with conventional fluoroscopy techniques.

INTRODUCTION: Fluoroscopy and MRI are currently used to investigate defaecation and pelvic floor dysfunction, with advantages and disadvantages to both modalities. Anecdotally it is suspected that MRI, allowing more privacy, may be better tolerated by patients but that symptoms may be more easily replicated with fluoroscopic technique due to the physiological position. The aim of this study was to evaluate the patient experience of both techniques to potentially help guide the choice of defaecating proctography modality in the future. METHODS: This prospective study was conducted June 2015-March 2017 in a large teaching hospital. Patients undergoing fluoroscopy (FDP) or MR defaecating proctography (MRDP) completed a post-procedure questionnaire rating their satisfaction (1-5, 5 being most satisfied) of different aspects of the test. RESULTS: 24 patients underwent FDP and 17 MRDP. Both procedures were scored highly in general for all questions with mean >4.1 and median 5, out of 5. Though not statistically significant, the mean scores for all aspects of the test were slightly higher for fluoroscopy than MR. As well as scoring higher for comfort (4.8 vs 4.4) and dignity maintained (4.6 vs 4.1), the patients who underwent fluoroscopy thought it was easier to replicate symptoms than the patient who underwent MR defaecating proctography (4.6 vs 4.2). CONCLUSION: This study shows that both FDP and MRDP are well tolerated in the investigation of defaecation and pelvic floor dysfunction. FDP was scored consistently higher than MRDP, but this was not statistically significant. Thus, this study suggests that patient tolerance of the test is unlikely to be any worse for FDP than for MRDP. Clinicians and radiologists should take into account risks of radiation exposure as well as potential for surgical management when making their decision as to which test is appropriate. The authors recommend that if the patient is unable to replicate their symptoms in MRDP, fluoroscopy should be performed to ensure significant pathology is not being missed.

Can acoustic radiation force imaging of the liver and spleen predict the presence of gastroesophageal varices?

AIM: To determine whether acoustic radiation force imaging (ARFI) of the liver/spleen could be used in patients with cirrhosis to predict the presence of gastroesophageal varices (GOVs). MATERIALS AND METHODS: Fifty-eight patients with cirrhosis who were undergoing 6-monthly ultrasound examinations for hepatoma surveillance and who were due to have oesophagogastroduodenoscopy (OGD) within 6 months of their ultrasound were recruited. During routine ultrasound, the patient's liver and spleen were also assessed using ARFI. Other clinical parameters (platelet count, spleen size, and transient elastography measurements) were also collected. Logistic regression was used to determine which variables were significantly associated with presence or absence of varices univariably and multivariably RESULTS: Fourteen patients (24%) had GOVs. Patients with GOVs had higher ARFI measurements in the liver and spleen than patients without GOVs (liver: 2.39 versus 2.13, spleen: 2.89 versus 2.82), but these results were not statistically significant (odds ratio=1.75, 95% confidence interval [CI]=0.82, 3.91 and odds ratio=1.12, 95% CI=0.33, 3.97, respectively). The platelet/splenic ratio, in comparison, was associated with the presence or absence of GOVs in multivariate analysis (odds ratio=0.32, 95% CI=0.008, 0.91). CONCLUSION: Although patients with GOVs had overall higher ARFI liver and spleen results, this was not statistically significant. As such, ARFI cannot yet replace OGD in predicting GOVs in this patient group.

A randomized controlled feasibility trial exploring partnered ballroom dancing for people with Parkinson's disease.

OBJECTIVE: To determine the feasibility of a Dance Centre delivering a programme of mixed dances to people with Parkinson's and identify suitable outcomes for a future definitive trial. DESIGN: A two-group randomized controlled feasibility trial. METHODS: People with Parkinson's were randomized to a control or experimental group (ratio 15:35), alongside usual care. In addition, participants in the experimental group danced with a partner for one hour, twice-a-week for 10 weeks; professional dance teachers led the classes and field-notes were kept. Control-group participants were given dance class vouchers at the end of the study. Blinded assessments of balance, mobility and function were completed in the home. Qualitative interviews were conducted with a subsample to explore the acceptability of dance. RESULTS: A total of 51 people with Parkinson's (25 male) with Hoehn and Yahr scores of 1-3 and mean age of 71 years (range 49-85 years), were recruited to the study. Dance partners were of similar age (mean 68, range 56-91 years). Feasibility findings focused on recruitment (target achieved); retention (five people dropped out of dancing); outcome measures (three measures were considered feasible, changes were recommended). Proposed sample size for a Phase III trial, based on the 6-minute walk test at six months was 220. Participants described dance as extremely enjoyable and the instructors were skilled in instilling confidence and motivation. The main organizational challenges for a future trial were transport and identifying suitable dance partners. CONCLUSION: We have demonstrated the feasibility of conducting the study through a Dance Centre and recommend a Phase III trial.

Are English CT departments and radiographers prepared for the morbidly obese patient?

INTRODUCTION: Morbid obesity is increasing in England, as is the use of CT scanning. All CT scanners have weight and body width limits. It is imperative that the radiographer performing the scan is aware of these limits, particularly in an emergency. This study aim was to determine whether radiographers are aware of their scanner limits, where they may be able to send a patient who exceeds these limits and whether a formal protocol exists. The secondary aim of the study was to determine capacities of scanners in acute trusts throughout England. METHODS: CT radiographers from 86 English Hospital Trusts with Emergency Departments were contacted and asked questions regarding their CT scanners and their practice of CT scanning morbidly obese patients. RESULTS: 21% of CT radiographers did not know the maximum width capacity of their scanner. Only 24% knew where a nearby larger capacity scanner was located and only 3% had a formal protocol for scanning obese patients. Weight capacities ranged from 147 to 305 kg. Width capacities ranged from 55 to 100 cm. 70% had weight capacity 226 kg or less and 70% had size capacity of 78 cm or less. CONCLUSION: Patients over 226 kg or 78 cm may not be accommodated in most (70%) trusts in England. Lack of knowledge of scanner capacities and alternative scanners for morbidly obese patients could have consequences for these patients, particularly in an emergency. The authors advise that all acute trusts have a protocol regarding CT scanning morbidly obese to prevent delays in accessing imaging.

The prevalence of dental caries in Missouri and its relation to systemic disease: opportunities for Missouri to improve the health of its citizens.

Recently, it has been recognized that poor oral health conditions, especially periodontitis, have been a contributing factor to several systemic diseases. Evidence shows that Missouri should be concerned about the current state of caries and its prevention. The prevalence of caries and lack of preventative care in Missouri warrants an examination of the current efforts in place to reduce caries and the creation of novel approaches that bridge the gap between oral and medical care. This paper discusses this problem in depth.

Resuming previously valued activities post-stroke: who or what helps?

PURPOSE: In this article, we aim to develop the understanding of what helps or hinders resumption of valued activities up to 12-months post-stroke. METHOD: As part of a longitudinal study, semi-structured interviews were conducted with 19 people with stroke and eight informal carers 12-months post-stroke. Interviews covered ongoing effects of stroke, experience of trying to resume activities highlighted as important pre-stroke and factors that influenced progress. Interviews were transcribed, coded and analysed in depth to explore this aspect of the experience of living with stroke. RESULTS: Valued activities discussed related to employment; domestic and social roles including driving; hobbies, sports and socialising. Outcomes for individuals were influenced by: aspects of physical or cognitive disability; environmental factors; the adaptability of the individual; support from others and professional help. Inability to resume activities impacted on people's sense of self and quality of life, but some tolerated change and presented themselves as adaptable. CONCLUSIONS: This study indicates a long-term role for rehabilitation services such as: identifying the significance of different types of activities; providing access to support and treatment for debilitating symptoms such as fatigue and dizziness; addressing patients' emotional and behavioural responses to their condition; working with patients' wider social networks and where appropriate, supporting adaptation to a changed way of life.

Going home to get on with life: patients and carers experiences of being discharged from hospital following a stroke.

PURPOSE: In this paper we aim to develop the understanding of what constitutes a 'good' or 'poor' experience in relation to the transition from hospital to home following a stroke. METHOD: Semi-structured interviews were carried out with 20 people and 13 carers within one month of being discharged from hospital following a stroke. Interviews covered views of mobility recovery and support from therapy and services. Interviews were transcribed verbatim, coded and analysed in depth in order to explore the discharge process. RESULTS: Participants described models of recovery, which involved a sense of momentum and getting on with their life. Discharge was successful if: (i) This sense of momentum was maintained, (ii) they felt supported, and (iii) they felt informed about what was happening. Discharge was seen as difficult when: (a) Momentum was perceived to be lost, (b) people did not feel supported, or (c) they felt in the dark about the plans or their recovery. CONCLUSIONS: The discharge experience could be improved by healthcare professionals understanding and exploring patients' individual models of recovery. This would allow professionals to: (a) Access patients concerns, (b) develop programmes addressing these, (c) correct misinterpretations, (d) keep people fully informed, and (e) share and validate the experience, to reduce their sense of isolation.

General practice critical incident reviews of patient suicides: benefits, barriers, costs, and family participation.

AIM: To explore the feasibility of holding critical incident reviews (CIRs) after patient suicides in general practice and their ability to change practice. METHODS: Thirteen practices were invited to conduct a facilitated CIR on 18 current patient suicides. Next of kin views were sought. All staff attending a CIR were interviewed after the review. RESULTS: Ten practices reviewed 12 deaths. Twenty six staff attended reviews; all were interviewed. Next of kin contributed to six reviews; only one criticised care. Changes following the reviews included steps to improve internal communication and bereavement support to set up internal CIRs and review prescribing policies. Communications between practices and other agencies were clarified. CONCLUSION: Practices were willing to hold CIRs and appreciated the potential positive value but need reassurance that they will not be blamed for suicides, and that the cost in time and resources will be recognised.

Patients' expectations of recovery following stroke: a qualitative study.

PURPOSE: Patients and carers frequently express disappointment with the extent of recovery achieved at the point of discharge from physiotherapy. Research has suggested that high expectations of recovery may be encouraged by physiotherapists. This study examined the information exchanged between physiotherapists and patients in relation to recovery following stroke in order to explore this issue. METHODS: The study comprised in-depth longitudinal case studies of 16 patients with a first incident stroke. Qualitative interviews were conducted with patients and their physiotherapists to explore their understandings and expectations of recovery and of physiotherapy at three time points. Patients were assessed for deficits of movement, function and mood at the same three stages and observations of out-patient sessions were also conducted. Qualitative data were analysed using thematic analysis. The assessment data were analysed using descriptive and comparative statistics. RESULTS: Data indicated deficits of movement improved significantly between the first and third assessments. The qualitative data showed that physiotherapists did not encourage over-optimistic expectations of recovery through the verbal information they provided to patients. Nevertheless patients did maintain high expectations of recovery throughout the three-month post-stroke period. CONCLUSION: Improved communication strategies, informed by an evidence base of recovery, should be used to encourage realistic expectations of physiotherapy without destroying the process of active participation and skill acquisition.

Patients' understandings of heart attack: implications for prevention of recurrence.

Patients' willingness to undertake secondary preventive strategies following heart attack are likely to be affected by their understandings of their condition. This qualitative study explored patients' understandings of heart attack in order to contribute to the design of effective secondary prevention services. In-depth interviews were conducted with 25 patients with myocardial infarction (MI). These data indicate that information received from health professionals encourages patients to view heart attack as an acute event rather than a symptom of a chronic condition and that this understanding provides patients with low motivation for long-term lifestyle change. Patients may benefit from understanding a heart attack as an acute symptom of an underlying disease process which long-term medication and behavioural change can help to check. In order to achieve this, health professionals need to examine patients' understandings of their heart attack and recovery and to provide information about lifestyle which engages with these understandings.

Nurse-led intermediate care: an opportunity to develop enhanced roles for nurses?

BACKGROUND: Nurse-led intermediate care units are being set up across the UK primarily as potential solutions to hospital bed crises. AIMS: This paper draws on data collected as part of a comprehensive evaluation of one 10-bedded nurse-led unit (NLU) located in the South of England. It explores the potential for enhanced nursing roles provided by such units by focusing on the views of NLU nursing staff and other professional groups within the Hospital Trust where the unit is located. METHODS: A total of 38 in-depth audio-taped qualitative interviews were conducted with NLU nursing staff and with a range of other professional groups (managers, acute ward nurses and doctors). FINDINGS: These data indicated that models of nurse-led postacute care do provide opportunities for nurses to develop enhanced nursing roles in which care associated with concepts of therapeutic nursing can be provided. However, even though the nurses derived satisfaction from their work on the NLU this model of care was seen by junior and middle grade nurses and other professional groups as being of low status. In contrast to senior nurses' views, they did not equate work on the NLU with the continuing professionalization of nursing. Senior nurses viewed the route to developing nursing on the NLU as involving nurses as doctor substitutes (extended roles) rather than as working in separate but complementary therapeutic domains (enhanced roles). CONCLUSIONS: NLUs provide opportunities for nurses to develop enhanced roles in which they can work autonomously in providing elements of therapeutic nursing aimed at improving patient outcomes at discharge. However, education, training and leadership will be needed to ensure that such opportunities are well understood and are optimized to the benefit of nurses and their patients.

Randomised controlled trial of self management leaflets and booklets for minor illness provided by post.

OBJECTIVE: To assess the effectiveness of providing information by post about managing minor illnesses. DESIGN: Randomised controlled trial. SETTING: Six general practices. PARTICIPANTS: Random sample of 4002 patients from the practice registers. INTERVENTION: Patients were randomised to receive one of three kinds of leaflet or booklet endorsed by their general practitioner: control (surgery access times), booklet, or summary card. MAIN OUTCOME MEASURES: Attendance with the 42 minor illnesses listed in the booklet. Perceived usefulness of leaflets or booklets, confidence in managing illness, and willingness to wait before seeing the doctor. RESULTS: 238 (6%) patients did not receive the intervention as allocated. Of the remaining 3764 patients, 2965 (79%) had notes available for review after one year. Compared with the control group, fewer patients attended commonly with the minor illnesses in the booklet group (>/=2 consultations a year: odds ratio 0.81, 95% confidence interval 0.67 to 0.99) and the summary card group (0.83; 0.72 to 0.96). Among patients who had attended with respiratory tract infections in the past year there was a reduction in those attending in the booklet group (0.81; 0.62 to 1.07) and summary card group (0.67; 0.51 to 0.89) compared with the control group. The incidence of contacts with minor illness fell slightly compared with the previous year in the booklet (incidence ratio 0.97; 0.84 to 1.13) and summary card groups (0.93; 0.80 to 1.07). More patients in the intervention groups felt greater confidence in managing illness (booklet 32%, card 34%, control 12%, P<0.001), but there was no difference in willingness to wait score (all groups mean=32, P=0.67). CONCLUSION: Most patients find information about minor illness provided by post useful, and it helps their confidence in managing illness. Information may reduce the number attending commonly with minor illness, but the effect on overall contacts is likely to be modest. These data suggest that posting detailed information booklets about minor illness to the general population would have a limited effect.

Therapeutic nursing or unblocking beds? A randomised controlled trial of a post-acute intermediate care unit.

OBJECTIVES: To compare post-acute intermediate care in an inpatient nurse-led unit with conventional post-acute care on general medical wards of an acute hospital and to examine the model of care in a nurse-led unit. DESIGN: Randomised controlled trial with six month follow up. SETTING: Urban teaching hospital and surrounding area, including nine community hospitals. PARTICIPANTS: 238 patients accepted for admission to nurse-led unit. INTERVENTIONS: Care in nurse-led unit or usual post-acute care. MAIN OUTCOME MEASURES: Patients' length of stay, functional status, subsequent move to more dependent living arrangement. RESULTS: Inpatient length of stay was significantly longer in the nurse-led unit than in general medical wards (14.3 days longer (95% confidence interval 7.8 to 20.7)), but this difference became non-significant when transfers to community hospitals were included in the measure of initial length of stay (4.5 days longer (-3.6 to 12.5)). No differences were observed in mortality, functional status, or living arrangements at any time. Patients in the nurse-led unit received significantly fewer minor medical investigations and, after controlling for length of stay, significantly fewer major reviews, tests, or drug changes. CONCLUSIONS: The nurse-led unit seemed to be a safe alternative to conventional management, but a full accounting of such units' place in the local continuum of care and the costs associated with acute hospitals managing post-acute patients is needed if nurse-led units are to become an effective part of the government's recent commitment to intermediate care.

Patients' and practice nurses' perceptions of secondary preventive care for established ischaemic heart disease: a qualitative study.

A significant proportion of patients with established ischaemic heart disease remain unrecognized in general practice and those who are receiving treatment are experiencing sub-optimal care. The provision of coronary prevention by practice nurses may be an important strategy to improve the quality of this care, and this is feasible and effective. This study explored what occurred during patients' initial assessment for secondary prevention of ischaemic heart disease with a practice nurse and investigated patients' and practice nurses' views ofnurse-led clinics in primary care. Nurses were effective in history taking and offering reassurance and dietary advice, yet were less confident in discussing patients' understandings of heart disease and related medication. Practice nurse-led coronary preventive care is acceptable to both nurses and patients. Further practice nurse education is required in heart disease, cardiac medications and skills necessary for exploring and challenging patients' understandings of these issues.