The role of scientific evidence in decisions to adopt complex innovations in cancer care settings: a multiple case study in Nova Scotia, Canada.

BACKGROUND: Health care delivery and outcomes can be improved by using innovations (i.e., new ideas, technologies, and practices) supported by scientific evidence. However, scientific evidence may not be the foremost factor in adoption decisions and is rarely sufficient. The objective of this study was to examine the role of scientific evidence in decisions to adopt complex innovations in cancer care. METHODS: Using an explanatory, multiple case study design, we examined the adoption of complex innovations in five purposively sampled cases in Nova Scotia, Canada. Data were collected via documents and key informant interviews. Data analysis involved an in-depth analysis of each case, followed by a cross-case analysis to develop theoretically informed, generalizable knowledge on the role of scientific evidence in innovation adoption that may be applied to similar settings and contexts. RESULTS: The analyses identified key concepts alongside important caveats and considerations. Key concepts were (1) scientific evidence underpinned the adoption process, (2) evidence from multiple sources informed decision-making, (3) decision-makers considered three key issues when making decisions, and (4) champions were essential to eventual adoption. Caveats and considerations related to the presence of urgent problems and short-term financial pressures and minimizing risk. CONCLUSIONS: The findings revealed the different types of issues decision-makers consider while making these decisions and why different sources of evidence are needed in these processes. Future research should examine how different types of evidence are legitimized and why some types are prioritized over others.

Evaluating cardioversion outcomes for atrial fibrillation on novel oral anticoagulants versus warfarin: experience at a tertiary referral centre.

BACKGROUND: Current guidelines recommend anticoagulation prior to cardioversion in patients with atrial fibrillation of >48 h or unknown duration to reduce thromboembolic risk. Therapeutic anticoagulation with warfarin, with INR between 2 and 3, is consistently achieved in approximately 60% of patients. AIMS: We evaluated outcomes and assessed differences in direct current cardioversion (DCCV) in patients treated with warfarin and novel oral anticoagulants (NOAC) at our institution. METHODS: A retrospective analysis of consecutive DCCV at a tertiary referral over 18 months was conducted. Analysis of cardioversion records allowed completion of a standardised dataset. Clinical variables recorded included (1) CHADSVASC score, (2) anticoagulant use, and (3) bleeding complications. RESULTS: During this period 187 DCCVs were scheduled; 119 on warfarin and 68 on NOAC. DCCV was deferred in 26% (n = 31) of the warfarin group and 4.4% (n = 3) of the NOAC group (p = 0.0002). The average time interval between referral and DCCV was 144.43 and 109.32 days for the warfarin and NOAC groups, respectively (p value = 0.023). 7.56% (n = 9) of the warfarin population had a bleeding event compared to a 2.94% total bleeding rate in NOAC group (p = 0.213). Deferral of elective DCCV and additional anticoagulant monitoring was estimated at €1160 per procedure. CONCLUSION: In elective cardioversions, the group anticoagulated with NOAC was less likely to have subtherapeutic anticoagulation and hence deferred procedures and had reduced health care consumption when compared to the group anticoagulated with warfarin.

The wealth, health and wellbeing of Ireland's older people before and during the economic crisis.

The economic crisis of 2008/9 was felt more acutely in Ireland relative to elsewhere and culminated in the international bailout in 2010. Given the economic collapse, Ireland provides an ideal case-study of the link between wealth collapses and movements in variables such as health and well-being. Using nationally-representative samples of older people collected before and during the crisis, we show that mean net assets fell by 45 percent between 2006/7 and 2012/13. In spite of this massive fall in wealth, measures of health and well-being remained broadly unchanged. However, expectations about future living standards became less optimistic. The results tend to support the findings of other recent studies that recessions do not have widespread negative effects on health and well-being.

Hunter-Schreger Band patterns and their implications for clinical dentistry.

Hunter-Schreger Bands (HSBs) are an optical phenomenon visualised when a cut or fractured enamel surface is viewed under reflected light. These bands demonstrate the synchronous decussation of individual or groups of enamel prisms. While the role of HSB patterns has been investigated in comparative anatomical studies, until recently there has been little consideration of HSB patterns in human teeth. The aim of this paper is to consider the significance of HSB patterns in the human dentition and in relation to clinical dentistry. It is concluded that within the human dentition, HSB patterns have evolved to optimise resistance to attrition, abrasion and tooth fracture. It appears that certain aspects of HSB packing densities and distributions have beneficial roles in enamel bonding. Hunter-Schreger Band patterns seem to passively facilitate conditions such as abfraction and cracked tooth syndrome.

Gabriel-Philippe de la Hire and the discovery of Hunter-Schreger bands.

Hunter-Schreger bands are an optical phenomenon observed in mammalian tooth enamel. Familiar to all current and former students of dental histology, this optical phenomenon appears as alternating patterns of dark and light bands when cut enamel is viewed under reflected light. The discovery of this important feature of mammalian enamel has been historically credited to two eighteenth-century investigators, Hunter and Schreger. A re-evaluation of the evidence would suggest that the bands were observed almost seventy years earlier by a French scientist, Gabriel-Philippe de la Hire, and subsequently confirmed by the famous French dentist Pierre Fauchard. This article reviews the contribution of de la Hire, as well as that of Fauchard, Hunter and Schreger, to the early recognition among the scientific community of what would now be referred to as 'enamel microstructure'.

Oh stuff it! The experience and explanation of diet failure: an exploration using interpretative phenomenological analysis.

Successful long-term weight-loss is exceptional, even with the best dietary and psychological interventions. Nomothetic accounts of diet failure focus on cognitive processes and emotional regulation. However, qualitative research suggests that successful dieters draw on wider understandings in explaining their success; this study extends this literature to address diet failure. Individual interviews with 10 self-selected UK dieters are analysed using IPA. Understandings of diet failure are explored and situated within wider cultural discourses. Five themes are identified: 'Dieting mode'; 'Multime'; 'Not me'; 'Modern life'; and 'Challenges of emotional and social eating'. Implications for weight-loss interventions are explored.

Prosthodontic rehabilitation of hypophosphatasia using dental implants: a review of the literature and two case reports.

There are reports in the literature of the various dental features of hypophosphatasia, especially where it affects the deciduous dentition. The descriptions include both the manifestations of the disorder and the subsequent patterns of tooth loss. There are fewer descriptions of the effects of hypophosphatasia on the permanent dentition and little information on the subsequent prosthodontic management of these patients, particularly in relation to the use of dental implants. The aim of this paper was to review the literature on the dental effects of hypophosphatasia, present two cases and describe how one of those patients, a young adult, was successfully rehabilitated using dental implants. That latter patient's pattern of tooth loss as well as some histological and scanning electron microscopic findings of root cementum from the other case is also described.

Pierre Fauchard: the 'father of modern dentistry'.

The development of the modern practice of dentistry can be traced to the work and life of Pierre Fauchard, a French dentist who worked in the first half of the eighteenth century. Fauchard was an exceptionally gifted and talented practitioner, who introduced many innovations to dentistry. In a significant break with the tradition of the time, he shared his knowledge and techniques with colleagues, and published these in the first comprehensive dental textbook. This paper reviews his life and contribution to modern dentistry.

Pierre Fauchard and his rôle in the development of obturators.

The design and fabrication of oral appliances to replace parts of the palate missing due to congenital defects or lost through tumours, infection or trauma has been a considerable challenge for clinicians throughout the history of dentistry. Significant advances were made during the eighteenth century towards resolving the problem of constructing satisfactory obturators by the first 'surgeon-dentist', Pierre Fauchard. This paper reviews his innovative designs.

Can ulnar artery velocity changes be used as a preoperative screening tool for radial artery grafting in coronary artery bypass?

Radial artery harvesting for coronary revascularization may result in digit ischemia if collateral circulation is inadequate. The purpose of this study was to compare changes in ulnar artery flow velocity during radial artery compression (RAC) with changes in first- and second-digit pressures during RAC, a previously validated predictor of digital ischemia. Photoplethysmography was used to measure first- and second-digit arterial pressures before and during RAC on 80 extremities. Color flow duplex imaging was used to measure distal ulnar artery peak systolic velocity before and during RAC. Seventy-eight of eighty extremities had a slight increase in ulnar artery velocity with RAC. There was no correlation between ulnar artery velocity changes and digit pressure changes. Measurement of ulnar artery velocity during RAC is not a useful predictor of digit pressure changes. Measurement of segmental upper extremity pressures with first- and second-digit pressure measurement during radial artery compression should remain the preferred preoperative screening tool for radial artery harvest prior to CABG.

Decrease in fibrin content of venous thrombi in selectin-deficient mice.

The purpose of this study was to quantify the fibrin content of thrombi produced in a mouse model of venous thrombosis and correlate this to thrombus mass. The role of P-selectin, E-selectin, and IL-10 on thrombus fibrin content was analyzed using knockout (KO) mice. Five groups of mice were evaluated: control (N = 10), P-selectin KO (N = 7), E-selectin KO (N = 5), combined E-/P-selectin KO (N = 12), and IL-10 KO (N = 10). Venous thrombosis was induced by ligation of the infrarenal IVC. Mice were sacrificed on postoperative days (POD) 2 and 6. Thrombus mass was calculated. Sections of IVC were stained with an antibody that cross reacts with mouse fibrin. The distribution of RGB color pixels was generated from digitized micrographs of the thrombus of each animal. The mean pixel value for each group was compiled and analyzed using 2-way ANOVA. Mean pixel value per group was correlated with the mean thrombus mass per group. Color analysis demonstrated significant decreases in the analyzed fibrin content on POD-2 between the control vs E-/P-selectin KO (P < 0.05) and control vs IL-10 KO (P < 0.05) groups. In addition, significantly less fibrin staining was noted on POD-6 between the control vs E-selectin KO (P = 0.03), control vs P-selectin KO (P = 0.01), and control vs E-/P-selectin KO (P < 0.01). There was a strong overall correlation between the mean pixel value for each group and the thrombus mass (R = 0.964; P < 0.01). This study demonstrates a difference in fibrin content of thrombi produced in animals deficient in E-selectin, P-selectin, and IL-10, supporting their importance in thrombus amplification, fibrin formation, and the mass of thrombus formed.

Cerebral perfusion SPET correlated with Braak pathological stage in Alzheimer's disease.

Reductions in regional cerebral perfusion, particularly in the posterior temporo-parietal lobes, are well recognized in Alzheimer's disease. We set out to correlate perfusion changes, using (99m)Tc-HMPAO single photon emission tomography (SPET), with the pathological stage of Alzheimer's disease. The 'Braak stage' of the distribution of neurofibrillary pathology in post-mortem brains was used to classify SPET scans taken in life from a mixed (dementia and control) elderly population into the entorhinal stage (n = 23 subjects), limbic stage (n = 30 subjects) and neocortical stage (n = 36 subjects) Alzheimer's disease pathology. The SPET scans were then registered to a common, standard Talaraich space, and single template scans produced for each pathological stage. Comparison of these templates revealed an evolution in the pattern of reduction in regional perfusion. Additional comparisons were performed using earlier SPET scans obtained 5 years before death. For comparisons between templates, a threshold of 10% perfusion change was chosen so as to be clinically relevant as well as statistically significant. Reduced perfusion appears between the entorhinal and limbic stages in the anterior medial temporal lobe, subcallosal area, posterior cingulate cortex, precuneus and possibly the supero-anterior aspects of the cerebellar hemispheres. Large posterior temporo-parietal perfusion defects then appear between the limbic and neocortical stages, before finally large frontal lobe perfusion defects. The time course of these perfusion defects appears relatively long, suggesting that perfusion changes may have scope to be a diagnostic aid in staging Alzheimer's disease in life. The reduction in anterior medial temporal lobe perfusion may have future relevance on modern high resolution SPET and PET systems and also perfusion-type MRI sequences.

Incidental discovery of an inferior vena cava aneurysm.

Inferior vena cava (IVC) aneurysms are extremely rare, with only 18 reported cases in the world literature. These aneurysms are categorized as acquired, congenital, or associated with arteriovenous fistulae. Thrombosis of an IVC aneurysm can lead to IVC syndrome characterized by massive lower extremity edema, pulmonary embolism, or even death. Therapeutic alternatives range from watchful waiting to operative resection. This report presents a case of an IVC aneurysm noted incidentally at the time of diagnostic computed tomography for the evaluation of blunt chest trauma following a motor vehicle collision. In addition, the classification, embryology, diagnosis, and management of this unusual clinical entity are reviewed.

Computed tomographic venography is specific but not sensitive for diagnosis of acute lower-extremity deep venous thrombosis in patients with suspected pulmonary embolus.

PURPOSE: Duplex ultrasound scanning (US) is the accepted standard means of diagnosis for lower-extremity suprageniculate deep venous thrombosis (LE-DVT). Computed tomographic venography (CTV) has been proposed as an alternative modality for diagnosis of LE-DVT in patients with suspected pulmonary embolism (PE). This study compared CTV with US as a means of diagnosing acute LE-DVT. METHODS: A retrospective review of US and CTV scans from 136 patients with suspected PE who underwent both studies to exclude acute LE-DVT at a single institution was performed. Studies were reviewed and coded in a blinded manner. US was considered to be the reference test. Direct costs of each study were determined by using commercial software. RESULTS: The sensitivity and specificity rates of CTV were 71% and 93%, respectively. The positive predictive value, negative predictive value, and accuracy rates of CTV were 53%, 97%, and 90%, respectively. DVT localization was the same in eight of 10 cases in which the results of both US and CTV were positive. CTV costs and charges per study were greater than those of US by $46.88 and $602.00, respectively. CONCLUSION: CTV is specific, but has a lower sensitivity rate and positive predictive value for the diagnosis of acute LE-DVT compared with US. Additionally, CTV is more costly than US scanning. Because of the lower sensitivity rate and positive predictive value and the increased cost of CTV, US remains the screening study of choice in cases of suspected acute LE-DVT.

Simultaneous bilateral upper extremity venous thrombosis in a factor V Leiden heterozygote: a case report and review.

Primary upper extremity deep venous thrombosis (DVT), or effort thrombosis, typically occurs in young, healthy individuals with a history of repetitive upper extremity movement while secondary upper extremity DVT is associated with a number of predisposing factors. The role of factors such as hypercoagulability in the development of effort thrombosis is less well described. This report describes a previously healthy 21-year-old man who presented with simultaneous bilateral upper extremity DVT after hours of pushing and lifting a heavy wheelbarrow. Treatment included thrombolytic therapy followed by delayed venolysis and vein patch angioplasty. Hypercoagulable screening revealed factor V Leiden heterozygous characteristics.

Upper extremity venous gangrene following coronary artery bypass. A case report and review of the literature.

Acute symptomatic upper extremity deep vein thrombosis (DVT) are estimated to account for only 2-4% of all deep vein thrombosis. Upper extremity DVT leading to phlegmasia cerulea dolens (PCD) occurs in an estimated 2-5% of these cases. Progression of PCD to venous gangrene is extremely rare with only 16 previously reported cases in the literature. Only 7 of the cited cases document significant tissue loss. This report describes a 61-year-old male who developed upper extremity DVT complicated by PCD which led to venous gangrene and limb loss.

Inappropriate sexual behaviours of patients towards practising physiotherapists: a study using qualitative methods.

BACKGROUND AND PURPOSE: Recent research recognizes the occurrence of inappropriate sexual behaviour (ISB) by patients towards health professionals. The objective of this study was to explore in-depth the clinical context and effect of incidents of ISB towards practising physiotherapists. METHOD: In-depth interviews were conducted with a sub-sample of nine physiotherapists who were part of a larger survey on ISB. Quantitative analyses of the survey responses are reported elsewhere. Interview participants were asked to describe an incident of ISB by a patient that was either perceived to be the worst or was the most recent. They were asked questions on a variety of themes, such as their relationship with the patient prior to incident, the effects of the incident, the strategies used to deal with the incident, and changes in practice as a result of the incident. RESULTS: All interview participants reported encountering some level of ISB from patients. Although the overall frequency of these behaviours was relatively low, the range of behaviours was diverse. Regardless of the perceived severity of the incident, only four participants labelled their experience as 'sexual harassment'. Many reported negative effects on work performance. Participants mainly used physical measures to prevent further incidents, rather than confronting the perpetrator or reporting the incident. CONCLUSIONS: The findings are discussed in the context of theory pertaining to boundaries and issues of transference and counter-transference. This emphasized the need for effective communication skills training of both undergraduate and graduate physiotherapists in the prevention and management of ISB from patients.

Anorexia nervosa: friend or foe?

OBJECTIVE: The aim of this study was to examine anorexics' attitudes towards anorexia nervosa. METHOD: Anorexic patients were asked to write two letters to their anorexia nervosa, one addressing it as a friend and the other addressing it as an enemy. A coding scheme was developed using a "Grounded Theory" methodology to group recurrent themes. The scheme was used independently by three raters: the first author, a rater with extensive experience in eating disorders, and a novice in the field. Use of the coding scheme showed high interrater reliability and comprehensivess. RESULTS: Commonly expressed benefits of anorexia nervosa included feeling looked after or protected, gaining a sense of control, and feeling special. Perceived costs of the disorder included constant thoughts about food, feeling taken over, and the damage done to personal relationships. DISCUSSION: The positive themes found in the letters are important indicators of factors which may maintain anorexia nervosa. The use of the letters to examine these factors has important clinical implications which are outlined.

The diagnostic interview schedule for deaf patients on interactive video: a preliminary investigation.

OBJECTIVE: The authors investigated the feasibility of translating the National Institute of Mental Health Quick Diagnostic Interview Schedule-III, Revised, computer version, for deaf individuals. METHOD: The study involved translation of selected scales into American Sign Language, Signed English, and speech reading; review by an advisory panel and back translator; and collection and analysis of deaf individuals' reactions to translations. RESULTS: Focus groups responded favorably, translation problems were revealed, and solutions were suggested. CONCLUSIONS: The findings support the feasibility of translation of the Quick Diagnostic Interview Schedule-III, Revised, into American Sign Language, Signed English, and speech reading for deaf patients.