Communicating with patients using a new vitamin B12 deficiency leaflet.

The aim of this quality improvement project was to improve patients' knowledge about their vitamin B12 deficiency by developing an information leaflet and engaging nursing staff in providing this educational tool to patients with the condition. Following two 'plan, do, study, act' cycles to test and improve implementation of the leaflet, the nursing team met the goal of 100% compliance with providing educational information to patients. An increase in patient knowledge following provision of the leaflet was predicted, and achieved.

Patient safety culture in maternity units: a review.

PURPOSE: The purpose of this paper is to summarize studies that have examined patient safety culture in maternity units and describe the different purposes, study designs and tools reported in these studies while highlighting gaps in the literature. DESIGN/METHODOLOGY/APPROACH: Peer-reviewed studies, published in English during 1961-2016 across eight electronic databases, were subjected to a narrative literature review. FINDINGS: Among 100 articles considered, 28 met the inclusion criteria. The main purposes for studying PSC were: assessing intervention effects on PSC (n=17), and assessing PSC level (n=7). Patient safety culture was mostly assessed quantitatively using validated questionnaires (n=23). The Safety Attitude Questionnaire was the most commonly used questionnaire (n=17). Interventions varied from a single action lasting five weeks to a more comprehensive four year package. The time between baseline and follow-up assessment varied from 6 to 24 months. No study reported measurement or intervention costs, and none incorporated the patient's voice in assessing PSC. PRACTICAL IMPLICATIONS: Assessing PSC in maternity units is feasible using validated questionnaires. Interventions to enhance PSC have not been rigorously evaluated. Future studies should report PSC measurement costs, adopt more rigorous evaluation designs and find ways to incorporate the patient's voice. ORIGINALITY/VALUE: This review summarized studies examining PSC in a highly important area and highlighted main limitations that future studies should consider.

Illusion or delusion--Lean management in the health sector.

PURPOSE: There has been considerable interest in the implementation of practices imported from manufacturing into healthcare as a solution to rising healthcare spending and disappointing patient safety indicators. One approach that has attracted particular interest is Lean management and the purpose of this paper is to engage with this topic. DESIGN/METHODOLOGY/APPROACH: Secondary research. FINDINGS: Despite widespread enthusiasm about the potential of Lean management processes, evidence about its contribution to higher organisational performance remains inconsistent. RESEARCH LIMITATIONS/IMPLICATIONS: This paper engages with the major Lean concepts of operations management and human resource management, including just-in-time, total quality management, total productive maintenance and does not engage in-depth with concepts related to employee empowerment, and training PRACTICAL IMPLICATIONS: This paper contributes to the organisational management literature in healthcare by showing that although Lean management seems to have the potential to improve organisational performance it is far from a panacea against under performing hospitals. SOCIAL IMPLICATIONS: It informs policy making by suggesting that a progressive managerial philosophy has a stronger impact on healthcare performance than the adoption of practices from any particular managerial approach. ORIGINALITY/VALUE: This paper provides a critical evaluation of the impact of Lean practices in informing healthcare policy. The paper contributes to the organisational management literature in healthcare by showing that even though Lean management in healthcare appears to have the potential to improve organisational performance; there remain problems with its application.

Physiologically relevant changes in serotonin resolved by fast microdialysis.

Online microdialysis is a sampling and detection method that enables continuous interrogation of extracellular molecules in freely moving subjects under behaviorally relevant conditions. A majority of recent publications using brain microdialysis in rodents report sample collection times of 20-30 min. These long sampling times are due, in part, to limitations in the detection sensitivity of high performance liquid chromatography (HPLC). By optimizing separation and detection conditions, we decreased the retention time of serotonin to 2.5 min and the detection threshold to 0.8 fmol. Sampling times were consequently reduced from 20 to 3 min per sample for online detection of serotonin (and dopamine) in brain dialysates using a commercial HPLC system. We developed a strategy to collect and to analyze dialysate samples continuously from two animals in tandem using the same instrument. Improvements in temporal resolution enabled elucidation of rapid changes in extracellular serotonin levels associated with mild stress and circadian rhythms. These dynamics would be difficult or impossible to differentiate using conventional microdialysis sampling rates.

Effects of stress on nursing integrity.

This article looks at the relationship between stress, nursing integrity and patient care. It has been argued that the professional integrity of nurses has been eroded and consequently they have become more susceptible to anxiety, stress and exhaustion, potentially affecting care delivery. The authors suggest that the goal of providing high professional standards is threatened by increased service demands, and there is therefore a need for nurses to develop effective coping strategies to manage stress resulting from competing tensions in the workplace.

Cancelled procedures: inequality, inequity and the National Health Service reforms.

Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive.

A necessary change: the transfer of care from hospital to community.

While there is ample evidence for the benefits of diverting resources from hospital delivery out to the community in terms of improved patient safety, very little is known about the impact on a healthcare provider's efficiency and output (Øvretveit, 2009).

Cancelled surgeries and payment by results in the English National Health Service.

OBJECTIVES: To model the frequency of 'last minute' cancellations of planned elective procedures in the English NHS with respect to the patient and provider factors that led to these cancellations. METHODS: A dataset of 5,288,604 elective patients spell in the English NHS from January 1st, 2007 to December 31st, 2007 was extracted from the Hospital Episode Statistics. A binary dependent variable indicating whether or not a patient had a Health Resource Group coded as S22--'Planned elective procedure not carried out'--was modeled using a probit regression estimated via maximum likelihood including patient, case and hospital level covariates. RESULTS: Longer waiting times and being admitted on a Monday were associated with a greater rate of cancelled procedures. Male patients, patients from lower socio-economic groups and older patients had higher rates of cancelled procedures. There was significant variation in cancellation rates between hospitals; Foundation Trusts and private facilities had the lowest cancellation rates. CONCLUSIONS: Further research is needed on why Foundation Trusts exhibit lower cancellation rates. Hospitals with relatively high cancellation rates should be encouraged to tackle this problem. Further evidence is needed on whether hospitals are more likely to cancel operations where the procedure tariff is lower than the S22 tariff as this creates a perverse incentive to cancel. Understanding the underlying causes of why male, older and patients from lower socio-economic groups are more likely to have their operations cancelled is important to inform the appropriate policy response. This research suggests that interventions designed to reduce cancellation rates should be targeted to high-cancellation groups.

Metachronous primary melanoma and lymphoma.

The association of cutaneous melanoma and non-Hodgkin lymphoma has been well documented. We identified 117 patients from the Connecticut Tumor Registry between 1973 and 2002 with diagnoses of both melanoma and non-Hodgkin lymphoma. Charts were reviewed based on patients identified with these diagnoses in the Tumor Registry at Yale-New Haven Hospital between 1926 and 2004. Data were analyzed for age at diagnosis, interval between diagnoses, survival, and gender comparisons were also made. Males comprised 62% of the patients. Females diagnosed initially with non-Hodgkin lymphoma developed melanoma after a longer interval than males. All patients diagnosed with non-Hodgkin lymphoma first had decreased survival. No gender-specific survival difference was seen regardless of which malignancy occurred first. The study patients had overall decreased survival than that expected with either melanoma or non-Hodgkin lymphoma alone. The effects of treatment, immunosuppression, viral induction, and genetic mutations may play various roles in the development of these neoplasms. Further research is required to provide insight into the link between melanoma and non-Hodgkin lymphoma.

Recombinant factor VIIa: hemostatic adjunct in the coagulopathic burn patient.

INTRODUCTION: Recombinant factor VIIa (rFVIIa; NovoSeven) is well recognized as an effective hemostatic agent in the management and prophylaxis of patients with hemophilia. We report here the successful use of rFVIIa in a coagulopathic burn patient. METHODS: A 63-year-old man was admitted with significant upper-body burns in a total body surface area of 60%. Initial management included early intubation and escharotomies, with subsequent admission to the burn unit. Fascial excision was carried out with allograft placement. During a complicated hospital course, decline in platelet function was noted and was associated with the development of a generalized coagulopathy with elevated international normalized ratio. Following a routine follow-up debridement and autografting, extensive bleeding was noted from donor sites. A period of increasing hemodynamic instability followed in the burn unit, with serial hematocrit measurements pointing toward ongoing bleeding from the surgical sites. Following administration of significant amounts of blood product, it was decided to administer rFVIIa per pharmacy protocol. RESULTS: Within 4 hours of administration of rFVIIa, the patient was noted to be hemodynamically stable with unchanging serial hematocrit measurements. Hemostasis was attributed to the use of rFVIIa with prior administration of platelets. CONCLUSIONS: Our case demonstrates the successful use of rFVIIa in the severely coagulopathic burn patient.

Utilization of postcranioplasty skull molding caps in the treatment of Apert syndrome.

Patients with Apert syndrome have bilateral coronal craniosynostosis as one of their many distinguishing features. Surgical correction of this deformity is the mainstay of treatment. Abnormal widening of the skull base progresses despite cranioplasty. We describe a patient for whom a skull molding cap (SMC) was used after barrel-stave osteotomy and orbital rim advancement. This successfully restricted widening of her skull base while allowing growth in other dimensions. Utilization of skull molding caps after cranial surgery shows promise in this setting.

Transcriptional regulation of bone marrow thrombopoietin by platelet proteins.

Platelet production is regulated primarily by the cytokine thrombopoietin (TPO). Although TPO is expressed in several different tissues, only in the bone marrow has the level of expression been reported to increase in response to reduced numbers of platelets. In these studies, we demonstrate that platelet granule proteins are able to transcriptionally repress TPO mRNA expression in a marrow stromal cell line as well as in primary bone marrow stromal cell cultures. Like TPO mRNA, secretion of TPO protein was also suppressed by serum treatment. Reporter gene constructs indicate that DNA elements located in an approximately 1.9-kb region between 250-bp upstream of the transcriptional initiation site and the middle of the second intron are able to mediate the transcriptional repression.

Staged arterial embolization and surgical resection of a giant splenic artery aneurysm.

Splenic artery aneurysms (SAAs) are increasingly being diagnosed as incidental findings. Management modalities include operative treatment, percutaneous embolization, laparascopic ligation, and observation. Giant SAAs larger than 8 cm are a rare entity. We report the case of a 78-year-old woman with an 11 cm SAA who underwent successful percutaneous embolization, followed by surgical excision. We discuss the management of this patient and provide a review of the relevant literature. The approach to SAA should remain individualized.