22 research outputs found

    Notes on pre-Nightingale nursing: what it was and what it was not

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    Tanya Langtree studied the evolution of nursing praxis between the sixteenth and mid-nineteenth centuries. Tanya found pre-professionalised nursing practice was scientifically informed and aimed to restore health, promote comfort and prevent complications. These findings disrupt assumptions about early nursing and encourages the profession to reframe its understanding of the past

    Application of intraoperative quality assurance to laparoscopic total mesorectal excision surgery

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    Introduction: The role of laparoscopy in the surgical management of rectal cancer is debated. Randomised trials have reported contrasting results with inadequate specimens obtained in a minority of patients. The reasons behind these findings are unclear. Complex surgical interventions and human performance are prone to variation, which may account for outcome differences, but neither are robustly measured. Application of quality assurance (QA) to the intraoperative period could explore surgical performance and any relationship with subsequent outcomes. The overarching aim of this thesis is the promotion of oncological and patient safety through application of QA to laparoscopic TME surgery. Methods: Evidence synthesis of QA tools was obtained through a systematic review to identify reported objective laparoscopic total mesorectal excision (TME) assessment tools. Development of novel QA tools for laparoscopic TME was performed and applied and validated using case video from two multicentre randomised trials with reliability and validity of the laparoscopic TME performance tool (L-TMEpt) assessed. A multicentre randomised trial comparing 3D vs. 2D laparoscopic TME was performed incorporating objective performance analyses. Scores divided surgeons into quartiles and compared with histopathological and clinical endpoints. A novel intraoperative adverse event classification was developed and piloted. Results: 176 cases from 48 credentialed surgeons were analysed. L-TMEpt inter-rater, test-retest and internal consistency reliabilities were established. Substantial variation in surgical performance were seen. Scores were strongly associated with the number of intraoperative errors, plane of mesorectal dissection and short-term patient morbidity. Upper quartile surgeons obtained excellent results compared with the lower quartile (mesorectal fascia 93% vs. 59%, NNT 2.9, p=0.002; 30-day morbidity 23% vs. 48%, NNT 4, p=0.043). Conclusions: Intraoperative QA using assessment tools can objectively and reliably measure complex cancer interventions. Laparoscopic TME surgical performance assessment showed substantial variation which is strongly associated with clinical outcomes holding implications for surgical trial design and interpretation.Open Acces

    Veterinary Transition Study - investigating the transition from veterinary student to practising veterinary surgeon: prospective cohort study

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    This is a study of mental health and transition. Despite concern about professional mental health, and a suicide rate among veterinary surgeons three to four times that of the general population, studies of veterinary professional mental health have largely been cross-sectional and descriptive; characterising a problem, and raising concern, but not exploring how professional mental health and work interrelate. This study is different. Following individuals over time, and exploring experiences in detail, it seeks to understand experiences of work and mental health at a significant point in veterinary working lives: the transition from university to professional practice. There is a lack of evidence around the impacts of transition from study to professional practice. The Veterinary Transition Study starts to address this gap in understanding. It is a qualitative, prospective, cohort study: first meeting participants in their final year of veterinary study, it follows them through graduation, and into their second year of veterinary practice. Three interviews with each participant in total over the 3 years of the study facilitate an in depth understanding of the process of transition, and participants’ experiences of mental health as they transition from student life to that of a professional veterinary surgeon. Thirty six participants were recruited. All but one took part in at least one subsequent interview at 1-2 months or 19-27 months post-graduation. The study explores mental health, experiences of support, and the development of professional identity. New findings included the importance of informal support for veterinary students and new graduates, which was as important as formal support, and a reluctance to access formal support for fear of career detriment. Those vets who experienced the greatest difficulty at transition were not those who had reported mental health problems as students. Participants’ experiences of support at transition included being let down, and a mismatch between their experience and clinical responsibility given to them. Through the analysis and trying to distinguish veterinary and non-veterinary factors affecting mental health, the importance of veterinary identity became more prominent. Most participants had been determined to become vets from an early age. However, participants did not identify as vets at the point of graduation but rather self-identified as vets only once they could operate as independent practitioners and not perceive that they needed support. Separating personal and veterinary factors was in many cases not possible, so central was the identity of being a vet to participants’ lives during transition to professional work, and all aspects of their lives were affected by it. Mental health both affected identity, and was affected by it, with personal identity and shared culture acting both for and against participants’ mental health. This study examines this relationship, and goes on to make suggestions from the findings for individual vets moving from university to professional work, for employers of new graduate vets, and for universities

    A corpus based, lexical analysis of patient information for radiography

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    Despite the importance and the ubiquity of medical patient information in many healthcare systems in the world, we know very little about the lexical characteristics of the register. We do not know how patients perceive the information in the leaflets or whether the messages are transmitted effectively and fully understood. How a medical authority instructs and obliges patients in written information is also unclear. While the number of radiographic examinations performed globally increases year on year, studies consistently show that patients lack basic knowledge regarding the commonly-performed exams and show very poor understanding of the concomitant risks associated with radiation. There is, then, a pressing need to investigate radiography patient information in order to better understand why, and where, it is less effective. This thesis applies three approaches common to the field of corpus linguistics to uncover some of the lexical characteristics of patient information for radiography. The approaches used in this thesis are a keyword extraction, a lexical bundles analysis and an investigation of modal verbs used to express obligation. The findings suggest that patient information for radiography possesses characteristics more common to academic prose than conversation, although the high informational content of the register goes some way to explaining this and suggests that the reliance on these structures may, to a certain extent, be unavoidable. Results also suggest that the reliance on should to oblige and instruct is problematic as it may cause interpretation problems for certain patients, including those for whom English is not a primary language. Certain other characteristics of patient information revealed by the analyses may also cause comprehension, and while further research is needed, none of these characteristics would be evaluated as problematic by standard readability measures, furthering doubts about the suitability of such measures for the evaluation of medical information

    Functional Outcomes of Anterior Cruciate Ligament Reconstruction Surgery

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    Anterior cruciate ligament (ACL) is one of the most common sports injuries with a reported yearly incidence rate of over two million injuries worldwide. The main aim of this thesis is to investigate various aspects related to the functional outcomes of ACLR through a series of clinical studies. Ethical approval was sought and granted by the North of Scotland Research Ethics Service. A systematic review was conducted to investigate the outcome measures used in Level I and II clinical ACLR studies. The review showed wide variability in the outcome measures utilised with no consensus on the ideal outcome instrument or combination of instruments to report the outcome of ACLR. Five-year results from the UK National Ligament Registry (NLR) were analysed with review for limitations of registry data and future recommendations. The data analysed provided a comprehensive review for the demographics, surgical techniques and functional outcomes of ACLR surgery across the UK. NLR data is limited by multiple factors including high rate of incomplete data, duplication of data, poor patient compliance and lack of validation of the data. A study was conducted to examine the hypothesis that patients with ACLR do not return to their pre-injury functional status at two years postoperatively. The study showed significant improvement in patient symptoms postoperatively compare to their post-injury scores, but the majority of patients failed to achieve their pre-injury functional outcome scores at 2 years postoperatively. In a comparative study, the anteromedial portal (AM) technique in femoral tunnel drilling was compared with the trans-tibial (TT) technique with respect to radiological and functional outcomes. The hypothesis was that AM portal produces better functional outcomes compared with TT technique. We found that the AM portal achieved a more anatomical position of the graft but there was no difference between the two techniques in functional outcome at 2 years postoperatively. However, ACLR with the AM portal technique had higher graft failure rate compared with the TT technique. The medium- term outcome of all-inside meniscal repairs was investigated in a longitudinal study. Meniscal repairs with concomitant ACLR had a lower failure rate compared with isolated meniscal repairs. This indicates that surgeons should have a low threshold for repairing meniscal tear during ACLR surgery. The healing response technique was studied in a selected group of patients with complete proximal ACL tears. This technique yielded good functional outcome for most of the patients at 2 years postoperative follow up. The studies included in this thesis provides substantial information for surgeons treating patients with ACL injuries. It provides a platform for further research studies investigating the outcomes of ACLR surgery

    The radiological investigation of musculoskeletal tumours : chairperson's introduction

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    Assembling practice in clinical placements at a new medical school

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    Sociological studies of undergraduate medical education classically concentrated on students and tutors in the clinical environment and paid scant attention to course structures, systems of assessment or the institutional context in which medical education is embedded (Merton, Becker, Foucault, Atkinson, Bosk). Like them, this thesis offers a close ethnographic focus on the clinical experience, but combines it with a sociology of associations that explores the network of institutions and processes that impinge on it. Employing an ‘extended case method’ it focuses on the creation of a new medical school, and building on previous studies applies new materialist perspectives to explore the development and processes of regulation, the organization of supervision and assessment, and the embodied nature of practice (Burawoy). After an analysis of the original aims and development of the GMC’s Tomorrows’ Doctors it examines the school’s early years, focusing on the assessment of professionalism. It shows how the need to transfer information between the school and the NHS shaped assessment, and explores the clinical legitimation of the types of assessment to inform a discussion of their exchange-value and use-value. It presents the results of observations in clinical placements through Foucault’s perspective of the gaze and the ‘implicit labour of language’ in the assembly of practice, and by treating the senses used in patient consultations as mediators. It shows how patient-centered practice continues to reproduce a traditional individualized medicine and its hierarchy, and argues that patients in the community of practice serve as exemplars for comparison, learning, and the definition of the field of medicine itself. Following Kuhn’s assertion that scientific communities are best discovered by examining patterns of education and communication, this broader perspective makes an original contribution to the sociology of knowledge as well as to the fields of professional education and healthcare provision

    Infective/inflammatory disorders

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    Doctor of Philosophy

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    dissertationPhysicians are routinely exposed to dying patients and death, although some encounters are emotionally and existentially problematic, creating problems on two levels. Individuals are taught through medicine's hidden curriculum to detach from patients at the end-of-life, which can conflict with their personal values and result in moral distress. Institutionally, medical discourse does not officially encompass personal reflective writing, although it has been cited as potential remediation. This study uses discourse analysis, narrative discourse analysis, and rhetorical genre theory to critically investigate 126 physicians' personal articles recounting experiences from their postgraduate training with dying patients, which have been published in 14 general medical journals over 47 years. Findings disclose six rich discoursal features that distinguish physicians' personal discourse as rhetorical: repetition, metadiscourse, emotive language, euphemisms, metaphors, and narrative. Analysis of narrative, the dominant feature, reveals that physician authors consistently use personal writing to resist the hidden curriculum. Recurring themes--challenges to medical enculturation, counter-cultural medical practices at the end of life, and reincorporation of humanistic values--represent genre knowledge critical to an ethical practice of medicine. Therefore, physicians' personal discourse warrants rhetorical recognition as another genre of medical discourse, which I provisionally call perspective writing. Texts that focus on dying and death constitute the subgenre necrography. Findings from analysis of necrography using a combined method of material rhetoric, critical rhetoric, and phenomenology further reveal that narrative enables physician-authors to relate to the corpse in terms of kairos. They reconceptualize death as a critical time in which they can reconnect to the human body of the dead person and to their own mortality, humanizing the patient and themselves. I propose this representation of the corpse as the kairotic body, a theoretical model that expands upon other theories of the power of the unruly body. Rhetorical recognition of the genre of perspective writing, and by extension necrography, would substantiate the value of an existing body of medical writing as a significant and beneficial corrective to moral distress. Necrography especially provides new, crucial perspectives on dying that may contribute to the demedicalization of death in the medical profession and ultimately, in American society-at-large

    IX Malta Medical School Conference

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    Abstracts of papers presented at the 9th Malta Medical School Conference held at the Hilton Malta Hotel, Portomaso, St. Julians between 3rd and 5th December 2015.peer-reviewe
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