False-negative upper extremity ultrasound in the initial evaluation of patients with suspected subclavian vein thrombosis due to thoracic outlet syndrome (Paget-Schroetter syndrome)

OBJECTIVE: To assess the utilization and consequences of upper extremity Duplex ultrasound in the initial diagnostic evaluation of patients with suspected subclavian vein (SCV) thrombosis and venous thoracic outlet syndrome (VTOS). METHODS: A retrospective single-center review was conducted for patients that underwent primary surgical treatment for VTOS between 2008 and 2017, in whom an upper extremity ultrasound had been performed as the initial diagnostic test (n = 214). Clinical and treatment characteristics were compared between patients with positive and false-negative ultrasound studies. RESULTS: There were 122 men (57%) and 92 women (43%) that had presented with spontaneous idiopathic arm swelling, including 28 (13%) with proven pulmonary embolism, at a mean age of 30.7 ± 0.8 years (range 14-69). Upper extremity ultrasound had been performed 23.8 ± 12.2 days after the onset of symptoms, with confirmation of axillary-SCV thrombosis in 169 patients (79%) and negative results in 45 (21%). Of the false-negative ultrasound study reports, only 8 (18%) acknowledged limitations in visualizing the central SCV. Definitive diagnostic imaging (DDI) had been obtained by upper extremity venography in 175 (82%), computed tomography angiography in 24 (11%), and magnetic resonance angiography in 15 (7%), with 142 (66%) undergoing catheter-directed axillary-SCV thrombolysis. The mean interval between initial ultrasound and DDI was 48.9 ± 14.2 days with no significant difference between groups, but patients with a positive ultrasound were more likely to have DDI within 48 hours than those with a false-negative ultrasound (44% vs 24%; P = .02). At the time of surgical treatment, the SCV was widely patent following paraclavicular decompression and external venolysis alone in 74 patients (35%). Patch angioplasty was performed for focal SCV stenosis in 76 (36%) and bypass graft reconstruction for long-segment axillary-SCV occlusion in 63 (29%). Patients with false-negative initial ultrasound studies were significantly more likely to require SCV bypass reconstruction than those with a positive ultrasound (44% vs 25%; P = .02). CONCLUSIONS: Duplex ultrasound has significant limitations in the initial evaluation of patients with suspected SCV thrombosis, with false-negative results in 21% of patients with proven VTOS. This is rarely acknowledged in ultrasound reports, but false-negative ultrasound studies have the potential to delay definitive imaging, thrombolysis, and further treatment for VTOS. Initial false-negative ultrasound results are associated with progressive thrombus extension and a more frequent need for SCV bypass reconstruction at the time of surgical treatment

Exercise physiologists: essential players in interdisciplinary teams for noncommunicable chronic disease management

Noncommunicable diseases (NCDs), such as obesity and type 2 diabetes mellitus, are a growing public health challenge in Australia, accounting for a significant and increasing cost to the health care system. Management of these chronic conditions is aided by interprofessional practice, but models of care require updating to incorporate the latest evidence-based practice. Increasing research evidence reports the benefits of physical activity and exercise on health status and the risk of inactivity to chronic disease development, yet physical activity advice is often the least comprehensive component of care. An essential but as yet underutilized player in NCD prevention and management is the “accredited exercise physiologist,” a specialist in the delivery of clinical exercise prescriptions for the prevention or management of chronic and complex conditions. In this article, the existing role of accredited exercise physiologists in interprofessional practice is examined, and an extension of their role proposed in primary health care settings

The Influence of Growing Degree Days on \u3cem\u3eRobinia Pseudoacacia\u3c/em\u3e Browse Quality and Productivity in the Southeastern USA

The possibility of estimating browse quality and productivity of black locust (BL; Robinia pseudoacacia L.) herbage from accumulated air temperature heat units (growing degree days, GDD) could be a valuable tool for researchers and graziers in efficient allocation of feed resources. Accumulated air temperature heat units (GDD) above a 10° C base have been used to predict several forage quality constituents (Onstad & Fick ,1983)

Developing metrics for nursing quality of care for low- and middle-income countries: a scoping review linked to stakeholder engagement.

BACKGROUND:The use of appropriate and relevant nurse-sensitive indicators provides an opportunity to demonstrate the unique contributions of nurses to patient outcomes. The aim of this work was to develop relevant metrics to assess the quality of nursing care in low- and middle-income countries (LMICs) where they are scarce. MAIN BODY:We conducted a scoping review using EMBASE, CINAHL and MEDLINE databases of studies published in English focused on quality nursing care and with identified measurement methods. Indicators identified were reviewed by a diverse panel of nursing stakeholders in Kenya to develop a contextually appropriate set of nurse-sensitive indicators for Kenyan hospitals specific to the five major inpatient disciplines. We extracted data on study characteristics, nursing indicators reported, location and the tools used. A total of 23 articles quantifying the quality of nursing care services met the inclusion criteria. All studies identified were from high-income countries. Pooled together, 159 indicators were reported in the reviewed studies with 25 identified as the most commonly reported. Through the stakeholder consultative process, 52 nurse-sensitive indicators were recommended for Kenyan hospitals. CONCLUSIONS:Although nurse-sensitive indicators are increasingly used in high-income countries to improve quality of care, there is a wide heterogeneity in the way indicators are defined and interpreted. Whilst some indicators were regarded as useful by a Kenyan expert panel, contextual differences prompted them to recommend additional new indicators to improve the evaluations of nursing care provision in Kenyan hospitals and potentially similar LMIC settings. Taken forward through implementation, refinement and adaptation, the proposed indicators could be more standardised and may provide a common base to establish national or regional professional learning networks with the common goal of achieving high-quality care through quality improvement and learning

Professional identity transitions, violations and reconciliations among new nurses in low- and middle-income countries

We examine how new nurses construct their professional identity in Low- and Middle-Income Countries (LMICs) when they enter clinical practice and encounter practical norms violating procedural standards. We conducted interviews and focus group discussions with 47 Kenyan nurses. We describe new nurses experiencing ‘shock’ entering nursing practice (working and learning alone while responsible for many patients and doing ‘dirty work’), which contrasted with their idealized image and expectations of nursing and prior training. We explain this transition using theory about identity and identity work, which we argue elucidates nurses' experiences in LMICs. We suggest that nurses' transition into clinical practice violated pre-existing expectations for their professional identities, which then triggered identity work of ‘toughening up’, ‘maturing through experience’, and ‘learning practical norms’. Through this identity work, and finally experiencing satisfaction from caring for and nursing patients back to health, some nurses were able to restore their valued professional identity

Lessons from a Health Policy and Systems Research programme exploring the quality and coverage of newborn care in Kenya.

There are global calls for research to support health system strengthening in low-income and middle-income countries (LMICs). To examine the nature and magnitude of gaps in access and quality of inpatient neonatal care provided to a largely poor urban population, we combined multiple epidemiological and health services methodologies. Conducting this work and generating findings was made possible through extensive formal and informal stakeholder engagement linked to flexibility in the research approach while keeping overall goals in mind. We learnt that 45% of sick newborns requiring hospital care in Nairobi probably do not access a suitable facility and that public hospitals provide 70% of care accessed with private sector care either poor quality or very expensive. Direct observations of care and ethnographic work show that critical nursing workforce shortages prevent delivery of high-quality care in high volume, low-cost facilities and likely threaten patient safety and nurses' well-being. In these challenging settings, routines and norms have evolved as collective coping strategies so health professionals maintain some sense of achievement in the face of impossible demands. Thus, the health system sustains a functional veneer that belies the stresses undermining quality, compassionate care. No one intervention will dramatically reduce neonatal mortality in this urban setting. In the short term, a substantial increase in the number of health workers, especially nurses, is required. This must be combined with longer term investment to address coverage gaps through redesign of services around functional tiers with improved information systems that support effective governance of public, private and not-for-profit sectors

International Migration of Doctors, and Its Impact on Availability of Psychiatrists in Low and Middle Income Countries

Background:Migration of health professionals from low and middle income countries to rich countries is a large scale and long-standing phenomenon, which is detrimental to the health systems in the donor countries. We sought to explore the extent of psychiatric migration. Methods: In our study, we use the respective professional databases in each country to establish the numbers of psychiatrists currently registered in the UK, US, New Zealand, and Australia who originate from other countries. We also estimate the impact of this migration on the psychiatrist population ratios in the donor countries. Findings: We document large numbers of psychiatrists currently registered in the UK, US, New Zealand and Australia originating from India (4687 psychiatrists), Pakistan (1158), Bangladesh (149) , Nigeria (384) , Egypt (484), Sri Lanka (142), Philippines (1593). For some countries of origin, the numbers of psychiatrists currently registered within high-income countries' professional databases are very small (e.g., 5 psychiatrists of Tanzanian origin registered in the 4 high-income countries we studied), but this number is very significant compared to the 15 psychiatrists currently registered in Tanzania). Without such emigration, many countries would have more than double the number of psychiatrists per 100, 000 population (e.g. Bangladesh, Myanmar, Afghanistan, Egypt, Syria, Lebanon); and some countries would have had five to eight times more psychiatrists per 100,000 (e.g. Philippines, Pakistan, Sri Lanka, Liberia, Nigeria and Zambia). Conclusions: Large numbers of psychiatrists originating from key low and middle income countries are currently registered in the UK, US, New Zealand and Australia, with concomitant impact on the psychiatrist/ population ratio n the originating countries. We suggest that creative international policy approaches are needed to ensure the individual migration rights of health professionals do not compromise societal population rights to health, and that there are public and fair agreements between countries within an internationally agreed framework. © 2010 Jenkins et al

Methodological considerations in the analysis of fecal glucocorticoid metabolites in tufted capuchins (Cebus apella)

Analysis of fecal glucocorticoid (GC) metabolites has recently become the standard method to monitor adrenocortical activity in primates noninvasively. However, given variation in the production, metabolism, and excretion of GCs across species and even between sexes, there are no standard methods that are universally applicable. In particular, it is important to validate assays intended to measure GC production, test extraction and storage procedures, and consider the time course of GC metabolite excretion relative to the production and circulation of the native hormones. This study examines these four methodological aspects of fecal GC metabolite analysis in tufted capuchins (Cebus apella). Specifically, we conducted an adrenocorticotrophic hormone (ACTH) challenge on one male and one female capuchin to test the validity of four GC enzyme immunoassays (EIAs) and document the time course characterizing GC me- tabolite excretion in this species. In addition, we compare a common field-friendly technique for extracting fecal GC metabolites to an established laboratory extraction methodology and test for effects of storing “field extracts” for up to 1 yr. Results suggest that a corticosterone EIA is most sensitive to changes in GC production, provides reliable measures when extracted according to the field method, and measures GC metabolites which remain highly stable after even 12 mo of storage. Further, the time course of GC metabolite excretion is shorter than that described yet for any primate taxa. These results provide guidelines for studies of GCs in tufted capuchins, and underscore the importance of validating methods for fecal hormone analysis for each species of interest

Dietary supplementation by older adults in southern China: a hospital outpatient clinic study

<p>Abstract</p> <p>Background</p> <p>There has been little knowledge about dietary supplementation by the Chinese elderly. The aim of this cross-sectional study was to investigate the usage of dietary supplements by older adults in southern China.</p> <p>Methods</p> <p>A total of 600 community-dwelling older adults were recruited from the outpatient clinics of three major hospitals in Foshan city between July 2007 and July 2008. Face-to-face interviews of participants were conducted to obtain information on demographics, lifestyle and dietary supplements use. Frequency and duration of usage were recorded for six categories of dietary supplements.</p> <p>Results</p> <p>Among the 446 consented participants (241 men and 205 women) who were over 55 years of age, 19.1% consumed one or more types of dietary supplements. The prevalence of usage was significantly higher (p = 0.008) for females (24.4%) than for males (14.5%). Dietary supplements were more likely to be consumed by non-smokers (p = 0.021) and those with hyperlipidemia (p = 0.003). The most popular supplement among users was calcium (53%). The majority (71%) of the users consumed supplements on a regular basis at one or more times per day, with an average duration of 2.95 (SD 4.80) years.</p> <p>Conclusion</p> <p>The overall prevalence of dietary supplementation in this older Chinese population was considerably lower than those in other Asia-Pacific countries.</p

Erratum to:Effects of a physical activity and nutrition program in retirement villages: a cluster randomised controlled trial

Abstract Background This cluster randomised controlled trial aimed to determine if a 6- month home-based intervention could improve the physical activity and dietary behaviours of adults aged 60 to 80 years living in retirement villages located in Perth, Western Australia. Methods Participants (n = 363) from 38 retirement villages were recruited into the trial and allocated to the intervention (n = 197: 17 sites) or control (n = 166: 21 sites) group and were blinded. Previously validated instruments-Fat and Fibre Barometer and International Physical Activity Questionnaire, along with anthropometric measures (weight, height, waist and hip circumferences) and blood pressure were collected at baseline and 6 -month time period. Comparisons between intervention and control groups were undertaken pre- and post- intervention using univariate chi-square and t-tests. Multi-level mixed regression analyses were then conducted to ascertain the effects of the intervention on changes in the outcome variables over time and between groups. Results A total of 139 (70.5%) intervention and 141 (84.9%) control group participants completed the program and post-test assessments. The intervention group demonstrated significant increases in time (80 min more per week on average) devoted to moderate-intensity physical activity, engagement in strength exercises (from 23.7% to 48.2%), frequency of fruit consumed as well as fat avoidance and fibre intake scores, in addition to a 0.5 kg mean reduction in weight post program, whereas no apparent changes were observed in the control group. Mixed regression results further confirmed statistically significant improvements in weight loss (p < 0.05), engagement in strength exercises (p < 0.001) and fruit intake (p = 0.012) by the intervention participants at post-test relative to their controls. Conclusions Retirement offers a time to reassess lifestyle, and adopt positive health enhancing physical activity and dietary behaviours. This intervention was successful in improving weight, engagement in strength exercises, increasing levels of moderate-intensity physical activity and consumption of fruit among retirement village residents. Further investigation is needed on how to better engage retirement village managers in such programs. Trial registration Australia and New Zealand Clinical Trial Registry (ACTRN12612001168842) registered November 2, 2012