Exploring how patients await scheduled surgery: Implications for quality of life

In this thesis, I explored the relationship between patient experience of wait time for consultation and scheduled surgery, type of illness (orthopaedic or cardiac), and descriptions of time using qualitative methodology. Thirty two patients awaiting orthopaedic or cardiac surgery were recruited by surgeons in Saskatoon, Saskatchewan during the period of September 2009 to November 2010. Those patients awaiting orthopaedic surgery were interviewed when the decision to treat was made and again at the midpoint of their waiting period. Cardiac surgery patients were interviewed after their angiography and consent to surgery, and again the day prior to surgery. Patients were asked about their perceptions of time while waiting, maximum acceptable wait time for consultation and surgery, and the effects of waiting. Interpretative phenomenology (1) was the method and data were analysed using interpretative phenomenological analysis.Participant suffering, the meaningfulness given to the experience, and the agency participants felt they had over the waiting period determined the lived duration of time experience. Participants considered pain, mobility restriction, disease progression and lethality of condition to be the primary determinants of wait time maximums. Waiting effects included restriction, uncertainty, resignation, coping with waiting, and opportunity. Few subtle differences between groups emerged indicating other variables may be more relevant to the quality of waiting experience. Participant suggestions for improving experience consisted of managing patient conditions and navigating the system. The findings suggest uncertainty in illness impacts the quality of wait time experience. The study denotes the experience of waiting for scheduled surgery is complex and not necessarily a linear relationship between greater symptom severity and less tolerance for wait time

Dickkopf-3 is upregulated in osteoarthritis and has a chondroprotective role

Objective Dickkopf-3 (Dkk3) is a non-canonical member of the Dkk family of Wnt antagonists and its upregulation has been reported in microarray analysis of cartilage from mouse models of osteoarthritis (OA). In this study we assessed Dkk3 expression in human OA cartilage to ascertain its potential role in chondrocyte signaling and cartilage maintenance. Methods Dkk3 expression was analysed in human adult OA cartilage and synovial tissues and during chondrogenesis of ATDC5 and human mesenchymal stem cells. The role of Dkk3 in cartilage maintenance was analysed by incubation of bovine and human cartilage explants with interleukin-1 (IL1) and oncostatin-M (OSM). Dkk3 expression was measured in cartilage following murine hip avulsion. Whether Dkk3 influenced Wnt, TGF and activin cell signaling was assessed in primary human chondrocytes and SW1353 chondrosarcoma cells using RT-qPCR and luminescence assays. Results Increased gene and protein levels of Dkk3 were detected in human OA cartilage, synovial tissue and synovial fluid. DKK3 expression was decreased during chondrogenesis of both ATDC5 cells and humans MSCs. Dkk3 inhibited IL1 and OSM-mediated proteoglycan loss from human and bovine cartilage explants and collagen loss from bovine cartilage explans. Cartilage DKK3 expression was decreased following hip avulsion injury. TGF signaling was enhanced by Dkk3 and Wnt3a and activin signaling were inhibited. Conclusions We provide evidence that Dkk3 is upregulated in OA and may have a protective effect on cartilage integrity by preventing proteoglycan loss and helping to restore OA-relevant signaling pathway activity. Targeting Dkk3 may be a novel approach in the treatment of OA

Waiting for surgery from the patient perspective

The aim of this study was to perform a systematic review of the impact of waiting for elective surgery from the patient perspective, with a focus on maximum tolerance, quality of life, and the nature of the waiting experience. Searches were conducted using Medline, PubMed, CINAHL, EMBASE, and HealthSTAR. Twenty-seven original research articles were identified which included each of these three themes. The current literature suggested that first, patients tend to state longer wait times as unacceptable when they experienced severe symptoms or functional impairment. Second, the relationship between length of wait and health-related quality of life depended on the nature and severity of proposed surgical intervention at the time of booking. Third, the waiting experience was consistently described as stressful and anxiety provoking. While many patients expressed anger and frustration at communication within the system, the experience of waiting was not uniformly negative. Some patients experienced waiting as an opportunity to live full lives despite pain and disability. The relatively unexamined relationship between waiting, illness and patient experience of time represents an area for future research

Social fragmentation, deprivation and urbanicity: relation to first-admission rates for psychoses

<i>Declaration</i> <i>of</i> <i>interest</i>: None. <i>Background</i>: Social disorganisation, fragmentation and isolation have long been posited as influencing the rate of psychoses at area level. Measuring such societal constructsis difficult. A census-based index measuring social fragmentation has been proposed. <i>Aims</i>: To investigate the association between first-admission rates for psychosis and area-based measures of social fragmentation, deprivation and urban/rural index. <i>Method</i>: We used indirect standardisation methods and logistic regression models to examine associations of social fragmentation, deprivation and urban/rural categories with first admissions for psychoses in Scotland for the 5-year period 1989–1993. <i>Results</i>: Areas characterised by high social fragmentation had higher first-ever admission rates for psychosis independent of deprivation and urban/rural status. There was a dose–response relationship between social fragmentation category and first-ever admission rates for psychosis. There was no statistically significant interaction between social fragmentation, deprivation and urban/rural index. <i>Conclusions</i>: First-admission rates are strongly associated with measures of social fragmentation, independent of material deprivation and urban/rural category

Legislating for a Pandemic: Exposing the Stateless State

Initially the subject of widespread consensus, legislative and policy responses to coronavirus are increasingly provoking predictable, albeit understandable, reactions. The right and the left are united by a concern that essential freedoms are being eroded by a State utilising the opportunity of the pandemic to make a power-grab. Focused on the Coronavirus Act 2020, this article takes a more cautious approach, suggesting instead that the law should be understood not as the product of a hierarchical State but rather as a demonstration of the ‘statelessness’ of the contemporary state. The article examines the Act, with particular focus on open justice, adult social care, and Business Improvement Districts. We argue that reading this unique piece of legislation through the lens of the stateless state reveals the complexities, ambiguities and contestations within contemporary policy making. We suggest that dismissing the Act as unnecessarily authoritarian is an insufficiently nuanced response, and furthermore, that this exploration of the law allows us to develop and complicate scholarship on the stateless state

Health state utility data in Cystic Fibrosis: A systematic review

Introduction: Cystic fibrosis (CF) is a life-limiting, hereditable condition, with the highest prevalence in Europe. CF treatments have led to improvements in clinical symptoms, disease management and decelerated disease progression. However, little is known about the health state utility (HSU) associated with CF disease states, adverse events, and changes in disease severity. Although HSU data have contributed to existing health economic modelling studies, a lack of such data have been highlighted. This systematic review aims to provide a summary of HSU-related research in CF and highlight related research gaps. Methods: Online searches were performed in six databases and studies in any of the following categories were included: (1) estimation of HSUs in CF; (2) mapping studies between patient-reported outcome measures (PROMs) and HSUs; (3) economic evaluations on the management of CF that report primary HSU data; and (4) any CF clinical trial that reported HSU as an outcome. Results: A total of 17 studies were reviewed, of which 12 provided HSU values for specific CF populations. The remaining five articles provided HSU data that were broken down by CF relevant health states, including lung transplantations, pulmonary exacerbation (PEx) events and forced expiratory volume in 1 s (FEV 1). Conclusion: Current HSU data in CF are limited and there is considerable scope for further research, both in providing HSU values for CF and in investigating methods for HSU elicitation/evaluation in CF populations

Barriers and facilitators in the delivery of a proportionate universal parenting program model (E-SEE Steps) in community family services

Background A proportionate universal (PU) approach to early years’ service provision has been advocated to improve children’s health and development and to reduce health inequality, by ensuring that services provide timely and high-quality parenting support commensurate with need. Process-oriented research is critical to examine the factors that contribute to, or hinder, the effective delivery/implementation of such a model in community-based family services. This study aimed to assess the delivery, acceptability and feasibility of a new PU parenting intervention model (called E-SEE Steps), using the Incredible Years® (IY) parent program, when delivered by trained health/family service staff in three “steps”—one universal step (the IY Babies Book), and two targeted steps (group-based IY Infant and Toddler programs). Methods An embedded mixed-methods process evaluation within a pragmatic parallel two-arm, assessor blinded, randomized controlled trial was conducted in community services in four local authorities in England. The process evaluation used qualitative data gathered via interviews and focus groups with intervention arm parents who were offered the targeted steps (n = 29), practitioners (n = 50), service managers (n = 7) and IY program mentors (n = 3). This was supplemented by quantitative data collected using group leader pre-training (n = 50) and post-delivery (n = 39) questionnaires, and research notes of service design decisions. Results The E-SEE Steps model was acceptable to most parents, particularly when it was accompanied by engagement strategies that supported attendance, such as providing childcare. Practitioners also highlighted the positive development opportunities provided by the IY training and supervision. However, participant views did not support the provision of the IY Babies book as a standalone universal component, and there were barriers to eligible parents—particularly those with low mood—taking up the targeted programs. Service providers struggled to align the PU model with their commissioned service contracts and with their staff capacity to engage appropriate parents, including tackling common barriers to attendance. Conclusions Despite general enthusiasm and support for delivering high-quality parenting programs in community services in the England, several barriers exist to successfully delivering IY in a proportionate universal model within current services/systems

A protocol for a pragmatic randomized controlled trial using the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) platform approach to promote person-focused primary healthcare for older adults

Detailed description of the intervention [57, 84–89]. (DOC 63 kb