“For review and management”: The role of the referral letter in surgical consultations

Background: The referral letter serves a central role in the transfer of patients from referring doctors to specialist care in Australia. Aim: We analysed the form and function of referral letters and examined their role in surgical consultations to better understand the information in the letter and what impact that may or may not have on consultation openings. Methods: Thirteen referral letters and their associated recorded surgical consultations were analysed with an iterative, multi-methods qualitative approach. Using inductive and deductive linguistic methods, we considered clinical and paraclinical information as well as contextual factors in the letters’ alignment with referral guidelines as well as overall relevance to the consultation. Results: The analysis showed that surgeons tend to have a “set piece” when opening a consultation that is independent of the content or style of the referral. While referral letters fell short of guidelines, additional patient information was frequently discussed in the consultation. Discussion: Patients and surgeons are generally able to work around interactional challenges related to patient information. However, recognising the need to supplement referral information particularly around paraclinical information and contextual factors is important. Conclusions: Future changes to referral letter guidelines could reflect these realities

Ultrasound-guided percutaneous delivery of tissue-engineered endothelial cells to the adventitia of stented arteries controls the response to vascular injury in a porcine model

Objective High restenosis rates are a limitation of peripheral vascular interventions. Previous studies have shown that surgical implantation of a tissue-engineered endothelium onto the adventitia surface of injured vessels regulates vascular repair. In the present study, we developed a particulate formulation of tissue-engineered endothelium and a method to deliver the formulation perivascular to injured blood vessels using a percutaneous, minimally invasive technique. Methods Stainless steel stents were implanted in 18 balloon-injured femoral arteries of nine domestic swine, followed by ultrasound-guided percutaneous perivascular injection of gelatin particles containing cultured allogeneic porcine aortic endothelial cells (PAE). Controls received injections of empty particles (matrix) or no perivascular injection (sham) after stent deployment. Animals were sacrificed after 90 days. Results Angiographic analysis revealed a significantly greater lumen diameter in the stented segments of arteries treated with PAE/matrix (4.72 ± 0.12 mm) compared with matrix (4.01 ± 0.20 mm) or sham (4.03 ± 0.16 mm) controls (P < .05). Similarly, histologic analysis revealed that PAE/matrix-treated arteries had the greatest lumen area (20.4 ± 0.7 mm[superscript 2]; P < .05) compared with controls (16.1 ± 0.9 mm[superscript 2] and 17.1 ± 1.0 mm[superscript 2] for sham and matrix controls, respectively) and the smallest intimal area (3.3 ± 0.4 mm[superscript 2]; P < .05) compared with controls (6.2 ± 0.5 mm[superscript 2] and 4.4 ± 0.5 mm[superscript 2] for sham and matrix controls, respectively). Overall, PAE-treated arteries had a 33% to 50% decrease in percent occlusion (P < .05) compared with controls. Histopathological analysis revealed fewer leukocytes present in the intima in the PAE/matrix group compared with control groups, suggesting that the biological effects were in part due to inhibition of the inflammatory phase of the vascular response to injury. Conclusions Minimally invasive, perivascular delivery of PAE/matrix to stented arteries was performed safely using ultrasound-guided percutaneous injections and significantly decreased stenosis. Application at the time of or subsequent to peripheral interventions may decrease clinical restenosis rates

Performance Characterisation and Optimisation of a Building Integrated Photovoltaic (BIPV) System in a Maritime Climate

A seasonal analysis of a long-term dataset produced by an off-grid classroom facility showcasing several solar orientated renewable technologies is presented. The performance of the building’s BIPV and battery storage system is characterised and optimisation strategies are discussed. The building experiences a typical oceanic climate defined by a relatively narrow annual temperature range and a high level of annual precipitation, resulting in significant fluctuation in PV performance throughout the year. On clear days, the battery system reaches capacity quickly and PV power output drops to the base load of the building. This curtailment of solar generation highlights the importance of developing control strategies to optimise system performance. Maximising the performance of the building requires accurate methodologies for predicting PV generation and detailed knowledge of building demand profiles. Significant correlation is observed between the solar irradiance, battery state of charge and PV power output, demonstrating the importance of these variables in any solar forecasting model. Demand profiles are deterministic and follow classroom routine. A baseline accounts for persistent systems such as the building management system that are active throughout the day, with demand peaking during occupancy. This information could be incorporated into scheduling algorithms to optimise performance. Consumption is more aligned with the solar generation profile than typical residential buildings that peak in the evening as levels of solar generation fall. The synergistic effect of buildings with different demand profiles could be a mitigation method to minimise the temporal mismatch between solar generation and consumption

Agency and ageing in place in rural Ireland

This report explores the experiences and preferences of older adults on ageing in place in rural Ireland. This exploration is undertaken through a participatory mixed-methods approach that seeks to foreground the voices of older adults themselves. The research study involved two phases. Phase one entailed a nationwide online and postal survey co-constructed with Age Action’s Glór advocacy group and University of the Third Age (U3A) membership and distributed to Age Action members living in rural areas across Ireland. 218 people aged 55 and older who live in rural areas took part in the survey and every county was represented, with 45% of respondents from Munster, 36% from Leinster, 12% from Connaught, and 7% from Ulster. Phase two involved a series of four focus groups in which 19 people took part. The focus groups explored the survey themes in more depth. The research highlights the diversity of experience of home and community among the older adults in rural Ireland who took part. Most participants expressed a strong desire to remain in their homes and communities as they age. The sense of attachment to home and place had, for many, strengthened since the pandemic. Some participants, however, highlighted the tenuous nature of their living arrangements and their sense of alienation from place. This was particularly the case for the participants who were renting, who had recently moved locations to be closer to children, or who found the limited facilities and social opportunities in their rural environments restrictive. Whether they were settled in their homes and communities or not, all participants highlighted the uncertainty of their positions and their fears for being able to have their preference for remaining in place realised as they aged. This was related to unpredictable factors such as their future health needs and availability of home care, their ongoing ability to drive, or their capacity to afford to live independently given the ambiguity surrounding future pension provision and the escalating costs associated with utilities, healthcare, home maintenance and expenses related to rural living, such as security, water, and sewerage costs. The general decline of towns and villages was highlighted by participants, as was the poor coverage of public transport in rural areas. These aspects not only heightened the sense of isolation of participants in terms of access to services and social activities; they also served to heighten their sense of marginalisation and perceived loss of agency in terms of policy formation and political representation. Participants also noted the limited options available to them should they consider moving from their rural locations, something that would be particularly challenging for most given their emotional connection to their homes and communities. The lack of affordable and suitable housing for older adults was a particular concern. Most participants were strongly opposed to nursing homes, a view which the experience of the pandemic had often reinforced. While a small number saw their benefit in cases of critical care, most were dissatisfied with the current ‘Fair Deal’ Scheme for funding nursing home care. They argued that, instead of focussing resources on a nursing home option not favoured by older adults, the government should develop an alternative statutory home care scheme that would support older adults to remain in their homes as they age. The supports which were noted as important in relation to allowing adults to age in their homes included a more accessible and fit-for-purpose grant system to fund modifications to the home – the most popular of these being an emergency response system, bathroom modifications, and improved heating. The need for a properly paid and resourced home help service, as well as a home and garden maintenance service, was emphasised. This was especially the case given the changing reality of ageing in Irish society and the fact that many older adults cannot rely on the availability or ability of family members to care for them in their homes. Access to broadband in rural areas was also noted as crucial, not only given the fact that more aspects of daily services are being conducted online but also given the importance of a reliable broadband connection in facilitating isolated rural older adults to connect to others. Participants highlighted their enjoyment of meeting each other and realising their difficulties were shared despite their diverse locations as benefits of the research process in the current study. They argued for the need for training in technology which could be a significant enabler to their remaining in place, as opposed to presenting a barrier to their doing so. They also argued that there was a need to tackle the covert ageism which was seen as endemic in institutions and everyday interactions, and which served to marginalise older adults further. Participants noted their preferences were they to need additional supports which could not be provided in their homes in the future. In this case, their favoured options would be co-operative or sheltered housing and retirement villages. These options were available for very few participants locally, however, meaning that they would be required to move from their communities, as well as their homes. The research, while small in scale resonates with global research on the theme,1 and highlights that the ability of older adults to age in place requires coordination among several different policy areas, not least housing, transport, technology, and healthcare. There is a need to adjust the funding focus from moving people who need help out of their homes to ensuring that the help they need is available to them in their homes for as long as possible. There is also a need to develop housing options, other than nursing homes, to address people’s preferences should staying at home be no longer a feasible option. Finally, and most importantly, there is a requirement to listen to older people in rural areas about where and how they wish to age in ways that support their sense of agency and challenge flawed assumptions about ageing. This research seeks to contribute to that aim both through its focus and its process

Delivery Site of Perivascular Endothelial Cell Matrices Determines Control of Stenosis in a Porcine Femoral Stent Model

PURPOSE: High restenosis rates are a major limitation of peripheral interventions. Endothelial cells, grown within gelatin matrices and implanted onto the adventitia of injured vessels, inhibit stenosis in experimental models. To determine if this technology could be adapted for minimally invasive procedures, we compared the effects of cells in an implantable sponge to an injectable formulation and investigated the importance of delivery site in a stent model. MATERIALS AND METHODS: Stents were implanted in the femoral arteries of 30 pigs followed by perivascular implantation of sponges or injection of particles containing allogeneic endothelial cells. Controls received acellular matrices or nothing. The effects of delivery site were assessed by injecting cellular matrices into or adjacent to the perivascular tissue, or into the neighboring muscle. Animals were sacrificed after 28 days. Pre-sacrifice angiograms and tissue sections were evaluated for stenosis. RESULTS: Arteries treated with cellular matrices had a 55 – 63% decrease in angiographic stenosis (P<0.05) and a 38 – 43% reduction (P<0.05) in histologic stenoses compared to controls. Intimal area was greatest when cellular matrices were delivered into the muscle (6.35 ± 0.95 mm2) compared to into or adjacent to the perivascular tissue (4.05 ± 0.56 mm2 and 4.73 ± 0.53 mm2, respectively, P < 0.05). CONCLUSIONS: Perivascular endothelial-cell matrices reduced stenosis after stent-induced injury. The effects were not dependent on the formulation but appeared to be dependent upon delivery site. Minimally invasive injections of endothelial-cell matrices to the adventitia of arteries following peripheral interventions may decrease restenosis rates.National Institutes of Health (U.S.) (Grant GM 49039

Case management of malaria fever in Cambodia: results from national anti-malarial outlet and household surveys

BACKGROUND: Continued progress towards global reduction in morbidity and mortality due to malaria requires scale-up of effective case management with artemisinin-combination therapy (ACT). The first case of artemisinin resistance in Plasmodium falciparum was documented in western Cambodia. Spread of artemisinin resistance would threaten recent gains in global malaria control. As such, the anti-malarial market and malaria case management practices in Cambodia have global significance. METHODS: Nationally-representative household and outlet surveys were conducted in 2009 among areas in Cambodia with malaria risk. An anti-malarial audit was conducted among all public and private outlets with the potential to sell anti-malarials. Indicators on availability, price and relative volumes sold/distributed were calculated across types of anti-malarials and outlets. The household survey collected information about management of recent "malaria fevers." Case management in the public versus private sector, and anti-malarial treatment based on malaria diagnostic testing were examined. RESULTS: Most public outlets (85%) and nearly half of private pharmacies, clinics and drug stores stock ACT. Oral artemisinin monotherapy was found in pharmacies/clinics (9%), drug stores (14%), mobile providers (4%) and grocery stores (2%). Among total anti-malarial volumes sold/distributed nationally, 6% are artemisinin monotherapies and 72% are ACT. Only 45% of people with recent "malaria fever" reportedly receive a diagnostic test, and the most common treatment acquired is a drug cocktail containing no identifiable anti-malarial. A self-reported positive diagnostic test, particularly when received in the public sector, improves likelihood of receiving anti-malarial treatment. Nonetheless, anti-malarial treatment of reportedly positive cases is low among people who seek treatment exclusively in the public (61%) and private (42%) sectors. CONCLUSIONS: While data on the anti-malarial market shows favourable progress towards replacing artemisinin monotherapies with ACT, the widespread use of drug cocktails to treat malaria is a barrier to effective case management. Significant achievements have been made in availability of diagnostic testing and effective treatment in the public and private sectors. However, interventions to improve case management are urgently required, particularly in the private sector. Evidence-based interventions that target provider and consumer behaviour are needed to support uptake of diagnostic testing and treatment with full-course first-line anti-malarials