Question design in nurse-led and GP-led telephone triage for same-day appointment requests: a comparative investigation

Objective: To compare doctors’ and nurses’ communication with patients in primary care telephone triage consultations. Design: Qualitative comparative study of content and form of questions in 51 telephone triage encounters between practitioners (general practitioners (GPs)=29; nurses=22) and patients requesting a same-day appointment in primary care. Audio-recordings of nurse-led calls were synchronised with video recordings of nurse's use of computer decision support software (CDSS) during triage. Setting: 2 GP practices in Devon and Warwickshire, UK. Participants: 4 GPs and 29 patients; and 4 nurses and 22 patients requesting a same-day face-to-face appointment with a GP. Main outcome measure: Form and content of practitioner-initiated questions and patient responses during clinical assessment. Results: A total of 484 question–response sequences were coded (160 GP; 324 N). Despite average call lengths being similar (GP=4 min, 37 s, (SD=1 min, 26 s); N=4 min, 39 s, (SD=2 min, 22 s)), GPs and nurses differed in the average number (GP=5.51, (SD=4.66); N=14.72, (SD=6.42)), content and form of questions asked. A higher frequency of questioning in nurse-led triage was found to be due to nurses’ use of CDSS to guide telephone triage. 89% of nurse questions were oriented to asking patients about their reported symptoms or to wider-information gathering, compared to 54% of GP questions. 43% of GP questions involved eliciting patient concerns or expectations, and obtaining details of medical history, compared to 11% of nurse questions. Nurses using CDSS frequently delivered questions designed as declarative statements requesting confirmation and which typically preferred a ‘no problem’ response. In contrast, GPs asked a higher proportion of interrogative questions designed to request information. Conclusions: Nurses and GPs emphasise different aspects of the clinical assessment process during telephone triage. These different styles of triage have implications for the type of information available following nurse-led or doctor-led triage, and for how patients experience triage

Implications of non-feasible transformations among icosahedral hh orbitals

The symmetric group $S_6$ that permutes the six five-fold axes of an icosahedron is introduced to go beyond the simple rotations that constitute the icosahedral group $I$. Owing to the correspondence $h\leftrightarrow d$, the calculation of the Coulomb energies for the icosahedral configurations $h^N$ based on the sequence $O(5) \supset S_6 \supset S_5 \supset I$ can be brought to bear on Racah's classic theory for the atomic d shell based on $SO(5) \supset SO_L(3) \supset I$. Among the elements of $S_6$ is the kaleidoscope operator ${\cal K}$ that rotates the weight space of SO(5) by $\pi/2$. Its use explains some puzzling degeneracies in d^3 involving the spectroscopic terms ^2P, ^2F, ^2G and ^2H.Comment: Tentatively scheduled to appear in Physical Preview Letters Apr 5, 99. Revtex, 1 ps figur

Evaluations of Livestock Protection Dogs for Deterring Deer and Cattle Interactions

Bovine Tuberculosis (bovine TB) in northern Michigan has proven a dilemma necessitating aggressive measures including depopulation of livestock operations, culling of wildlife, banning the feeding of wildlife, and fencing livestock feed with high fences. Bovine TB is believed to be transmitted from white-tailed deer (Odocoileus virginianus) to domestic cattle through feces, urine, saliva, and nasal secretions on contaminated feed (indirect transmission) and from animal to animal (direct transmission). Effective methods for excluding deer from cattle enclosures would minimize the potential for indirect and direct transmission of bovine TB between infected deer and cattle. We combined an idea used historically in Europe to control predation on sheep with the concept of modem frightening devices that often fall short when the motivation of offending species is high. The use of livestock protection dogs (LPDs) seemed like an ideal solution in controlling the transmission of bovine TB from white-tailed deer to cattle. We felt LPDs raised and bonded with cattle would reduce use of cattle pastures and cattle feed by deer and minimize contact between deer and cattle, thereby reducing the potential for the transmission of bovine TB. We evaluated 4 LPDs over a 5-month period utilizing 2 primary data collection methods (direct observations and motion-activated video) on farmed deer facilities in Michigan. Following the initial evaluation of the LPDs, we relocated the dogs to working livestock operations in Michigan for further evaluation to gain an understanding of their practicality and long-term efficacy. Pastures protected by dogs had fewer intrusions by deer, fewer contacts (within 5m) between deer and cattle, and lower use of cattle feed by deer. Overall, we successfully decreased the potential for disease transmission with 66% fewer intrusions by deer into protected pastures, 96% fewer contacts (within 5m) between deer and cattle, and 100% lower use of cattle feed by deer (based of observation data). Livestock protection dogs were more effective in protecting animals and their immediate surroundings than excluding animals from entire study pastures. We found a strong treatment effect within the High Density Site; while within the Very High Density Site, we had high variability within intrusion rates at protected pastures and relatively low use of unprotected pastures resulting in no significant treatment effect. In conclusion, when properly trained and confined with the protected animals, LPDs minimize the potential for livestock to contract bovine TB from infected deer

A new quality of life consultation template for patients with venous leg ulceration

OBJECTIVE: Chronic venous leg ulcers (CVLUs) are common and recurrent, however, care for patients predominantly has a focus which overlooks the impact of the condition on quality of life. The aim of this study was to develop a simple, evidence-based consultation template, with patients and practitioners, which focuses consultations on quality of life themes. METHOD: A nominal group was undertaken to develop a new consultation template for patients with CVLUs based on the findings of earlier qualitative study phases. RESULTS: A user-friendly two-sided A4 template was designed to focus nurse-patient consultations on the quality of life challenges posed by CVLUs. CONCLUSION: CVLUs impact negatively on the quality of life of the patient but this receives inadequate attention during current consultations. This new template will help to ensure that key concerns are effectively raised, explored and addressed during each consultation. DECLARATION OF INTEREST: The NHS West Midlands Strategic Health Authority funded this study. The authors have no conflicts of interest to declare.NHS West Midlands Health Authorit

Standing Practice In Rehabilitation Early after Stroke (SPIRES): a functional standing frame programme (prolonged standing and repeated sit to stand) to improve function and quality of life and reduce neuromuscular impairment in people with severe sub-acute stroke-a protocol for a feasibility randomised controlled trial.

Background: The most common physical deficit caused by a stroke is muscle weakness which limits a person's mobility. Mobility encompasses activities necessary for daily functioning: getting in and out bed, on/off toilet, sitting, standing and walking. These activities are significantly affected in people with severe stroke who typically spend most of their time in bed or a chair and are immobile. Immobility is primarily caused by neurological damage but exacerbated by secondary changes in musculoskeletal and cardiorespiratory systems. These secondary changes can theoretically be prevented or minimised by early mobilisation, in this case standing up early post-stroke.Standing up early post-stroke has been identified as an important priority for people who have suffered a severe stroke. However, trials of prolonged passive standing have not demonstrated any functional improvements. Conversely, task-specific training such as repeated sit-to-stand has demonstrated positive functional benefits. This feasibility trial combines prolonged standing and task-specific strength training with the aim of determining whether this novel combination of physiotherapy interventions is feasible for people with severe stroke as well as the overall feasibility of delivering the trial. Methods/design: This is a pragmatic multi-centre parallel single-blinded two-armed feasibility randomised controlled trial. Fifty people with a diagnosis of severe stroke will be randomly allocated to either the functional standing frame programme or usual physiotherapy. All patient participants will be assessed at baseline and followed up at 3 weeks, then 3, 6 and 12 months post-randomisation. Trial objectives are to determine the feasibility according to the following indicators:: (i) Process: recruitment and retention rate, ability to consent, eligibility criteria, willingness/ability of physiotherapists to recruit, willingness of patients to be randomised, and acceptability of the intervention; (ii) Resource: burden and potential costs; (iii) Management: treatment fidelity, participant adherence, acceptability and completeness of outcome measures, impact and management or orthostatic hypotension; and (iv) Safety: number and nature of adverse and serious adverse events. Discussion: The functional standing frame programme addresses a key concern for people who have suffered a severe stroke. However, several uncertainties exist which need to be understood prior to progressing to a full-scale trial, including acceptability and tolerance of the functional standing frame programme intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties. Trial registration: International Standard Randomised Controlled Trial Number ISRCTN15412695. Registration on 19 December 2016

Does pulmonary rehabilitation alter patients’ experiences of living with chronic respiratory disease? A qualitative study.

PURPOSE: Chronic respiratory disease (CRD) including COPD carries high and rising morbidity and mortality in Africa, but there are few available treatments. Pulmonary rehabilitation (PR) is a non-pharmacological treatment with proven benefits in improving symptoms and exercise capacity, which has not been tested in Africa. We aimed to evaluate the lived experience of people with CRD, including physical and psychosocial impacts, and how these are addressed by PR. PATIENTS AND METHODS: A team of respiratory specialists, nurses, and physiotherapists implemented PR to meet the clinical and cultural setting. PR consisted of a 6-week, twice-weekly program of exercise and self-management education. Forty-two patients were recruited. Qualitative data were collected through interviews with patients at baseline and six weeks post-completion, focus group discussions, ethnographic observations, and brief interviews. RESULTS: Before and after PR, a total of 44 semi-structured interviews, 3 focus group discussions, and 4 ethnographic observations with brief interviews were conducted. Participants reported profound problems with respiratory symptoms, functional impairment, wide-reaching economic and psychological impacts, and social isolation. Patients who were debilitated by their condition before PR reported that PR addressed all their major concerns. It was reported that breathlessness, pain, immobility, weight loss, and other CRD-related symptoms were reduced, and social and intimate relationships were improved. Local materials were used to improvise the exercises, enabling some to be maintained at home. Recommendations for future PR programs included patient information to take home as a reminder of the exercises, and to show their families, and the support of a community health worker to help maintenance of exercises at home. CONCLUSION: PR has the potential to restore the physical, mental, and social functioning in patients with CRD, whereas medication has much more narrow effects. PR offers a major new option for treatment of a neglected group of patients

Theory of Spontaneous Polarization of Endohedral Fullerenes

A pseudo-Jahn-Teller model describing central atom distortions is proposed for endohedral fullerenes of the form A@C$_{60}$ where A is either a rare gas or a metal atom. A critical (dimensionless) coupling $g_c$ is found, below which the symmetric configuration is stable and above which inversion symmetry is broken. Vibronic parameters are given for selected endohedral fullerenes.Comment: 4 pages, REVTEX, 1 Postscript figure. [Phys. Rev. Lett. (in press)

Reduced number of axonal mitochondria and tau hypophosphorylation in mouse P301L tau knockin neurons.

Expression of the frontotemporal dementia-related tau mutation, P301L, at physiological levels in adult mouse brain (KI-P301L mice) results in overt hypophosphorylation of tau and age-dependent alterations in axonal mitochondrial transport in peripheral nerves. To determine the effects of P301L tau expression in the central nervous system, we examined the kinetics of mitochondrial axonal transport and tau phosphorylation in primary cortical neurons from P301L knock-in (KI-P301L) mice. We observed a significant 50% reduction in the number of mitochondria in the axons of cortical neurons cultured from KI-P301L mice compared to wild-type neurons. Expression of murine P301L tau did not change the speed, direction of travel or likelihood of movement of mitochondria. Notably, the angle that defines the orientation of the mitochondria in the axon, and the volume of individual moving mitochondria, were significantly increased in neurons expressing P301L tau. We found that murine tau phosphorylation in KI-P301L mouse neurons was diminished and the ability of P301L tau to bind to microtubules was also reduced compared to tau in wild-type neurons. The P301L mutation did not influence the ability of murine tau to associate with membranes in cortical neurons or in adult mouse brain. We conclude that P301L tau is associated with mitochondrial changes and causes an early reduction in murine tau phosphorylation in neurons coupled with impaired microtubule binding of tau. These results support the association of mutant tau with detrimental effects on mitochondria and will be of significance for the pathogenesis of tauopathies