Multidimensional collaboration; reflections on action research in a clinical context

This paper reflects on the challenges and benefits of multidimensional collaboration in an action research study to evaluate and improve preoperative education for patients awaiting colorectal surgery. Three cycles of planning, acting,observing and reflecting were designed to evaluate practice and implement change in this interactive setting, calling for specific and distinct collaborations. Data collection includes: observing educational interactions; administering patient evaluation questionnaires; interviewing healthcare staff, patients and carers; patient and carer focus groups; and examining written and audiovisual educational materials. The study revolves around and depends on multi-dimensional collaborations. Reflecting on these collaborations highlights the diversity of perspectives held by all those engaged in the study and enhances the action research lessons. Successfully maintaining the collaborations recognises the need for negotiation, inclusivity, comprehension, brokerage,and problem-solving. Managing the potential tensions is crucial to the successful implementation of changes introduced to practice and thus has important implications for patients’ well-being. This paper describes the experiences from an action research project involving new and specific collaborations, focusing on a particular healthcare setting. It exemplifies the challenges of the collaborative action research process and examines how both researchers and practitioners might reflect on the translation of theory into educational practices within a hospital colorectal department. Despite its context-specific features, the reflections on the types of challenges faced and lessons learned provide implications for action researchers in diverse healthcare settings across the world

Patient-directed self-management of pain (PaDSMaP) compared to treatment as usual following total knee replacement; a randomised controlled trial

Background Self-administration of medicines by patients whilst in hospital is being increasingly promoted despite little evidence to show the risks and benefits. Pain control after total knee replacement (TKR) is known to be poor. The aim of the study was to determine if patients operated on with a TKR who self-medicate their oral analgesics in the immediate post-operative period have better pain control than those who receive their pain control by nurse-led drug rounds (Treatment as Usual (TAU)). Methods A prospective, parallel design, open-label, randomised controlled trial comparing pain control in patient-directed self-management of pain (PaDSMaP) with nurse control of oral analgesia (TAU) after a TKR. Between July 2011 and March 2013, 144 self-medicating adults were recruited at a secondary care teaching hospital in the UK. TAU patients (n = 71) were given medications by a nurse after their TKR. PaDSMaP patients (n = 73) took oral medications for analgesia and co-morbidities after two 20 min training sessions reinforced with four booklets. Primary outcome was pain (100 mm visual analogue scale (VAS)) at 3 days following TKR surgery or at discharge (whichever came soonest). Seven patients did not undergo surgery for reasons unrelated to the study and were excluded from the intention-to-treat (ITT) analysis. Results ITT analysis did not detect any significant differences between the two groups’ pain scores. A per protocol (but underpowered) analysis of the 60% of patients able to self-medicate found reduced pain compared to the TAU group at day 3/discharge, (VAS -9.9 mm, 95% CI -18.7, − 1.1). One patient in the self-medicating group over-medicated but suffered no harm. Conclusion Self-medicating patients did not have better (lower) pain scores compared to the nurse-managed patients following TKR. This cohort of patients were elderly with multiple co-morbidities and may not be the ideal target group for self-medication

Numerial analysis of flow in micromixer of type T up series with internal configuration of line of diaphragms and investigation of most optimal geometry

118 σ.Σε αυτή την διπλωματική εργασία παρουσιάζονται διάφορα συστήματα και τεχνικές μικροανάμιξης που εμφανίστηκαν και χρησιμοποιούνται έως και σήμερα με παραλλαγές και βελτιώσεις. Γίνεται εμβάθυνση στην διαδικασία ανάμιξης, όπου αξιοποιείται η μοριακή διάχυση ή το φαινόμενο Dean, ενώ ταυτόχρονα παρουσιάζονται τα πλεονεκτήματα και τα μειονεκτήματα της κάθε δομής. Επιπλέον, εντοπίζεται η αποδοτικότητα του κάθε μικροαναμίκτη, με στόχο την χρήση του σε υβριδικά μοντέλα μικροανάμιξης τα οποία συνδυάζουν νέες τεχνολογίες με συμβατικές. Στο δεύτερο μέρος της εργασίας, επιχειρείται αριθμητική επίλυση της ροής σε μικροαναμίκτη τύπου T, με έναν γνωστό εμπορικό κώδικα CFD, με σκοπό την σύγκριση των διαφορετικών δομών που δημιουργούνται με διαμόρφωση εμποδίων – διαφραγμάτων στο μικροκανάλι ανάμιξης και τη μελέτη της συμπεριφοράς και της απόδοσής τους σε ένα ευρύ φάσμα αριθμού Reynolds. Επίσης, διερευνάται η βέλτιστη εσωτερική διάταξη των διαφραγμάτων (βέλτιστο μήκος τους κάθετα στη ροή και βέλτιστη μεταξύ τους απόσταση), με κριτήριο τη μεγιστοποίηση του βαθμού ανάμιξης και την ταυτόχρονη ελαχιστοποίηση των απωλειών ενέργειας (πτώση πίεσης).In this dissertation we present various systems and techniques of micromixing that initially were presented and still being used until today with some variants even improvements. We get deeper into the mixing process, byexploiting the molecular diffusion or Dean phenomenon, while simultaneously we present the advantages and the disadvantages of each structure. Moreover, the efficiency of each micromixer is being located, aiming to be used in hybrid micromixing models, were new technologies are being combined with conventional. On the second part of this dissertation, a numerical solution of flow in a micromixer type T (know with the commercial code CFD), isbeing attermpted in order to compare the different structures that are created with configuration of obstacles - diaphragms in the microchannel of mixture. We also examine the dehavior and the performance of those structures, into a wide renge of the Reynolds number. In addition, we examine the optimal internal provision of diaphragms (diaphragms optimal length vertical at the flow and optimal from each other distance), with criterion at the same time the maximization of the degree of mixing and the minimization of energy losses (pressure drop).Κωνσταντίνος Π. Καστανιά

Numerial analysis of flow in micromixer of type T up series with internal configuration of line of diaphragms and investigation of most optimal geometry

118 σ.Σε αυτή την διπλωματική εργασία παρουσιάζονται διάφορα συστήματα και τεχνικές μικροανάμιξης που εμφανίστηκαν και χρησιμοποιούνται έως και σήμερα με παραλλαγές και βελτιώσεις. Γίνεται εμβάθυνση στην διαδικασία ανάμιξης, όπου αξιοποιείται η μοριακή διάχυση ή το φαινόμενο Dean, ενώ ταυτόχρονα παρουσιάζονται τα πλεονεκτήματα και τα μειονεκτήματα της κάθε δομής. Επιπλέον, εντοπίζεται η αποδοτικότητα του κάθε μικροαναμίκτη, με στόχο την χρήση του σε υβριδικά μοντέλα μικροανάμιξης τα οποία συνδυάζουν νέες τεχνολογίες με συμβατικές. Στο δεύτερο μέρος της εργασίας, επιχειρείται αριθμητική επίλυση της ροής σε μικροαναμίκτη τύπου T, με έναν γνωστό εμπορικό κώδικα CFD, με σκοπό την σύγκριση των διαφορετικών δομών που δημιουργούνται με διαμόρφωση εμποδίων – διαφραγμάτων στο μικροκανάλι ανάμιξης και τη μελέτη της συμπεριφοράς και της απόδοσής τους σε ένα ευρύ φάσμα αριθμού Reynolds. Επίσης, διερευνάται η βέλτιστη εσωτερική διάταξη των διαφραγμάτων (βέλτιστο μήκος τους κάθετα στη ροή και βέλτιστη μεταξύ τους απόσταση), με κριτήριο τη μεγιστοποίηση του βαθμού ανάμιξης και την ταυτόχρονη ελαχιστοποίηση των απωλειών ενέργειας (πτώση πίεσης).In this dissertation we present various systems and techniques of micromixing that initially were presented and still being used until today with some variants even improvements. We get deeper into the mixing process, byexploiting the molecular diffusion or Dean phenomenon, while simultaneously we present the advantages and the disadvantages of each structure. Moreover, the efficiency of each micromixer is being located, aiming to be used in hybrid micromixing models, were new technologies are being combined with conventional. On the second part of this dissertation, a numerical solution of flow in a micromixer type T (know with the commercial code CFD), isbeing attermpted in order to compare the different structures that are created with configuration of obstacles - diaphragms in the microchannel of mixture. We also examine the dehavior and the performance of those structures, into a wide renge of the Reynolds number. In addition, we examine the optimal internal provision of diaphragms (diaphragms optimal length vertical at the flow and optimal from each other distance), with criterion at the same time the maximization of the degree of mixing and the minimization of energy losses (pressure drop).Κωνσταντίνος Π. Καστανιά

THE CONTRIBUTION OF HYPOGONADISM TO THE DEVELOPMENT OF OSTEOPOROSIS IN THALASSEMIA MAJOR - NEW THERAPEUTIC APPROACHES

OBJECTIVE The osteoporosis seen in thalassaemia major is of multifactorial origin. The aim of the study was to evaluate the contribution of hypogonadism to the development of this osteoporosis and to assess the efficacy of new sex hormone replacement therapy regimens. DESIGN AND PATIENTS Sixty-seven patients were studied: 12 were hypogonadal, 32 had been on previous hormone replacement therapy (conjugated oestrogens plus medroxyprogesterone for females, depot testosterone esters for males); 10 had received continuous courses of treatment and 22 3-monthly on/off courses, and 22 were eugonadal without previous replacement therapy. Twenty-seven of the above patients were evaluated prospectively at 16 and 32 months during different therapeutic approaches (12 without treatment, 7 on continuous replacement and 8 on/off schemes followed by continuous therapy during the second observation period). The continuous schemes comprised either transdermal oestradiol (100 mu g) plus medroxyprogesterone for females or hCG to produce serum testosterone concentrations within normal range, for males. MEASUREMENTS Bone mineral density (BMD) end bone mineral content (BMC) of lumbar spine and distal end of radius were measured by dual-energy X-ray absorptiometry. RESULTS Spinal BMD was found to be more than 30% lower than that of controls matched for sex and age with no difference between sexes. Radial BMD was less impaired and showed significantly (P < 0.01) higher levels in males (decrease of 5.8% +/- 2.3, mean +/- SD) than in females (- 14.5 +/- 3.4%, mean +/- SD). In the retrospective evaluation it was found that the hypogonadal group had the lowest (P < 0.0001) BMD levels (0.62 +/- 0.01, mean +/- SE) and the highest were observed on the continuous replacement group (0.83 +/- 0.04), whereas the values of the other groups were similar. In a multiple regression analysis model it was found that only sex steroid levels were related to the BMD measurements (for oestradiol t = 2.6, P = 0.01 and for testosterone t = 6.5, P = 0.0001), whereas parameters related to haemolytic anaemia and desferrioxamine treatment were not. In the prospective study the continuous replacement group increased BMD and BMC values more than the on/off treatment courses (P = 0.01). CONCLUSIONS Hypogonadism seems to play an important role in the development of osteopenia-osteoporosis in thalassaemia major; continuous hormone replacement therapy with transdermal oestrogen for females or hCG for responding males best improves the bone density parameters

Effect of growth hormone cotreatment with human chorionic gonadotropin in testicular steroidogenesis and seminal insulin-like growth factor-1 in oligozoospermia

Objective: To study the GH synergy with hCG in testicular steroidogenesis and seminal insulin-like growth factor-1 (IGF-1) in oligozoospermia. Setting: University endocrine unit. Patients: Eight oligospermic, non-GH-deficient men. Interventions: Three different protocols spaced 3 months apart were applied in each man: plain hCG protocol: 1,500 IU IM three times every other day; GH + hCG protocol: with the addition of 4 IU SC GH daily 8 days before and throughout the hCG phase; placebo + hCG: substitution of GH by NaCl 0.9%. Blood sampling was performed before and on the 8th day (for 2nd- and 3rd-day protocols) and 24 hours after each hCG administration. Semen was collected three times during each protocol. Main Outcome Measures: Plasma for P, 17-OHP, androstenedione, DHEA, DHEAS, T, and E(2) and plasma and seminal IGF-1 three times during each study. Results: Serum IGF-1 levels increased more than threefold after GH administration. Seminal IGF-1 activity was unaffected by GH treatment or hCG administration, showing random fluctuations within each subject without correlation to the respective plasma levels. The incremental response of each steroid under hCG did not differ between the three protocols, apart from increased P levels under GH. Conclusions: Short-term GH cotreatment with hCG did not affect seminal IGF-1 concentration and had a weak synergist effect on steroidogenesis

The contribution of vitamin D receptor gene polymorphisms in osteoporosis and familial osteoporosis

It is well established that genetic factors play a major role in the pathogenesis of osteoporosis. Previous reports have suggested that vitamin D receptor (VDR) gene polymorphisms, particularly the BE, tt and AA genotypes, are associated with low bone mineral density (BMD). If these VDR genotypes are indeed an important determinant of BMD, then a population of related osteoporotic individuals (mother-daughter or sister-sister relationship) should have a high prevalence of the BE, tt or AA VDR genotypes. To test this hypothesis we determined the VDR genotypes in 26 osteoporotic persons (age 44.3 +/- 12.7 years, mean +/- SD) belonging to 12 families. Furthermore, for comparison with existing studies, we applied the VDR genotype analysis in a population of 53 unrelated healthy subjects (age 45.2 +/- 9.8 years, mean +/- SD) and 59 unrelated osteoporotic subjects (age 52.1 +/- 9.0 years, mean +/- SD). The menopausal status of the healthy and osteoporotic populations was pre-, peri- and mostly early postmenopausal. The proportions of the three genotypes, BE, tt and AA, within the 12 osteoporotic families were 15%, 12% and 27%, respectively, whereas the proportions of the other three homozygous genotypes (bb, TT, aa) were 50%, 50% and 23%. The distribution of the BE, tt and AA genotypes in the normal population was 21%, 21% and 36%, respectively (vs bb, TT, aa: 36%, 38%, 21%), whereas in the osteoporotic population it was 23%, 20% and 34% (vs bb, TT, aa: 27%, 34%, 14%). Our data indicate that there is not a statistically significant (p>0.05) difference in the VDR genotype frequencies within osteoporotic families as compared with the same genotypes in the population of unrelated normal or osteoporotic subjects. VDR genotype analysis showed no significant relation between VDR polymorphisms and BMD or Z-score values at the lumbar spine. This study demonstrates the lack of a heritability pattern between the BE, tt and PLA genotypes and low BMD

A [24-MC-6] Zinc Metallacoronate with a Nonsteroidal Antiinflammatory Drug as the Constructing Ligand

The interaction of ZnCl₂ with 2-dipyridylketonoxime (=Hpko) and flufenamic acid (=Hfluf) in a basic methanolic solution leads to the formation of a hexanuclear 24-membered metallacoronate, [Zn₆(OH)₂(pko)₄(fluf)₆] (<b>1</b>), with a [Zn–O–C–O] repeat unit and a nonsteroidal antiinflammatory drug as the constructing ligand. Compound <b>1</b> retains its structure in a dimethyl sulfoxide solution, as shown by ¹H NMR spectroscopy and molar conductance

Patient directed self management of pain (PaDSMaP) compared to treatment as usual following total knee replacement: study protocol for a randomised controlled trial

Background: In 2009, 665 patients underwent total knee replacements (TKRs) at the Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH), representing nearly 1% of the national total. Pain control following the operation can be poor, and this can cause poor mobilization and potential long-term adverse events. Although high levels of pain are not associated with patient dissatisfaction, brief periods of pain may lead to neuronal remodeling and sensitization. Patient controlled oral analgesia (PCOA) may improve pain relief; however, the evidence to date has been inconclusive. Patient directed self management of pain (PaDSMaP) is a single center randomized controlled trial, which aims to establish if patient self-medication improves, or is equivalent to, treatment as usual and to create an educational package to allow implementation elsewhere.Methods/design: Patients eligible for a TKR will be recruited and randomized in the outpatient clinic. All patients will undergo their operations according to normal clinical practice but will be randomized into two groups. Once oral medication has commenced, one group will have pain relief administered by nursing staff in the usual way (treatment as usual; TAU), whilst the second group will self manage their pain medication (patient directed self management of pain; PaDSMaP). Those recruited for self-medication will undergo a training program to teach the use of oral analgesics according to the World Health Organization (WHO) pain cascade and how to complete the study documentation. The primary endpoint of the trial is the visual analogue scale (VAS) pain score at 3 days or discharge, whichever is sooner. The follow-up time is 6 weeks with a planned trial period of 3 years. The secondary objectives are satisfaction with the management of patient pain post-operatively whilst an inpatient after primary TKR; overall pain levels and pain on mobilization; satisfaction with pain management information provided; global outcomes, such as quality of life (QOL) and activities of daily living (ADLs); time to mobilization and whether time to mobilization is associated with frequency of adverse events, improvements in QOL, ADLs and pain at 6 weeks after the operation; incidence of adverse events; quantity and type of pain medications used whilst an inpatient; the acceptability of PaDSMaP and/or TAU protocols for patients and the healthcare professionals involved in their care; to investigate the health-related costs associated with a PaDSMaP system; and to estimate the cost-effectiveness of PaDSMaP compared to TAU.Trial registration: Current Controlled Trials ISRCTN: 10868989. © 2012 Donell et al.; licensee BioMed Central Ltd