A Study of the Factors Affecting Perceptions of Science, Engineering and Technology (SET) in Young People

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Investigating mechanisms of breast implant failure and the role of radiotherapy

Breast implants have a role in both aesthetic and reconstructive surgery. They are however, associated with long-term complications including capsular contracture (a fibrotic encapsulation of the implant), implant rupture and leakage often necessitating further corrective surgery. The mechanisms driving these complications are not fully understood. Indications for post mastectomy radiation therapy are expanding leading to more patients with implant based breast reconstructions receiving it. The aim of this thesis was to investigate failure mechanisms of breast implants and the role of radiation therapy in its pathogenesis. Meta-analysis was performed investigating the clinical outcomes of PMRT directly upon the permanent implant in patients undergoing breast reconstruction. Retrieved breast implants and the corresponding capsular tissue from patients were collected and their material characteristics and histology studied. Un-implanted (control) Silicone breast implant shells were submitted to treatment dose radiation therapy and their material characteristics evaluated and compared to those of casted PCU and POSS-PCU. Meta-analysis demonstrated increased surgical complication rates and poorer patient satisfaction and cosmetic outcome in the PMRT group. Retrieved breast implants demonstrated a significant reduction in mechanical strength properties with increasing duration of implantation but there was no correlation with thickness of the corresponding retrieved fibrotic capsule. Treatment dose radiation to un-implanted silicone breast implant shells had no overall significant effect on its material characteristics or in vitro cellular response. This was in keeping with the response to PMRT of PCU and POSS-PCU, however POSS-PCU demonstrated different mechanical properties in comparison to silicone. These results indicate that although radiation therapy is significantly associated with poorer clinical outcomes for patients with implant based reconstruction, it is not due to alterations in the mechanical strength and surface chemical properties of the silicone implant shells. Therefore further study evaluating the tissue response to the implant in the setting of radiation therapy is required

A comprehensive systematic review of the impact of planned interventions offered to pregnant women who have requested a caesarean section as a result of tokophobia (fear of childbirth)

Background: Tokophobia, a deep‐seated fear of childbirth, causes women emotional anguish and affects the mother‐baby relationship. It can result in women avoiding future pregnancies or requesting caesarean section. This review examines evidence for the effectiveness of planned interventions in women with okophobia in both reducing requests for caesarean section and in ameliorating maternal distress. Objectives: 1) To synthesise the best available quantitative evidence for the effectiveness of planned interventions in reducing: a) fear/anxiety in tokophobic women, b) planned caesarean sections 2) To synthesise the best available qualitative evidence relating to the experiences of tokophobic women who request a caesarean section, particularly satisfaction with interventions and the childbirth experience. Inclusion criteria: This review considered studies that included pregnant women requesting a caesarean section for tokophobia in the absence of medical (or obstetric) indications who were offered a planned intervention. Search strategy: The literature search focused on published and unpublished studies in English distributed between January 1990 and April 2012. An initial limited database search was undertaken to identify keywords, followed by an extensive search of relevant databases and potential grey material. Methodological quality: Assessment for methodological quality was carried out independently by two reviewers using the standardised appraisal tools from the Joanna Briggs Institute. Data extraction: Data were extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute. Data synthesis: Statistical meta‐analysis was not possible due to heterogeneity. Therefore, a narrative summary of the data was undertaken. Results: Nine quantitative papers (comprising eight studies: one randomised controlled trial, five case control studies and two descriptive case series) were included; two of these papers appertained to the same study. No qualitative papers were found. Definitions for tokophobia varied. Samples were confounded by the inclusion of women with complex obstetric histories or with mental health issues. Comparison groups were sometimes non‐tokophobic women. Interventions were complex and descriptions sometimes lacked clarity. Although the randomised controlled trial found no difference in birth choices between samples, a group therapy intervention predisposed women to vaginal birth. One study measured whether interventions reduced fear, finding that they did. Four studies explored satisfaction with the intervention. In three cases interventions were evaluated positively. These involved midwifery input and birth planning. Conclusion: More research is needed to identify how tokophobic women might be helped. Current guidelines should be upheld for the time being, in the absence of further evidence. Implications for practice: Due to the heterogeneous nature of the research it is impossible at this stage to draw conclusions for practice. Implications for research: Due to ethical concerns about randomising tokophobic women to non‐treatment groups, innovative research designs should be considered. More research is needed on the effectiveness of group interventions and the role of midwives in administering interventions. A standard, measurable definition for tokophobia is needed and careful documentation and differential analysis of women's parity, mental health and obstetric status should be made. Outcomes should include fear reduction. Satisfaction and birth outcome should be measured on more than one occasion

Using PDAs for CAA: practicalities, disasters, apathy

For the last 3 years the Departments of Electronics & Electrical Engineering and the Robert Clark Centre for Technological Education at the University of Glasgow have been collaborating on projects to investigate the potential of PDAs in flexible learning and the use of highly portable mobile devices as CAA delivery platforms. During this time a number of challenges have been identified which will have implications for more widespread deployment of mobile devices. The project has now been extended and PDAs have been given to the students to use throughout their 4 years at university. This paper describes some of the technical, institutional and social factors that have been encountered during the project, various methods we have used to overcome these difficulties, and an assessment of the merit of each method, singly and in concert. Although our chosen platform has been a Palm OS based device the problems encountered are largely platform independent

Old hat in a brave new world – the impact of technology ageing in managed learning environments

This paper reports on the progress of a project at the University of Glasgow to investigate the benefits of PDAs (Personal Digital Assistant) as teaching, learning and revision tools and the practicalities of deploying PDAs and measuring their use. A pilot study in 2003, funded by LTSN Engineering, highlighted additional benefits of CAA assessment methods when CAA is combined with PDAs, allowing fully ubiquitous use by students1,2. Each student was loaned a PDA which contained a logging application to record when the PDA was used along with a quiz application to deliver formative self- assessment questions. Additional applications were pre- installed on each PDA, the applications included chemical tables, a scientific calculator and document readers. The students were encouraged to install their choice of additional applications on the PDA’s. The students used the PDAs during lecture and practical laboratory sessions and were allowed to take the device home

The HOME Study: Statistical and economic analysis plan for a randomised controlled trial comparing the addition of Proactive Psychological Medicine to usual care, with usual care alone, on the time spent in hospital by older acute hospital inpatients.

BACKGROUND: Prolonged acute hospital stays are a problem for older people and for health services. Failure to effectively manage the psychological and social aspects of illness is an important cause of prolonged hospital stay. Proactive Psychological Medicine (PPM) is a new way of providing psychiatry services to medical wards which is proactive, focussed, intensive and integrated with medical care. The primary aim of PPM is to reduce the time older people spend in hospital because of unmanaged psychological and social problems. The HOME Study will test the effectiveness and cost-effectiveness of PPM. METHODS/DESIGN: The study is a two-arm, parallel-group, randomised, controlled superiority trial with linked health economic analysis and an embedded process evaluation. The target population is people aged 65 years and older admitted to acute hospitals. Participants will be randomly allocated to either usual care plus PPM or usual care alone. The primary outcome is the number of days spent as an inpatient in a general hospital in the month following randomisation. Secondary outcomes include quality of life, cognitive function, independent functioning, symptoms of anxiety and depression, and experience of hospital stay. The cost-effectiveness of usual care plus PPM compared with usual care alone will be assessed using quality-adjusted life-years as an outcome as well as costs from the NHS perspective. DISCUSSION: This update to the published trial protocol gives a detailed plan of the statistical and economic analysis of The HOME Study. TRIAL REGISTRATION: ISRCTN registry, ISRCTN86120296. Registered on 3 January 2018

MAJOR DEPRESSION AND SURVIVAL IN PEOPLE WITH CANCER

OBJECTIVE: The question of whether depression is associated with worse survival in people with cancer remains unanswered because of methodological criticism of the published research on the topic. We aimed to study the association in a large methodologically robust study. METHODS: We analyzed data on 20,582 patients with breast, colorectal, gynecological, lung, and prostate cancers who had attended cancer outpatient clinics in Scotland, United Kingdom. Patients had completed two-stage screening for major depression as part of their cancer care. These data on depression status were linked to demographic, cancer, and subsequent mortality data from national databases. We estimated the association of major depression with survival for each cancer using Cox regression. We adjusted for potential confounders and interactions between potentially time-varying confounders and the interval between cancer diagnosis and depression screening, and used multiple imputation for missing depression and confounder data. We pooled the cancer-specific results using fixed-effects meta-analysis. RESULTS: Major depression was associated with worse survival for all cancers, with similar adjusted hazard ratios (HRs): breast cancer (HR = 1.42, 95% confidence interval [CI] = 1.15-1.75), colorectal cancer (HR = 1.47, 95% CI = 1.11-1.94), gynecological cancer (HR = 1.36, 95% CI = 1.08-1.71), lung cancer (HR = 1.39, 95% CI = 1.24-1.56), and prostate cancer (HR = 1.76, 95% CI = 1.08-2.85). The pooled HR was 1.41 (95% CI = 1.29-1.54, p < .001, I2 = 0%). These findings were not materially different when we only considered the deaths (90%) that were attributed to cancer. CONCLUSIONS: Major depression is associated with worse survival in patients with common cancers. The mechanisms of this association and the clinical implications require further study

Depression and anxiety during the year before death from cancer.

OBJECTIVE: Previous studies of depression and anxiety during the year before death have reported different findings. We therefore aimed to study depression and anxiety in patients who had died from cancer and had previously attended cancer clinics. METHODS: We analysed routine data on 4869 deceased patients who had completed the Hospital Anxiety and Depression Scale (HADS) as part of their routine cancer care. The HADS data were linked with demographic, cancer and mortality data from national registries. We used data from all HADS completed in the last year of life to investigate the relationships between mean depression (HADS-D) and anxiety (HADS-A) scores and the percentages of high scores (≥11 on each subscale) and time to death (Analysis 1). This analysis used multivariable linear regression with cubic splines and robust standard errors to allow for multiple HADS from the same patients. We also investigated within-patient changes in scores (Analysis 2) in a subset of patients who had completed more than one HADS. RESULTS: In Analysis 1, modelled mean HADS-D scores increased by around 2.5 and the percentage of high HADS-D scores increased from 13% at six months before death to 30% at one month before death. Changes in HADS-A were smaller and occurred later. In Analysis 2, similar patterns were observed in individual patients' HADS scores. CONCLUSION: Depression should be looked for and treated in patients with cancer and a prognosis of six months or less, in order to maximise the quality of patients' remaining life

Implementing collaborative care for major depression in a cancer center: An observational study using mixed-methods.

OBJECTIVES: To describe the implementation of a collaborative care (CC) screening and treatment program for major depression in people with cancer, found to be effective in clinical trials, into routine outpatient care of a cancer center. METHOD: A mixed-methods observational study guided by the RE-AIM implementation framework using quantitative and qualitative data collected over five years. RESULTS: Program set-up took three years and required more involvement of CC experts than anticipated. Barriers to implementation were uncertainty about whether oncology or psychiatry owned the program and the hospital's organizational complexity. Selecting and training CC team members was a major task. 90% (14,412/16,074) of patients participated in depression screening and 61% (136/224) of those offered treatment attended at least one session. Depression outcomes were similar to trial benchmarks (61%; 78/127 patients had a treatment response). After two years the program obtained long-term funding. Facilitators of implementation were strong trial evidence, effective integration into cancer care and ongoing clinical and managerial support. CONCLUSION: A CC program for major depression, designed for the cancer setting, can be successfully implemented into routine care, but requires time, persistence and involvement of CC experts. Once operating it can be an effective and valued component of medical care

'Do not attempt cardiopulmonary resuscitation' (DNACPR)-difficulty in discussions with older medical inpatients and their families: a survey of hospital doctors.

OBJECTIVES: To determine, for doctors looking after older medical inpatients: (1) how difficult they find discussions about 'do not attempt cardiopulmonary resuscitation' (DNACPR); (2) whether difficulty is associated with doctors' personal and professional characteristics; (3) how frequently DNACPR discussions are made more difficult by practical issues and by doctors' uncertainties. METHODS: Survey of hospital doctors working on the acute medical wards of a UK NHS teaching hospital. RESULTS: 171/200 (86%) of eligible doctors participated. 165 had experience of DNACPR discussions with older inpatients and/or their families and were included in our analysis. 'Difficulty' (defined as finding discussions 'fairly difficult' or 'difficult') was experienced by 52/165 (32%) for discussions with patients and 60/165 (36%) for discussions with families. Doctors with specific training in DNACPR discussions were less likely to have difficulty in discussions with patients. Older, more experienced doctors were less likely to have difficulty in discussions with families. Lack of time and place, and uncertainty about prognosis were the most frequently reported causes of difficulty. CONCLUSIONS: Many doctors have difficulty in DNACPR discussions. Training needs to include managing discussions with families, as well as with patients, and doctors need time and space to deliver this important part of their job