Meeting the four-hour deadline in an A&E department

This is the print version of the Article. The official published version can be obtained from the link below - Copyright @ 2011 EmeraldPurpose – Accident and emergency (A&E) departments experience a secondary peak in patient length of stay (LoS) at around four hours, caused by the coping strategies used to meet the operational standards imposed by government. The aim of this paper is to build a discrete-event simulation model that captures the coping strategies and more accurately reflects the processes that occur within an A&E department. Design/methodology/approach – A discrete-event simulation (DES) model was used to capture the A&E process at a UK hospital and record the LoS for each patient. Input data on 4,150 arrivals over three one-week periods and staffing levels was obtained from hospital records, while output data were compared with the corresponding records. Expert opinion was used to generate the pathways and model the decision-making processes. Findings – The authors were able to replicate accurately the LoS distribution for the hospital. The model was then applied to a second configuration that had been trialled there; again, the results also reflected the experiences of the hospital. Practical implications – This demonstrates that the coping strategies, such as re-prioritising patients based on current length of time in the department, employed in A&E departments have an impact on LoS of patients and therefore need to be considered when building predictive models if confidence in the results is to be justified. Originality/value – As far as the authors are aware this is the first time that these coping strategies have been included within a simulation model, and therefore the first time that the peak around the four hours has been analysed so accurately using a model

Lack of involvement of known DNA methyltransferases in familial hydatidiform mole implies the involvement of other factors in establishment of imprinting in the human female germline

BACKGROUND: Differential methylation of the two alleles is a hallmark of imprinted genes. Correspondingly, loss of DNA methyltransferase function results in aberrant imprinting and abnormal post-fertilization development. In the mouse, mutations of the oocyte-specific isoform of the DNA methyltransferase Dnmt1 (Dnmt1o) and of the methyltransferase-like Dnmt3L gene result in specific failures of imprint establishment or maintenance, at multiple loci. We have previously shown in humans that an analogous inherited failure to establish imprinting at multiple loci in the female germline underlies a rare phenotype of recurrent hydatidiform mole. RESULTS: We have identified a human homologue of the murine Dnmt1o and assessed its pattern of expression. Human DNMT1o mRNA is detectable in mature oocytes and early fertilized embryos but not in any somatic tissues analysed. The somatic isoform of DNMT1 mRNA, in contrast, is not detectable in human oocytes. In the previously-described family with multi-locus imprinting failure, mutation of DNMT1o and of the other known members of this gene family has been excluded. CONCLUSIONS: Mutation of the known DNMT genes does not underlie familial hydatidiform mole, at least in the family under study. This suggests that trans-acting factors other than the known methyltransferases are required for imprint establishment in humans, a concept that has indirect support from recent biochemical studies of DNMT3L

Designing movement into automotive seating - does it improve comfort?

Comfort is important for a good driving experience and automotive seat technology is an important enabler of this. Movement through frequent changes in posture is beneficial for reducing fixed postures. This paper reports on a laboratory study to investigate a novel automotive seat movement concept aiming to delay the onset of driving-related musculoskeletal fatigue and improve feelings of comfort and wellbeing, making the driver feel refreshed and ultimately improving driver performance. The research involved comparison of three seat conditions while driving - no seat movement, fore-aft movement, cushion and backrest angle movement. The movement was designed to be at a fixed speed, slow, smooth and only slightly perceptible while driving. A sample of 10 participants was recruited to take part in a 60 minute drive for each condition-single blind, repeated measures, balanced order and sessions at a similar time of day. Discomfort and wellbeing questionnaires, driver Seat Fidgets and Movements (SFMs), posture capture and a de-brief were used as data collection methods. Results indicate that the two seat movement concepts were positively received. Statistically significant differences were found at minute 60 for buttock area discomfort, with less reported discomfort for the two movement conditions. As expected, overall discomfort ratings and SFMs frequency increased with time spent driving for all trials. Posture scores verified that driver posture was within comfortable ranges and as expected fairly static while driving

Mapping task-switching in frontal cortex through neuropsychological group studies

This paper considers evidence provided by large neuropsychological group studies and meta-analyses of functional imaging experiments on the location in frontal cortex of the subprocesses involved in the carrying out of task-switching paradigms. The function of the individual subprocesses is also considered in the light of analyses of the performance of normal subjects

Clinical features and survival among children with retinoblastoma in Uganda

AIMS: To characterise the clinical features, treatment and outcome of children diagnosed with retinoblastoma in Uganda. METHODS: The study comprised a 6-year nationwide enrolment with follow-up. RESULTS: In total, 282 cases were enrolled, 26% (72) were bilateral; 6% were lost to follow-up. Almost all diagnoses in the first affected eye were International Classification of Retinoblastoma group E or worse. Histology was available for 92%; of those, 45%, had extraocular tumour at diagnosis. Enucleation of the first eye was done for 271; 94 received radiotherapy to the socket and in the last 2 years, 70 children received chemotherapy. At close of study, 139 children had died. Survival, as determined in a proportional hazards model adjusted for age, sex, laterality and treatment era (pre or post introduction of chemotherapy), varied by extent of the tumour (p<0.001); children with only intraocular involvement were 80% less likely to die (HR=0.21, 95% CI 0.12 to 0.35) compared with children with extraocular involvement. CONCLUSIONS: Diagnostic delay results in relatively high mortality among children with retinoblastoma in Uganda. There is an urgent need for more effective treatment modalities, particularly chemotherapy, and nationwide efforts to encourage earlier access to medical care

Clinical features and survival among children with retinoblastoma in Uganda

AIMS: To characterise the clinical features, treatment and outcome of children diagnosed with retinoblastoma in Uganda. METHODS: The study comprised a 6-year nationwide enrolment with follow-up. RESULTS: In total, 282 cases were enrolled, 26% (72) were bilateral; 6% were lost to follow-up. Almost all diagnoses in the first affected eye were International Classification of Retinoblastoma group E or worse. Histology was available for 92%; of those, 45%, had extraocular tumour at diagnosis. Enucleation of the first eye was done for 271; 94 received radiotherapy to the socket and in the last 2 years, 70 children received chemotherapy. At close of study, 139 children had died. Survival, as determined in a proportional hazards model adjusted for age, sex, laterality and treatment era (pre or post introduction of chemotherapy), varied by extent of the tumour (p<0.001); children with only intraocular involvement were 80% less likely to die (HR=0.21, 95% CI 0.12 to 0.35) compared with children with extraocular involvement. CONCLUSIONS: Diagnostic delay results in relatively high mortality among children with retinoblastoma in Uganda. There is an urgent need for more effective treatment modalities, particularly chemotherapy, and nationwide efforts to encourage earlier access to medical care

A spinal organ of proprioception for integrated motor action feedback

Proprioception is essential for behavior and provides a sense of our body movements in physical space. Proprioceptor organs are thought to be only in the periphery. Whether the central nervous system can intrinsically sense its own movement remains unclear. Here we identify a segmental organ of proprioception in the adult zebrafish spinal cord, which is embedded by intraspinal mechanosensory neurons expressing Piezo2 channels. These cells are late-born, inhibitory, commissural neurons with unique molecular and physiological profiles reflecting a dual sensory and motor function. The central proprioceptive organ locally detects lateral body movements during locomotion and provides direct inhibitory feedback onto rhythm-generating interneurons responsible for the central motor program. This dynamically aligns central pattern generation with movement outcome for efficient locomotion. Our results demonstrate that a central proprioceptive organ monitors self-movement using hybrid neurons that merge sensory and motor entities into a unified network

The presentation and management of post-partum choriocarcinoma

Post-partum choriocarcinoma is a rare complication of pregnancy. We have analysed a series of nine consecutive patients presenting with choriocarcinoma after a full-term non-molar pregnancy. All patients were managed at the Supraregional Trophoblastic Disease Screening and Treatment Centre at Weston Park Hospital, Sheffield between 1987 and 1996. All presented with persistent primary or secondary post-partum haemorrhage. Treatment with multiagent chemotherapy (initially methotrexate, dactinomycin and etoposide) was successful in all cases. Early diagnosis is important because this rare condition is potentially curable with appropriate chemotherapy. © 1999 Cancer Research Campaig

Improving survival of retinoblastoma in Uganda

BACKGROUND: Diagnostic delay results in relatively high mortality among children with retinoblastoma in Uganda, where treatment was limited to surgery and, for some, radiotherapy. In order to improve outcomes, a simple programme of neoadjuvant and adjuvant chemotherapy was introduced. Here we report survival before and after this change to medical practice. METHODS: Affordable standard off-patent chemotherapy agents were administered by trained paramedical staff to groups of patients at the same time. Survival before and after the introduction of chemotherapy was monitored. Between 2006 and 2013 a total of 270 patients with retinoblastoma were included, 181 treated prior to chemotherapy and 89 after (beginning in 2009). We had 94% follow-up and 249 had histological verification of diagnosis. RESULTS: Using a proportional hazards model adjusted for age, sex and laterality, children treated after chemotherapy was introduced had a 37% lower risk of dying (HR 0.63, 95% CI 0.41 to 0.99) compared with children treated before. Prior to the introduction of chemotherapy only 15% of children who survived bilateral disease retained vision after treatment compared with 71% after chemotherapy. CONCLUSIONS: The introduction of chemotherapy proved safe and cost-effective in non-specialist hands and was associated with significant improvements in survival and, among bilateral cases, in preserving vision