Palliative care in the community

Primary care has a vital role in delivering palliative care. In most developed countries more people die in hospital than at home, although substantially more people would prefer to die at home. Primary care professionals play a central role in optimising available care, but they often lack the processes and resources to do this effectively

Anoxia tolerance, anaerobic metabolism, and the lack of a mitochondrial permeability transition in the ghost shrimp, Lepidophthalmus louisianensis, Schmitt, 1935

The ghost shrimp, Lepidophthalmus louisianensis, burrows up to meters deep in oxygen-limited marine sediments along the Gulf coast. During low tides these animals are subjected to extended periods of anoxia. The main objective of this study was to assess survival under anoxia and evaluate the physiological mechanisms that underlie the anoxia tolerance of this species. I observed large specimens of L. louisianensis (\u3e2g) having an LT50 of 64 h under anoxia at 25º C. Smaller specimens (\u3c1g) have a significantly higher LT50 of 113 h under identical conditions (P\u3c0.0001). I measured whole body lactate levels in shrimp exposed to anoxia for up to 72 h, and recorded significant accumulation of this anaerobic end product (ANOVA, P\u3c0.001). I also measured adenylates and arginine phosphate in shrimp exposed to anoxia for up to 48 h, and after a 24-h recovery period. Adenylates were not significantly altered during the anoxia regime, and reductions in arginine phosphate occurred after 12 and 24 h, but returned to normoxic values during recovery (ANOVA, P\u3c0.001). While reserves of arginine phosphate are used to some extent to buffer losses in ATP, substantial contribution to the maintenance of energetic status comes from the high rate of anaerobic glycolysis. Energized mitochondria isolated from ghost shrimp hepatopancreas possess a pronounced ability to take up exogenous Ca2+ (compared to mitochondria-free controls) as measured by following the external free Ca2+ concentration with the fluorogenic dye Fluo-5N. Importantly, Ca2+ was not released from the mitochondrial matrix at any level of exogenous Ca2+ tested (up to 1.0 mM, in the presence of 5 mM phosphate). Thus, Ca2+ does not stimulate opening of the mitochondrial permeability transition pore, which potentially could help prevent apoptotic and necrotic cell death during extended periods of anoxia. (Supported by NIH grant 1-RO1-GM0-71345-01 and by SIGMA XI GIAR)

Activism and leadership development: Examining the relationship between college student activism involvement and socially responsible leadership capacity

The purpose of this study was to examine the relationship between participation in student activism and leadership development among college students. This study applied the social change model of leadership development (SCM) as the theoretical model used to measure socially responsible leadership capacity in students. The study utilized data collected from the Multi-Institutional Study of Leadership (MSL), a research project examining the influences of higher education on leadership development in college students across the country. The sample of 12,510 students consisted of respondents who participated in a sub-study on student activism within the MSL survey. Hierarchical multiple regression models were constructed to investigate the research question using an adapted version of Astin's (1991) I-E-O college impact model. Regression models included participant demographic characteristics, pre-college experiences, institutional descriptors, and consideration of select college experiences in examining the relationship between activism and leadership development. Results indicated that the regression models explained a significant amount of the variance in participant scores. Participation and holding a leadership position in on-campus and off-campus organizations, community service conducted on one's own, and participation in an internship emerged as significant predictors of socially responsible leadership capacity among the collegiate experiences included in the model. Participation in activism also emerged as significant, as awareness of local, national, and global issues indicated influence on all leadership development measures, and participating in protests, contacting public officials, signing a petition, and buying or not buying products due to personal views significantly contributed to measures of citizenship. These findings served to address the existing gap in the literature pertaining to the relationship of student activism and leadership development, and indicated the developmental and educational potential to providing these experiences for students on campus

Emergency nurse practitioners and doctors consulting with patients in an emergency department : a comparison of communication skills and satisfaction

Background: Emergency nurse practitioners (ENPs) play an increasingly important role in UK emergency departments (EDs), but there is limited evidence about how this affects patient care and outcome. A study was undertaken to compare the content of, and satisfaction with, consultations made with patients presenting with problems of low acuity to an ED. Methods: Patients presenting with "primary care" problems were allocated to senior house officers (SHOs, n = 10), specialist registrars/staff grades (n = 7), sessionally-employed general practitioners (GPs, n = 12) or ENPs (n = 6) randomly rostered to work in a consulting room that had a wall-mounted video camera. At the end of each consultation the doctor/ENP and the patient were asked to complete the Physician/Patient Satisfaction Questionnaire. A stratified sample of videotaped consultations (n = 296) was analysed in depth using the Roter Interaction Analysis System. The main outcome measures were length of consultation; numbers of utterances of doctor/ENP and patient talk related to building a relationship, data gathering, activating/partnering, and patient education/counselling; doctor/ENP and patient consultation satisfaction scores. Results: ENPs and GPs focused more on patient education and counselling about the medical condition or therapeutic regimen than did ED doctors. There were no significant differences in consultation length. ENPs had higher levels of overall self-satisfaction with their consultations than ED doctors. Patient satisfaction with how actively they participated in the consultation was significantly associated with the amount of talk relating to building a relationship and activating and partnering, and patient satisfaction with information giving in the consultation was significantly associated with the amount of talk relating to building a relationship. Conclusion: These findings suggest differences between ENP and ED doctor consultations which are associated with some aspects of patient satisfaction. In contrast to previous reports, consultation length was not greater for ENPs than for doctors. There is a need for further research to test the generalisability of these findings and their impact on clinical outcome

A psychological approach to providing self-management education for people with type 2 diabetes : the diabetes manual

Background: The objectives of this study were twofold (i) to develop the Diabetes Manual, a selfmanagement educational intervention aimed at improving biomedical and psychosocial outcomes (ii) to produce early phase evidence relating to validity and clinical feasibility to inform future research and systematic reviews. Methods: Using the UK Medical Research Council's complex intervention framework, the Diabetes Manual and associated self management interventions were developed through preclinical, and phase I evaluation phases guided by adult-learning and self-efficacy theories, clinical feasibility and health policy protocols. A qualitative needs assessment and an RCT contributed data to the pre-clinical phase. Phase I incorporated intervention development informed by the preclinical phase and a feasibility survey. Results: The pre-clinical and phase I studies resulted in the production in the Diabetes Manual programme for trial evaluation as delivered within routine primary care consultations. Conclusion: This complex intervention shows early feasibility and face validity for both diabetes health professionals and people with diabetes. Randomised trial will determine effectiveness against clinical and psychological outcomes. Further study of some component parts, delivered in alternative combinations, is recommended

GP perspectives on hospital discharge letters : an interview and focus group study

Background: Written discharge communication following inpatient or outpatient clinic discharge is essential for communicating information to the GP, but GPs’ opinions on discharge communication are seldom sought. Patients are sometimes copied into this communication, but the reasons for this variation, and the resultant effects, remain unclear. Aim: To explore GP perspectives on how discharge letters can be improved in order to enhance patient outcomes. Design & setting: The study used narrative interviews with 26 GPs from 13 GP practices within the West Midlands, England. Method: Interviews were transcribed and data were analysed using corpus linguistics (CL) techniques. Results Elements pivotal to a successful letter were: diagnosis, appropriate follow-up plan, medication changes and reasons, clinical summary, investigations and/or procedures and outcomes, and what information has been given to the patient. GPs supported patients receiving discharge letters and expounded a number of benefits of this practice; for example, increased patient autonomy. Nevertheless, GPs felt that if patients are to receive direct discharge letter copies, modifications such as use of lay language and avoidance of acronyms may be required to increase patient understanding. Conclusion: GPs reported that discharge letters frequently lacked content items they assessed to be important; GPs highlighted that this can have subsequent ramifications on resources and patient experiences. Templates should be devised that put discharge letter elements assessed to be important by GPs to the forefront. Future research needs to consider other perspectives on letter content, particularly those of patients

Oral health awareness and care preferences in patients with diabetes : a qualitative study

Background People with type 2 diabetes have an increased risk of oral health problems; however, oral health is currently not included in structured diabetes reviews and education in the UK. Aim and Objectives This study explores the patient experience related to oral health and diabetes, especially in relation to: • Awareness of the link between oral health and diabetes and oral self care needs • Interaction with health professionals in dental and general practice • Preferences for receiving oral health information and education Methods This nested qualitative study involved semi-structured telephone interviews with a purposive sample of 20 participants from a questionnaire study on oral health awareness in patients with diabetes. Interview transcripts were analysed using a thematic framework approach. Results Participants were mostly unaware of the link between oral health and diabetes. Those that had been made aware by a health professional were not given concrete self care advice. Interactions with dental professionals were often limited to informing the dental practice of their diagnosis and current medication. Most participants were in favour of dentists screening for diabetes, but as their general practice was the hub for diabetes care, they felt GPs or nurses should provide oral health information and discuss oral health with patients. Conclusions Written information regarding diabetes and its possible effects on oral health needs to be more readily available to people with diabetes, especially at diagnosis. There may be a place for introducing a structured oral health question in routine diabetes reviews

Learner experiences of a blended course incorporating a MOOC on Haskell functional programming

There is an increasing move in higher education to blend university courses to include a Massive Open Online Course (MOOC). This article reports on the learner experiences of such a course, which incorporated a purposely designed MOOC as part of the blend, to teach Haskell functional programming. A survey revealed that students most valued the programming exercises, quizzes and instructional videos, while the follow-up focus group highlighted the flexibility of the MOOC, usefulness of the videos, drop-in sessions and programming exercises. The overall mix of activities was regarded as particularly useful. While discussions were not rated as highly in the survey, students in the focus group commented on their value, particularly for getting support from external learners. The perceived lack of face-to-face contact was the biggest issue; however, this reflected a lack of awareness of lab sessions which could have been better signposted. There was perceived to be a gap between the MOOC and the rest of the course in terms of level of difficulty and authenticity of learning tasks. These issues were positively addressed in subsequent runs of the course. The outcomes of this study are relevant to educators seeking to incorporate MOOCs into blended courses

A national facilitation project to improve primary palliative care : impact of the Gold Standards Framework on process and self-ratings of quality

Background: Improving quality of end-of-life care is a key driver of UK policy. The Gold Standards Framework (GSF) for Palliative Care aims to strengthen primary palliative care through facilitating implementation of systematic clinical and organisational processes. Objectives: To describe the general practices that participated in the GSF programme in 2003–5 and the changes in process and perception of quality that occurred in the year following entry into the programme, and to identify factors associated with the extent of change. Methods: Participating practices completed a questionnaire at baseline and another approximately 12 months later. Data were derived from categorical questions about the implementation of 35 organisational and clinical processes, and self-rated assessments of quality, associated with palliative care provision. Participants: 1305 practices (total registered population almost 10 million). Follow-up questionnaire completed by 955 (73.2%) practices (after mean (SD) 12.8 (2.8) months; median 13 months). Findings: Mean increase in total number of processes implemented (maximum = 35) was 9.6 (95% CI 9.0 to 10.2; p<0.001; baseline: 15.7 (SD 6.4), follow-up: 25.2 (SD 5.2)). Extent of change was largest for practices with low baseline scores. Aspects of process related to coordination and communication showed the greatest change. All dimensions of quality improved following GSF implementation; change was highest for the "quality of palliative care for cancer patients" and "confidence in assessing, recording and addressing the physical and psychosocial areas of patient care". Conclusion: Implementation of the GSF seems to have resulted in substantial improvements in process and quality of palliative care. Further research is required of the extent to which this has enhanced care (physical, practical and psychological outcomes) for patients and carers

Learning from the transfer of a fellowship programme to support primary care workforce needs in the UK: a qualitative study

Objectives Service redesign, including workforce development, is being championed by UK health service policy. It is allowing new opportunities to enhance the roles of staff and encourage multiprofessional portfolio working. New models of working are emerging, but there has been little research into how innovative programmes are transferred to and taken up by different areas. This study investigates the transferability of a 1-year post-Certification of Completion of Training fellowship in urgent and acute care from a pilot in the West Midlands region of England to London and the South East. Design A qualitative study using semistructured interviews supplemented by observational data of fellows’ clinical and academic activities. Data were analysed using a thematic framework approach. Setting and participants Two cohorts of fellows (15 in total) along with key stakeholders, mentors, tutors and host organisations in London and the South East (LaSE). Fellows had placements in primary and secondary care settings (general practice, emergency department, ambulatory care, urgent care and rapid response teams), together with academic training. Results Seventy-six interviews were completed with 50 participants, with observations in eight clinical placements and two academic sessions. The overall structure of the West Midlands programme was retained and the core learning outcomes adopted in LaSE. Three fundamental adaptations were evident: broadening the programme to include multiprofessional fellows, changes to the funding model and the impact that had on clinical placements. These were felt to be key to its adoption and longer-term sustainability. Conclusion The evaluation demonstrates a model of training that is adaptable and transferable between National Health Service regions, taking account of changing national and regional circumstances, and has the potential to be rolled out widely