Auscultating heart and breath sounds through patients’ gowns: who does this and does it matter?

Background Doctors are taught to auscultate with the stethoscope applied to the skin, but in practice may be seen applying the stethoscope to the gown. Objectives To determine how often doctors auscultate heart and breath sounds through patients’ gowns, and to assess the impact of this approach on the quality of the sounds heard. Methods A sample of doctors in the west of Scotland were sent an email in 2014 inviting them to answer an anonymous questionnaire about how they auscultated heart and breath sounds. Normal heart sounds from two subjects were recorded through skin, through skin and gown, and through skin, gown and dressing gown. These were played to doctors, unaware of the origin of each recording, who completed a questionnaire about the method and quality of the sounds they heard. Results 206 of 445 (46%) doctors completed the questionnaire. 124 (60%) stated that they listened to patients’ heart sounds, and 156 (76%) to patients’ breath sounds, through patients’ gowns. Trainees were more likely to do this compared with consultants (OR 3.39, 95% CI 1.74 to 6.65). Doctors of all grades considered this practice affected the quality of the sounds heard. 32 doctors listened to the recorded heart sounds. 23 of the 64 (36%) skin and 23 of the 64 (36%) gown recordings were identified. The majority of doctors (74%) could not differentiate between skin or gown recordings, but could tell them apart from the double layer recordings (p=0.02). Trainees were more likely to hear artefactual added sounds (p=0.04). Conclusions Many doctors listen to patients’ heart and breath sounds through hospital gowns, at least occasionally. In a short test, most doctors could not distinguish between sounds heard through a gown or skin. Further work is needed to determine the impact of this approach to auscultation on the identification of murmurs and added sounds

Cardioverting acute atrial fibrillation and the risk of thromboembolism: not all patients are created equal

Current guidelines support the well-established clinical practice that patients who present with atrial fibrillation (AF) of less than 48 hours duration should be considered for cardioversion, even in the absence of pre-existing anticoagulation. However, with increasing evidence that short runs of AF confer significant risk of stroke, on what evidence is this 48-hour rule based and is it time to adopt a new approach? We review existing evidence and suggest a novel approach to risk stratification in this setting. Overall, the risk of thromboembolism associated with acute cardioversion of patients with AF that is estimated to be of <48 hours duration is low. However, this risk varies widely depending on patient characteristics. From existing evidence, we show that using the CHA2DS2-VASc score may allow better selection of appropriate patients in order to prevent exposing specific patient groups to an unacceptably high risk of a potentially devastating complication

On the long and short nulls, modes and interpulse emission of radio pulsar B1944+17

We present a single pulse study of pulsar B1944+17, whose non-random nulls dominate nearly 70% of its pulses and usually occur at mode boundaries. When not in the null state, this pulsar displays four bright modes of emission, three of which exhibit drifting subpulses. B1944+17 displays a weak interpulse whose position relative to the main pulse we find to be frequency independent. Its emission is nearly 100% polarized, its polarization-angle traverse is very shallow and opposite in direction to that of the main pulse, and it nulls approximately two-thirds of the time. Geometric modeling indicates that this pulsar is a nearly aligned rotator whose alpha value is hardly 2 degrees--i.e., its magnetic axis is so closely aligned with its rotation axis that its sightline orbit remains within its conal beam. The star's nulls appear to be of two distinct types: those with lengths less than about 8 rotation periods appear to be pseudonulls--that is, produced by "empty" sightline traverses through the conal beam system; whereas the longer nulls appear to represent actual cessations of the pulsar's emission engine

The potential of generic social outcomes in promoting the positive impact of the public library: Evidence from the National year of reading in Yorkshire

Objective - To present the development, planning and implementation of a qualitative research project on the impact of National Year of Reading in Yorkshire. Methods - Generic Social Outcomes (GSO) were used to develop a theoretical framework. Data were gathered via in-depth interviews and focus groups with National Year of Reading (NYR) steering group partners in Calderdale and North Lincolnshire, selected as the two case study authorities. The use of MAXQDA computer-assisted qualitative data analysis software (CAQDAS) enabled data and coding structures to be stored and facilitated comparison in this longitudinal study. Results - The findings using the GSO framework show considerable evidence of NYR related activities in supporting the three first-tier social outcomes: 'Stronger and Safer Communities', 'Health and Well-Being' and 'Strengthening Public Life.' Conclusion - The GSO framework can be used by practitioners to help provide evidence for how public libraries contribute to diverse agendas and demonstrate their value to the community. Public library authorities can use this evidence for planning and for advocacy with a range of audiences including local and central government. © 2012 Rankin

Building Sustainable Communities: Integrated Services and Improved Financial Outcomes for Low-Income Households

After decades of investing in blighted communities across the country, Local Initiatives Support Corp. (LISC) knows that healthy neighborhoods rest as much on whether residents can earn a decent wage and build financial security as they do on good housing, strong schools and vibrant businesses. As part of our comprehensive strategy, LISC is tackling this pressing need through an expansive network of Financial Opportunity Centers (FOCs) in dozens of communities nationwide. FOCs help clients find and maintain good jobs, stick to realistic budgets, improve their credit and save for the future. And they are located in the same neighborhoods where LISC is investing in housing and health, reducing crime, strengthening schools and re-energizing commercial corridors.The research shows a direct relationship between the number and type of services accessed and the FOC clients' ability to grow their earnings and secure their finances. For instance, those who spent the most time on all three bundled services offered by the FOCs (employment, coaching and public benefits) had the highest job placement rates and the highest job retention rates -- a 74 percent placement rate and a 78 percent six-month retention rate. Clients who received both financial counseling and employment services had net income increases that were 89 percent higher than those receiving only financial or income support counseling.We also learned that:* 76 percent of clients increased their net income.* More than half increased their net worth.* 60 percent either increased their credit score or acquired a credit score.* 58 percent of those who started with zero or negative net income moved to positive net income