The development of the PROMPT (PRescribing Optimally in Middle-aged People’s Treatments) criteria

BACKGROUND: Whilst multimorbidity is more prevalent with increasing age, approximately 30% of middle-aged adults (45-64 years) are also affected. Several prescribing criteria have been developed to optimise medication use in older people (≥65 years) with little focus on potentially inappropriate prescribing (PIP) in middle-aged adults. We have developed a set of explicit prescribing criteria called PROMPT (PRescribing Optimally in Middle-aged People's Treatments) which may be applied to prescribing datasets to determine the prevalence of PIP in this age-group.

METHODS: A literature search was conducted to identify published prescribing criteria for all age groups, with the Project Steering Group (convened for this study) adding further criteria for consideration, all of which were reviewed for relevance to middle-aged adults. These criteria underwent a two-round Delphi process, using an expert panel consisting of general practitioners, pharmacists and clinical pharmacologists from the United Kingdom and Republic of Ireland. Using web-based questionnaires, 17 panellists were asked to indicate their level of agreement with each criterion via a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree) to assess the applicability to middle-aged adults in the absence of clinical information. Criteria were accepted/rejected/revised dependent on the panel's level of agreement using the median response/interquartile range and additional comments.

RESULTS: Thirty-four criteria were rated in the first round of this exercise and consensus was achieved on 17 criteria which were accepted into the PROMPT criteria. Consensus was not reached on the remaining 17, and six criteria were removed following a review of the additional comments. The second round of this exercise focused on the remaining 11 criteria, some of which were revised following the first exercise. Five criteria were accepted from the second round, providing a final list of 22 criteria [gastro-intestinal system (n = 3), cardiovascular system (n = 4), respiratory system (n = 4), central nervous system (n = 6), infections (n = 1), endocrine system (n = 1), musculoskeletal system (n = 2), duplicates (n = 1)].

CONCLUSIONS: PROMPT is the first set of prescribing criteria developed for use in middle-aged adults. The utility of these criteria will be tested in future studies using prescribing datasets.

Cancer survivors with self-reported late effects: their health status, care needs and service utilisation

OBJECTIVE: Cancer survivors (CSs) are at risk of developing late effects (LEs) associated with the disease and its treatment. This paper compares the health status, care needs and use of health services by CSs with LEs and CSs without LEs.

METHODS: Cancer survivors (n = 613) were identified via the Northern Ireland Cancer Registry and invited to participate in a postal survey that was administered by their general practitioner. The survey assessed self-reported LEs, health status, health service use and unmet care needs. A total of 289 (47%) CSs responded to the survey, and 93% of respondents completed a LEs scale.

RESULTS: Forty-one per cent (111/269) of CSs reported LEs. Survivors without LEs and survivors with LEs were comparable in terms of age and gender. The LEs group reported a significantly greater number of co-morbidities, lower physical health and mental health scores, greater overall health service use and more unmet needs. Unadjusted logistic regression analysis found that cancer site, time since diagnosis and treatment were significantly associated with reporting of LEs. CSs who received combination therapies compared with CSs who received single treatments were over two and a half times more likely to report LEs (OR = 2.63, 95% CI = 1.32-5.25) after controlling for all other variables.

CONCLUSIONS: The CS population with LEs comprises a particularly vulnerable group of survivors who have multiple health care problems and needs and who require tailored care plans that take account of LEs and their impact on health-related quality of life.

Geographical differences in first acquisition of Pseudomonas aeruginosa in cystic fibrosis

RATIONALE: Risk of infection with Pseudomonas aeruginosa in cystic fibrosis (CF) may be associated with environmental factors.

OBJECTIVES: To determine whether residential location is associated with risk of first acquisition of P. aeruginosa.

METHODS: We performed bronchoalveolar lavage and upper airway cultures in children newly diagnosed with CF to identify infection with P. aeruginosa during infancy and early childhood. Children were assessed according to their residence in a regional or metropolitan area. Multilocus sequence typing was used to determine P. aeruginosa genotype. An environmental questionnaire was also administered.

MEASUREMENTS AND MAIN RESULTS: A total of 105 of 120 (87.5%) infants diagnosed with CF were included in this study. Diagnosis in 65 infants (61.9%) followed newborn screening at mean age of 4.6 weeks. Sixty subjects (57.1%) were homozygous ΔF508, and 47 (44.8%) were female. Fifty-five (52.3%) infants were regional, of whom 26 (47.3%), compared with 9 of 50 (18.0%) metropolitan children, acquired infection with P. aeruginosa (odds ratio, 4.084; 95% confidence interval, 1.55-11.30). Age at acquisition was similar (regional: median, 2.31 yr; range, 0.27-5.96 yr; metropolitan: median, 3.10 yr, range, 0.89-3.70 yr). Strain typing identified P. aeruginosa genotypes often encountered in different ecological settings and little evidence of cross-infection. Ninety questionnaires (85.7%) were completed. Those who acquired P. aeruginosa were more likely to be living in a household that used water sprinkler systems (P = 0.032), but no differences were identified to explain increased risk of acquisition of P. aeruginosa in regional children.

CONCLUSIONS: Geographical difference in residence of children with CF was associated with increased risk of first acquisition of P. aeruginosa, usually with strains associated with the environment rather than with cross-infection.

Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology

A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with established CHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.

Urethral atrophy after artificial urinary sphincter placement:Is cuff downsizing effective?

Purpose: We reviewed the outcome of cuff downsizing with an artificial urinary sphincter for treating recurrent incontinence due to urethral atrophy.

Materials and Methods: We analyzed the records of 17 patients in a 7-year period in whom clinical, radiological and urodynamic evidence of urethral atrophy was treated with cuff downsizing. Cuff downsizing was accomplished by removing the existing cuff and replacing it with a 4 cm. cuff within the established false capsule. Incontinence and satisfaction parameters before and after the procedure were assessed by a validated questionnaire.

Results: Mean patient age was 70 years (range 62 to 79). Average time to urethral atrophy was 31 months (range 5 to 96) after primary sphincter implantation. Mean followup after downsizing was 22 months (range 1 to 64). Cuff downsizing caused a mean decrease of 3.9 to 0.5 pads daily. The number of severe leakage episodes decreased from a mean of 5.4 to 2.1 The mean SEAPI (stress leakage, emptying, anatomy, protection, inhibition) score decreased from 8.2 to 2.4. Patient satisfaction increased from 15% to 80% after cuff downsizing. In 1 patient an infected cuff required complete removal of the device.

Conclusions: Patient satisfaction and continence parameters improved after cuff downsizing. We believe that this technique is a simple and effective method of restoring continence after urethral atrophy.

Cadaveric fascia lata pubovaginal slings:early results on safety, efficacy and patient satisfaction

Objective To prospectively evaluate and quantify the efficacy of cadaveric fascia lata (CFL) as an allograft material in pubovaginal sling placement to treat stress urinary incontinence (SUI).

Patients and methods Thirty-one women with SUI (25 type II and six type III; mean age 63 years, range 40-75) had a CFL pubovaginal sling placed transvaginally. The operative time, blood loss, surgical complications and mean hospital stay were all documented. Before and at 4 months and 1 year after surgery each patient completed a 3-day voiding diary and validated voiding questionnaires (functional inquiry into voiding habits, Urogenital Distress Inventory and Incontinence Impact Questionnaire, including visual analogue scales).

Results The mean (range) operative time was 71 (50-120) min, blood loss 78.7 (20-250) mL and hospital stay 1.2 (1-2) days; there were no surgical complications. Over the mean follow-up of 13.5 months, complete resolution of SUI was reported by 29 (93%) patients. Overactive bladder symptoms were present in 23 (74%) patients before surgery, 21 (68%) at 4 months and two (6%) at 1 year; 80% of patients with low (<15 cmH (2) O) voiding pressures before surgery required self-catheterization afterward, as did 36% at 4 months, but only one (3%) at 1 year. Twenty-four (77%) patients needed to adopt specific postures to facilitate voiding. After surgery there was a significant reduction in daytime frequency, leakage episodes and pad use (P <0.05). The severity of leak and storage symptoms was also significantly less (P <0.002), whilst the severity of obstructive symptoms remained unchanged. Mean subjective levels of improvement were 69% at 4 months and 85% at 1 year, with corresponding objective satisfaction levels of 61% and 69%, respectively. At 1 year, approximate to 80% of the patients said they would undergo the procedure again and/or recommend it to a friend.

Conclusion Placing a pubovaginal sling of CFL allograft is a highly effective, safe surgical approach for resolving SUI, with a short operative time and rapid recovery. Storage symptoms are significantly improved, and subjective improvement and satisfaction rates are high.

Evaluation of Video Presentation to Deliver Surgical Anatomy Teaching

Title Evaluation of Video Presentation to Deliver Surgical Anatomy Teaching

Authors Walsh I.K., Boohan M., Dorman A.

Objectives To evaluate the efficacy of newly introduced video presentation to deliver Surgical Anatomy teaching to undergraduate medical students.

Design and Setting Qualitative and quantitative study using questionnaires and focus groups, employing students undertaking the perioperative medicine module of the phase 4 undergraduate medical curriculum at Queen’s University Belfast.

Outcome Measures To determine:
(1) if video presentation is effective in delivering surgical anatomy teaching,
(2) student’s learning preferences regarding this teaching method.
Results The questionnaire response rate was 89% (216 of 244 students; female: male ratio 1.25) and 42 students participated in 6 focus groups. Mean questionnaire responses indicated a favourable opinion on quality assurance items, with a mixed response to video presentation as a learning method. 71% of students preferred to receive a lecture in person, rather than via video presentation. There were no statistically significant differences between genders regarding learning preferences in general and regarding video versus live presentation in particular. Exploratory factor analysis demonstrated that favourable responses to video presentation were strongly associated with perceived audiovisual quality and learning preferences (Cronbach’s alpha coefficient 0.77), with 72% of students considering video presentation worthwhile. Positive perception of overall quality was strongly associated with learning preferences as well as more generic quality assurance issues (80% students; alpha coefficient 0.83).
The results were supported by triangulation of the above quantitative data with qualitative data generated by the focus groups. Students further articulated the view that video presentation may be more appropriate and effective in a mixed method setting.

Reference Basu Roy R, McMahon GT. Video-based cases disrupt deep critical thinking in problem-based learning. Med Educ 2012 Apr;46(4):426-435.

Evaluation of Multidisciplinary Delivery of Surgical Anatomy Teaching

Title Evaluation of Multidisciplinary Delivery of Surgical Anatomy Teaching

Authors Walsh I.K., Taylor S.J., Dorman A, Boohan M.

Objectives To evaluate the efficacy of newly introduced multidisciplinary methods to deliver Surgical Anatomy teaching to undergraduate medical students.

Design and Setting Qualitative and quantitative study using questionnaires and focus groups, employing students of the perioperative and emergency medicine (POEM) module of the phase 4 undergraduate medical curriculum at Queen’s University Belfast.

Outcome Measures To determine:
(1) if multidisciplinary teaching is effective in delivering surgical anatomy teaching,
(2) student’s learning preferences regarding this teaching method.
Results The questionnaire response rate was 89% (216 of 244 students; female: male ratio 1.25) and 42 students participated in 6 focus groups. Mean questionnaire responses indicated a favourable opinion on quality assurance items and multidisciplinary teaching. 81% of students agreed that multidisciplinary teaching enhanced learning and 86% felt that this did not adversely affect interaction. A positive contribution towards POEM learning was reported for Radiology (95% of students), Anatomy (93%) and Surgery (78%). The benefits of multidisciplinary teaching were congruent for Anatomy, Radiology and Surgery with 78% of students indicating a perceived favourable association with learning. Multidisciplinary teaching was not associated with diluted interaction, with 62% of students describing interaction as sufficient. 88% of students positively ranked tutor characteristics of enthusiasm and encouragement as being strongly associated with teacher quality. Positive perception of overall quality was strongly associated with learning preferences as well as more generic quality assurance issues (80% students; alpha coefficient 0.83).
The results were supported by triangulation of the above quantitative data with qualitative data generated by the focus groups. Whilst students frequently misunderstood the meaning of “multidisciplinary teaching”, there was an appreciation of the method’s worth; students recognised and valued the relevance of Anatomy, Radiology and Surgery teaching to POEM learning. The importance of vertically integrating Anatomy into all stages of the undergraduate curriculum was especially recognised.

Reference Aarnio M, Nieminen J, Pyorala E, Lindbolm-Ylanne S. Motivating medical students to learn. 2010 Med Teach;32(4):199-204.

Long-term health-related quality of life of prostate cancer survivors varies by primary treatment. Results from the PiCTure (Prostate Cancer Treatment, your experience) study

PURPOSE: Men are living longer with prostate cancer. In a two-country study, we investigated the health-related quality of life (HRQoL) of prostate cancer survivors up to 18 years post-diagnosis.

METHODS: Postal questionnaires were administered in 2012 to 6559 prostate cancer (ICD10 C61) survivors 2-18 years post-diagnosis, identified through population-based cancer registries in Ireland. HRQoL was measured using QLQ-C30 and QLQ-PR25. HRQoL, functional and symptom scores were compared by primary treatment(s) using multiple linear regression.

RESULTS: Fifty-four percent responded (n = 3348). After controlling for socio-demographic and clinical factors, global HRQoL varied significantly by primary treatment (p < 0.001); compared to radical prostatectomy (RP), survivors who received androgen deprivation therapy alone (ADT; p < 0.001) or external beam radiotherapy (EBRT) without concurrent ADT (p = 0.001) had significantly lower global HRQoL. The global HRQoL of men who received brachytherapy (p = 0.157), EBRT with concurrent ADT (p = 0.940) or active surveillance/watchful waiting (p = 0.388) was not significantly different from men treated with RP. There were statistically and clinically significant differences in general (fatigue, pain, dyspnoea, appetite loss, constipation, diarrhoea, financial difficulties) and disease-specific symptoms (sexual, urinary, bowel, ADT) by primary treatment. Fatigue and insomnia scores were high for survivors in all treatment groups.

CONCLUSIONS: Prostate cancer survivors' long-term HRQoL varied with primary treatment.

IMPLICATIONS OF CANCER SURVIVORS: Population-based information regarding statistically and clinically significant treatment effects on long-term global HRQoL, symptom burden and functionality should be provided during treatment decision-making. Screening for symptoms and utilising interventions during long-term follow-up may improve survivors' HRQoL.

Understanding the practice nurse’s role in the cancer care tapestry

Background: The are currently 2 million people in the UK living with or
after cancer, and this number is expected to double by 2030 (Maddams et
al, 2012). However, many report unmet physical and psychological needs.

Aim: To determine the learning needs of practice nurses to take on an
enhanced role with people affected by cancer, particularly after primary
treatment, and to develop a course to meet these needs.

Method: The Macmillan Steering Group designed and developed a course for practice
nurses to identify their learning needs, enabling participating practice
nurses to work collaboratively with each other and the course facilitator.
There was strong patient involvement throughout. The course was
evaluated by self-assessment of knowledge, skills and confidence, patient
satisfaction questionnaires and in-depth, qualitative telephone interviews
with the participants and their supporting GPs.

Results: The practice nurses reported changed practice, with increased confidence in discussing
issues relating to cancer and its treatment with patients and relatives.
They understood the importance of supported self-management and were
able to signpost patients to appropriate sources of information and
support. Many of the practice nurses started initiating and undertaking
Cancer Care Reviews, both as planned appointments and opportunistically.
Over the past year, a further nine pilots have been completed throughout
the UK, demonstrating that these results are reproducible in other settings.

Conclusions: With appropriate support and training and protected time
to include cancer care into their everyday work, practice nurses can take
on an important role in the support and care of people affected by cancer

An analysis of the attitudes of dental patients attending general dental practice in Galway

AIM: To describe the patterns of dental attendance and attitudes towards tooth loss of general dental practice patients in Galway.

OBJECTIVES: 1. To determine the pattern of adult dental attendance in general practices in Galway; and, 2. To examine the oral health attitudes of these patients.

METHOD: Questionnaires were distributed to 311 consecutive adult patients in the waiting rooms of ten general dental practices in Galway, which were randomly selected from the telephone directory.

RESULTS: A total of 254 of the 311 questionnaires distributed were fully completed, returned and included in the results, giving a response rate of 81.7%. A total of 59% of dentate participants attended their dentist for annual or biannual examinations compared to 23% of edentate patients. Some 10.5% of medical card holders and 0.5% of non-medical card holders were edentulous.

CONCLUSIONS: The data from the survey indicated that medical card holders in Galway were more likely to be edentulous than nonmedical card holders. Edentate patients were less likely to be regular dental attenders than dentate patients.

Attitudes of Irish dental graduates to vocational training

INTRODUCTION: Vocational training (VT) is a mandatory 12 month period for UK dental graduates after graduation. Graduates of Irish Dental Schools are eligible to enter the general dental service in Ireland or obtain an NHS performers list number in the UK immediately after qualification. Reports would suggest that some graduates of Irish Dental Schools are choosing to take part in VT in the UK and find the experience beneficial. This study aimed to record the uptake of VT amongst recent graduates from University College Cork and to document their experiences. It was designed to compare the attitudes and experiences of graduates of Irish Dental Schools who undertook VT compared with those who entered the general dental service.

METHOD: A self-completion questionnaire was distributed by e-mail to dental graduates from University College Cork who had graduated 2001-2007. Responses were returned by e-mail or post.

RESULTS: The response rate was 68.9%. There has been an increase in the numbers of graduates taking part in VT each year since 2004. 92.5% of Vocational Dental Practitioners (VDPs) found their experience beneficial as they received a guaranteed source of income, had a supportive peer network and worked in a positive learning environment. However, some felt that they earned a lower income than their associate colleagues, others found the pace of practice slow and that the duration of the training period was excessive. Eighty-five per cent of VDPs would choose the same position again after graduation as compared with 61.8% of associates (P < 0.001). Ninety per cent of VDPs would advise current undergraduates to take part in VT as compared with 51% of associates (P < 0.001). A larger proportion of VDPs had taken part in postgraduate studies but there was no significant difference between the two groups.

CONCLUSIONS: Larger proportions of recent graduates are undertaking vocational training.--The majority of VDPs and associates find their initial employment position beneficial.--VDPs benefit from a guaranteed source of income, a supportive peer network and a positive learning environment.--Some associates suffered from a lack of support, feeling isolated and overwhelmed with patients.--The majority of previous VDPs and associates would recommend VT to current undergraduates.--Almost 40% of associates would now choose to take part in VT if given the opportunity.

Career choices on graduation--a study of recent graduates from University College Cork

INTRODUCTION: Irish dental graduates are eligible to enter general dental practice immediately after qualification. Unlike their United Kingdom counterparts, there is no requirement to undertake vocational training (VT) or any pre-registration training. VT is a mandatory 12-month period for all UK dental graduates who wish to work within the National Health Service. It provides structured, supervised experience in training practices and through organised study days.

AIMS: This study aimed to profile the career choices made by recent dental graduates from UCC. It aimed to record the uptake of VT and associate posts, and where the graduates gained employment.

METHODOLOGY: A self-completion questionnaire was developed and circulated electronically to recent graduates from UCC. An existing database of email addresses was used and responses were returned by post or by email. A copy of the questionnaire used is included as Appendix 1.

RESULTS: Questionnaires were distributed over an eight-week period and 142 were returned, giving a response rate of 68.90%. Responses were gathered from those who graduated between 2001 and 2007; however, the majority came from more recent classes. Overall, the majority of graduates took up associate positions after qualification (71.8%) with smaller numbers undertaking VT (28.2%). Increasing numbers have entered VT in recent years, including 54.3% from the class of 2007. Overall, the majority of graduates initially took up positions in England (43%); however, in recent times more have been employed in Scotland. Subsequent work profiles of the graduates illustrate that the majority are now working as associates in general practice (51.4%) and in Ireland (54.2%).

CONCLUSIONS: There has been an increase in the proportion of UCC graduates undertaking VT. Graduates tended to move away from Ireland initially to gain employment. There has been a shift away from employment in England towards Scotland where the majority of new UCC graduates are now initially employed. The majority of graduates returned to Ireland for employment after the initial move away.

A study of patient attitudes towards fasting prior to intravenous sedation for dental treatment in a dental hospital department

INTRODUCTION: Intravenous sedation is the most commonly used method of sedation for the provision of adult dental care. However, disparity exists in pre-operative fasting times in use for patients throughout the United Kingdom.

AIMS: The aims of the study were to obtain information on the effects of existing extended pre-operative fasting regimens, to canvas patient opinions on the fasting process, and to record their positive and negative experiences associated with it.

METHODS: A prospective cross-sectional descriptive study using survey methodology was conducted of adult patients attending a dental hospital for operative treatment under intravenous sedation. Sixty-four questionnaires were distributed over a four-month period, beginning 2nd October 2007.

RESULTS: The surveyed patient pool consisted of 38 females and 14 males with a mean age of 32.4 years. The response rate achieved was 81.2%. Seventy-one per cent of patients indicated that normally they consumed something for breakfast, the most common items being tea and toast. Fifty-one per cent of patients indicated that they would wish to eat the same as normal prior to their appointment and 59% wished to drink as normal. Only 19% of respondents reported that they did not wish to eat anything, with 8% preferring not to drink anything at all. Seventy-nine per cent of the patients reported that they had experienced at least one adverse symptom after fasting and 42% had experienced two or more such symptoms. In general, those patients with more experience of sedation found fasting less unpleasant than those attending for the first time (P<0.05). In addition, one-quarter of all patients indicated that the fasting process had made them feel more nervous about their sedation appointment.

CONCLUSIONS: The extended fasting regimen prior to intravenous sedation appeared to affect patients' wellbeing, as the majority reported adverse symptoms.

Patient preferences for dental clinical attire: a cross-sectional survey in a dental hospital

AIMS AND OBJECTIVES: This cross sectional descriptive study was designed to survey patient opinion towards dental clinical attire, name badges and commonly used cross-infection control measures.

METHOD: Patients attending a dental hospital for a consultation appointment were asked to complete a questionnaire accompanied by photographs of models portraying a range of clinical attire. A representative sample of patients completed 188 questionnaires over a four week period.

RESULTS: The study found that the majority of patients felt clinical attire was important and that they preferred dental professionals to wear name badges. The majority of patients also preferred dentists to use both safety glasses and face masks. When asked to indicate which clinical attire was most appropriate for a consultant/specialist to wear, the overwhelming opinion was that of smart dress accompanied with a white coat. In addition, most respondents wished their dentist to wear a traditional white, dental tunic.

CONCLUDING REMARKS: It is hoped that this study will be informative for the dental team and that the results will be taken into consideration when considering appropriate clinical attire in accordance with patient opinions.