A decade of silicone hydrogel development:surface properties, mechanical properties, and ocular compatibility

Since the initial launch of silicone hydrogel lenses, there has been a considerable broadening in the range of available commercial material properties. The very mobile silicon–oxygen bonds convey distinctive surface and mechanical properties on silicone hydrogels, in which advantages of enhanced oxygen permeability, reduced protein deposition, and modest frictional interaction are balanced by increased lipid and elastic response. There are now some 15 silicone hydrogel material variants available to practitioners; arguably, the changes that have taken place have been strongly influenced by feedback based on clinical experience. Water content is one of the most influential properties, and the decade has seen a progressive rise from lotrafilcon-A (24%) to efrofilcon-A (74%). Moduli have decreased over the same period from 1.4 to 0.3 MPa, but not solely as a result of changes in water content. Surface properties do not correlate directly with water content, and ingenious approaches have been used to achieve desirable improvements (e.g., greater lubricity and lower contact angle hysteresis). This is demonstrated by comparing the hysteresis value of the earliest (lotrafilcon-A, >40°) and most recent (delefilcon-A, <10°) coated silicone hydrogels. Although wettability is important, it is not of itself a good predictor of ocular response because this involves a much wider range of physicochemical and biochemical factors. The interference of the lens with ocular dynamics is complex leading separately to tissue–material interactions involving anterior and posterior lens surfaces. The biochemical consequences of these interactions may hold the key to a greater understanding of ocular incompatibility and end of day discomfort.

Using XML and XSLT for flexible elicitation of mental-health risk knowledge

Current tools for assessing risks associated with mental-health problems require assessors to make high-level judgements based on clinical experience. This paper describes how new technologies can enhance qualitative research methods to identify lower-level cues underlying these judgements, which can be collected by people without a specialist mental-health background. Content analysis of interviews with 46 multidisciplinary mental-health experts exposed the cues and their interrelationships, which were represented by a mind map using software that stores maps as XML. All 46 mind maps were integrated into a single XML knowledge structure and analysed by a Lisp program to generate quantitative information about the numbers of experts associated with each part of it. The knowledge was refined by the experts, using software developed in Flash to record their collective views within the XML itself. These views specified how the XML should be transformed by XSLT, a technology for rendering XML, which resulted in a validated hierarchical knowledge structure associating patient cues with risks. Changing knowledge elicitation requirements were accommodated by flexible transformations of XML data using XSLT, which also facilitated generation of multiple data-gathering tools suiting different assessment circumstances and levels of mental-health knowledge. © 2007 Informa UK Ltd All rights reserved.

Investigating the influence of African American and African Caribbean race on primary care doctors' decision making about depression

This paper explores differences in how primary care doctors process the clinical presentation of depression by African American and African-Caribbean patients compared with white patients in the US and the UK. The aim is to gain a better understanding of possible pathways by which racial disparities arise in depression care. One hundred and eight doctors described their thought processes after viewing video recorded simulated patients presenting with identical symptoms strongly suggestive of depression. These descriptions were analysed using the CliniClass system, which captures information about micro-components of clinical decision making and permits a systematic, structured and detailed analysis of how doctors arrive at diagnostic, intervention and management decisions. Video recordings of actors portraying black (both African American and African-Caribbean) and white (both White American and White British) male and female patients (aged 55 years and 75 years) were presented to doctors randomly selected from the Massachusetts Medical Society list and from Surrey/South West London and West Midlands National Health Service lists, stratified by country (US v.UK), gender, and years of clinical experience (less v. very experienced). Findings demonstrated little evidence of bias affecting doctors' decision making processes, with the exception of less attention being paid to the potential outcomes associated with different treatment options for African American compared with White American patients in the US. Instead, findings suggest greater clinical uncertainty in diagnosing depression amongst black compared with white patients, particularly in the UK. This was evident in more potential diagnoses. There was also a tendency for doctors in both countries to focus more on black patients' physical rather than psychological symptoms and to identify endocrine problems, most often diabetes, as a presenting complaint for them. This suggests that doctors in both countries have a less well developed mental model of depression for black compared with white patients. © 2014 The Authors.

Glasgow antipsychotic side-effects scale for Clozapine - development and validation of a clozapine-specific side-effects scale

OBJECTIVE: The authors developed and validated a clozapine-specific side-effects scale capable of eliciting the subjectively unpleasant side-effects of clozapine. METHODS: Questions from the original Glasgow Antipsychotic Side-effects Scale (GASS) were compared to a list of the most commonly reported clozapine side-effects and those with a significant subjective burden were included in the GASS for Clozapine (GASS-C). The original authors of the GASS and a group of mental health professionals from the UK and Ireland were enlisted to comment on the questions in the GASS-C based on their clinical experience. 110 clozapine outpatients from two sites completed the GASS-C, the original GASS and a repeat GASS-C. Statistical analyses were performed using SPSS for Windows version 19. RESULTS: The GASS-C was shown to have construct validity, in that Spearman's correlation coefficient was 0.816 (p<0.001) with the original GASS, whilst Cohen's kappa coefficient was >0.77 (p<0.001) for one question and >0.81 (p<0.001) for remaining relevant questions. GASS-C was also shown to have strong test-retest reliability, in that Cronbach's alpha coefficient was >0.907 (p<0.001), whilst Cohen's kappa coefficient was >0.81 (p<0.001) for 12 questions and >0.61 (p<0.001) for the remaining four questions. CONCLUSION: The GASS-C is a valid and reliable clinical tool to enable a systematic assessment of the subjectively unpleasant side-effects of clozapine. Future research should focus on how the scale can be utilised as a clinical tool to improve real-world outcomes such as adherence to clozapine therapy and quality of life.

The 2012 update to the anticholinergic cognitive burden scale

Background: In 2008, the Anticholinergic Cognitive Burden (ACB) scale was generated through a combination of laboratory data, literature review, and expert opinion. This scale identified an increased risk in mortality and worsening cognitive function in multiple populations, including 13,000 older adults in the United Kingdom. We present an updated scale based on new information and new medications available to the market. Methods: We conducted a systematic review for publications recognizing medications with adverse cognitive effects due to anti-cholinergic properties and found no new medications since 2008.Therefore we identified medications from a review of newly ap-proved medications since 2008 and medications identified throughthe clinical experience of the authors. To be included in the updatedACB scale, medications must have met the following criteria; ACBscore of 1: evidence from in vitro data that the medication has antag-onist activity at muscarinic receptors; ACB score of 2: evidence fromliterature, prescriber’s information, or expert opinion of clinical anti-cholinergic effect; ACB score of 3: evidence from literature, pre-scriber’s information, or expert opinion of the medication causingdelirium. Results: The reviewer panel included two geriatric pharmacists,one geriatric psychiatrist, one geriatrician, and one hospitalist.Twenty-three medications were eligible for review and possible inclu-sion in the updated ACB scale. Of these, seven medications were ex-cluded due to a lack of evidence for anticholinergic activity. Of the re-maining 16 medications, ten had laboratory evidence ofanticholinergic activity and added to the ACB list with a score of one.One medication was added with a score of two. Five medicationswere included in the ACB scale with a score of three.Conclusions: The revised ACB scale provides an update of med-ications with anticholinergic effects that may increase the risk of cog-nitive impairment. Future updates will be routinely conducted tomaintain an applicable library of medications for use in clinical andresearch environments.

The use of treatment theories and procedures for postural control in adult with hemiplegia: A national survey

This study investigated the use of treatment theories and procedures for postural control training used by Occupational Therapists (OTs) when working with hemiplegic adults who have had cerebrovascular accident (CVA) or traumatic brain injury (TBI). The method of data collection was a national survey of 400 randomly selected physical disability OTs with 127 usable surveys returned. Results showed that the most common used treatment theory was neurodevelopmental treatment (NDT), followed by motor relearning program (MRP), proprioceptive neuromuscular facilitation (PNF), Brunnstrom's approach, and the approach of Rood. The most common treatment posture used was sitting, followed by standing, mat activity, equilibrium reaction training, and walking. The factors affecting the use of various treatment theories procedures were years certified, years of clinical experience, work situation and work status. Pearson correlation coefficient analyses found significant positive relationships between treatment theories and postures. There were significant high correlations between usage of all pairs of treatment procedures. ^

Ethics in the provision of removable partial dentures

Aim: To investigate the construction of cobalt-chromium removable partial dentures by commercial private dental laboratories. Methods: Ninety master casts for fabrication of cobalt-chromium removable partial dentures were obtained from three commercial laboratories randomly selected. Casts were assessed for dental arch treated, Kennedy classification, cast surveying, denture design information provided by the dentist, and mouth preparation (rest seat, guiding plane and retentive area). Dental technicians answered a questionnaire regarding qualification of assisted dentists, monthly number of framework castings, and use of dental surveyor. Mouth preparation was compared among laboratories using Kruskal-Wallis test (α=0.05). Results: The percentage of Kennedy class I was 16%, class II 19%, class III 56%, and class IV 9%. The majority of master cats (51%) examined was sent to dental laboratories without any design information and did not comply with ethical guidelines in the provision of RPD. Approximately half of the casts were considered “inappropriate” for guiding planes and retentive areas. One of the laboratories presented all casts “inappropriate” for rest seat distribution (p<0.001). Conclusions: Mouth preparation frequently failed for guiding planes, retentive areas and distribution of rest seats. It is necessary to provide students with adequate clinical experience at the dental school environment, which will actually be carried into the practice of dentistry.

Ethics in the provision of removable partial dentures

Aim: To investigate the construction of cobalt-chromium removable partial dentures by commercial private dental laboratories. Methods: Ninety master casts for fabrication of cobalt-chromium removable partial dentures were obtained from three commercial laboratories randomly selected. Casts were assessed for dental arch treated, Kennedy classification, cast surveying, denture design information provided by the dentist, and mouth preparation (rest seat, guiding plane and retentive area). Dental technicians answered a questionnaire regarding qualification of assisted dentists, monthly number of framework castings, and use of dental surveyor. Mouth preparation was compared among laboratories using Kruskal-Wallis test (α=0.05). Results: The percentage of Kennedy class I was 16%, class II 19%, class III 56%, and class IV 9%. The majority of master cats (51%) examined was sent to dental laboratories without any design information and did not comply with ethical guidelines in the provision of RPD. Approximately half of the casts were considered “inappropriate” for guiding planes and retentive areas. One of the laboratories presented all casts “inappropriate” for rest seat distribution (p<0.001). Conclusions: Mouth preparation frequently failed for guiding planes, retentive areas and distribution of rest seats. It is necessary to provide students with adequate clinical experience at the dental school environment, which will actually be carried into the practice of dentistry.

Nutrition

This new edition of The Perioperative Medicine Consult Handbook provides useful information, advice, and guidelines based on a combination of clinical experience and evidence-based medicine.

Nurses’ perceptions of nursing presence and the relationship between nursing presence and moral sensitivity in nurses working with people with dementia in residential care

Aim: The aim of this study was to measure nursing presence among nurses caring for people with dementia in residential care settings, and to investigate the relationship between nursing presence and moral sensitivity. Background: Nursing presence is a core relational skill in nursing and holds many benefits for nurses and their patients. Moral sensitivity is defined as how one recognises the moral elements of a situation, and how one’s moral or ethical decision making may impact on an individual. Methods: A descriptive, cross sectional quantitative methodology was used with a sample of 150 registered nurses. The Presence of Nursing Scale for Registered Nurses was used to investigate nursing presence, and the Moral Sensitivity Questionnaire for moral sensitivity. Results: Findings from the study demonstrated that participants agreed with the majority of elements of nursing presence, (mean 76.97, SD= 7.51). A mean score of 36.22 was evidence of a well developed level of moral sensitivity in participants. Nurses who perceived themselves to be highly present to their patients also scored highest on certain elements of moral sensitivity such as moral strength. Nursing presence was also found to be more developed in those participants that rated themselves as having higher levels of expertise based on Benner’s (1984) definitions. Older nurses also scored higher on nursing presence. There was a high level of agreement that factors such as lack of time (n=133), and heavy workload influenced nursing presence. Nurses, who were older and had longer clinical experience, were shown to have greater moral strength. There were differences in elements of moral sensitivity between groups of nurses who ranked themselves according to Benner’s (1984) competence framework with higher scores evident in the more expert groups. Conclusion: Overall, this study showed that participants had a well developed level of nursing presence, and certain elements of moral sensitivity are positively related to nursing presence. Nursing presence appears to be linked to the level of expertise of the nurse but factors such as time and workload do influence nursing presence.

Addressing the theory practice gap in nurse education: evaluating teaching through audit against NMC standards and final management placement

Introduction
This paper outlines an innovative approach to auditing and evaluating the content of a management and leadership module for undergraduate nursing students after their final management clinical placement. Normally evaluations of teaching in a module take place at the end of a teaching module and therefore do not properly reflect the value of the teaching in relation to practical clinical experience.
Aim
This audit and evaluation sought to explore both the practical value of the teaching and learning, and also the degree to which it the teaching reflected against the NMC Standards of Education and Learning (2010 domain 3).
Methods
Having piloted the evaluative tool with an earlier cohort of nursing students, this evaluation explored both a quantitative assessment employing a Personal Response System (n =172), together with a qualitative dimension (n=116), thus delivering paper-based comments and reflections from students on the value and practicality of the module teaching theory to their final clinical management experience. The quantitative audit data were analysed for frequencies and cross tabulation and the qualitative audit data were thematically analysed.
Results
Results suggest a significant proportion of the students, appreciated the quality of the standard of teaching, but more importantly, ‘valued or highly valued’ the teaching and learning in relation to how it helped to significantly inform their management placement experience. A smaller proportion of the students underlined limitations and areas in which further improvement can be made in teaching and learning to the module.
Conclusion
Significantly positive evaluation by the students of the practical value of teaching and learning, to the theoretical management module. This has proved a useful auditing approach in assessing the theoretical teaching to student’s Level 3 clinical experience, and facilitated significant recommendations as far as developing the teaching and learning to better reflect the practice needs of nursing students

Is renal medullary carcinoma the seventh nephropathy in sickle cell disease? A multi-center Nigerian survey.

Introduction: Previous studies had enlisted renal medullary carcinoma (RMC) as the seventh nephropathy in sickle cell disease (SCD). Clinical experience has contradicted this claim and this study is targeted at refuting or supporting this assumption. Objective: To estimate the prevalence of RMC and describe other renal complications in SCD. Materials and methods: 14 physicians (haematologists and urologists) in 11 tertiary institutions across the country were collated from patients’ case notes and hospital SCD registers. Results: Of the 3,596 registered sickle patients, 2 (0.056%) had been diagnosed with RMC over a ten year period, thereby giving an estimated prevalence rate of 5.6 per 100,000. The most common renal complication reported by the attending physicians was chronic kidney disease (CKD). The frequency of routine renal screening for SCD patients varied widely between centres – most were done at diagnosis, annually or bi-annually. Conclusion: The ten year prevalence of RMC in Nigerian SCD patients was determined to be 5.6 (estimated incidence of 0.56). RMC is not more common in SCD patients and therefore cannot be regarded as a “Seventh Sickle nephropathy”. Most of the managing physicians reported that the commonest nephropathy observed in their SCD patients was chronic kidney disease.

Spanish Rheumatology Society and Hospital Pharmacy Society Consensus on recommendations for biologics optimization in patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis

The aim of this study was to establish guidelines for the optimization of biologic therapies for health professionals involved in the management of patients with RA, AS and PsA. Recommendations were established via consensus by a panel of experts in rheumatology and hospital pharmacy, based on analysis of available scientific evidence obtained from four systematic reviews and on the clinical experience of panellists. The Delphi method was used to evaluate these recommendations, both between panellists and among a wider group of rheumatologists. Previous concepts concerning better management of RA, AS and PsA were reviewed and, more specifically, guidelines for the optimization of biologic therapies used to treat these diseases were formulated. Recommendations were made with the aim of establishing a plan for when and how to taper biologic treatment in patients with these diseases. The recommendations established herein aim not only to provide advice on how to improve the risk:benefit ratio and efficiency of such treatments, but also to reduce variability in daily clinical practice in the use of biologic therapies for rheumatic diseases

Les Perceptions des Étudiants en Soins Infirmiers Pédiatriques en Milieu Communautaire

Over the last decade health care delivery has shifted from hospitals to the community resulting in a significant reduction of hospital-based clinical placements for nursing students to practice and learn. Studies have emerged describing this problem and outlining the ways in which Colleges and Universities have attempted to deal with the acute shortage of clinical areas in nursing and other health care programs. Several studies describe the development of community-based clinical experiences, and some of these examined students’ perceptions. One finding appears to be constant: student perceptions of community experiences have an effect on their learning outcomes. There is an increasing need to teach nursing students in community settings both to contend with the shortage of hospital-based placements and to prepare students for future practice. Pediatric hospitals are no longer able to provide as many clinical placements as they once did. This has created a problem for college nursing departments. Over the past five years, John Abbott College’s pediatric nursing teachers have attempted to deal with this problem in numerous ways; however, students and faculty were dissatisfied with the solutions as there was a lack of development of the pediatric community clinical component. The purpose of this study is to explore nursing students’ perceptions of pediatric community experiences both prior to the start of the clinical rotation and following the experience. Student perceptions of nursing in community settings are an important element in the level of student satisfaction and ultimately their learning in pediatric clinical settings. In order to explore the John Abbott College’s nursing students’ perceptions, data was collected from a small segment of the population. Students’ perceptions were explored quantitatively through the use of questionnaires using a Likert scale administered both prior to the clinical experience and following the experience; and qualitatively, using content analysis of reflective journals and focus group discussions. The results of the study demonstrated that prior to the community rotations; students did not know what the experience would involve. They felt apprehensive due to being inadequately prepared for the experience and questioned the actual learning they would acquire from a community setting. Following the pediatric community experience, students perceived benefits to their learning particularly in the development of their abilities to communicate with children, and to recognize and apply principles of growth and development to children of different age groups and with different health needs. In addition, students perceived an increase in their self- confidence when teaching children. They also developed an appreciation of the role of the nurse in health promotion for individuals’ in community settings. Furthermore, students described an increase in their awareness of resources that are available in the community. Overall, students were satisfied with their pediatric community clinical experience. The results of this study indicate that adequate student preparation is required prior to the community clinical experience. This preparation would include a clear description of the clinical objectives and associated learning activities, as well as an explicit explanation of the evaluation process. Finally, it is recommended that the pediatric nursing teachers continue to search for community clinical areas that can enhance student learning in pediatrics. This study contributes to the literature on community experiences for nursing students since it explored students’ perceptions before and after the community clinical rotation.

Une comparaison des journaux non structurés et des journaux structurés rédigés par les étudiants en hygiène dentaire

The Canadian Dental Hygienists Association (CDHA) has indicated that there is a need for research in education in the field of dental hygiene. It seems that when compared to the nursing profession, the profession of dental hygiene is only in the earliest stages of investigating ways of teaching critical thinking. The faculty of the dental hygiene program at John Abbott College has always valued the skill of self-assessment in the students, yet there are few specific learning activities provided whereby the students can learn how to perfect and work on this invaluable skill of self-reflection in order to better self-assess. Although self-assessment is required of the students upon the completion of each clinical experience in Clinic 1, 2 and 3, a modest amount of clinical time is allotted to reflect upon this most important skill. It appears that more could be done to prepare our students to assess their learning and clinical practice. Self-reflection as an essential element of practice has a valid place in professional education. The purpose of conducting this study was to find out whether unstructured or structured self-reflective journal writing is a sound pedagogical technique to encourage dental hygiene students’ self-assessment through self-reflection. The research design for the project was a single case study. The paradigm for the study was chosen with a purposeful selection of participants, involving twenty-seven, third-year dental hygiene students at John Abbott College. The students were arbitrarily enrolled in two sections, which for the purpose of this study were referred to as Group A and Group B. Three duplicated coded anonymous journal entries from each student were collected over a ten-week period during the Fall 2009 semester. To examine the students’ level of self-reflection, two methods were used. First a content analysis of reflective journals was used to ascertain the level and substance of the reflections from their clinical experiences with the intent of looking more specifically at the students’ self-assessment. The journal entries were coded and analyzed after the grades were submitted at the end of the school term. This was followed by the distribution of an anonymous questionnaire to the students in both sections. The responses of the questionnaire were tabulated and analyzed. An analysis was done on the data collected in order to determine whether age, education and or mother tongue of the students in both Groups A and B had an influence on their perceptions of journal writing, as well as the student’s opinions about the value of journal writing. This questionnaire included two open-ended questions to assist in gathering additional data on the student’s thoughts on writing journals. A content analysis of the qualitative data collected from the open-ended questions in the questionnaire was also analyzed. Results indicated there were very few differences in the level of self-reflection leading to self-assessment. However, students in Group B who were assigned structured journals showed more evidence of deeper learning. Taken as a whole, the journal entries clearly showed the students were involved in ‘reflection-on-action’ of their clinical experiences (Schon 1987, as cited in Asadoorian & Batty, 2005). The quality of the responses for the most part indicated the students took the time and effort to record their perceptions of their clinical experiences. It is important to note that the results do indicate that students did show a need to self-reflect and assess. The students did in fact validate the importance of reflection through journal writing, even though they did not particularly like it as an added assignment. The journals were found to be very helpful to the research in getting to know what the issues were that held the students’ attention. They explained how and to what extent the students developed relationships with their clients. It was obvious that clinicians have an impact and influence on student learning. The students value the help, role modeling, patience, encouraging words and or gestures, positive reinforcement, and understanding provided by their clinicians. This research provides some evidence that students do believe that self-reflection through structured journal writing helped them better prepare for future clinical sessions with their clients. Our goal as educators should be to encourage dental hygiene students to self-assess through written self-reflection as an established practice for deeper learning.