Bereavement Assessment Practice in Hospice Settings: Challenges for Palliative Care Social Workers

The management and delivery of bereavement support services in palliative care settings presents practical and ethical challenges. A national survey, conducted in 2007, examined bereavement practice in ten Marie Curie hospices across the United Kingdom. This qualitative study was undertaken using semi-structured telephone interviews with Bereavement Service Leaders located in each hospice. Although findings revealed that bereavement services were in operation and had been reviewed in response to the National Institute for Clinical Excellence Guidance (2004), and all bereaved families were offered support, there was no standardisation of service delivery across sites. Multi-disciplinary team meetings facilitated shared decision-making for bereavement follow-up, and expanded and clarified documentation completed by nursing staff around the time of the patient’s death. However, there was ambiguity regarding professional ‘duty of care’ and agency responses to bereaved individuals who were suicidal. Questions were raised around clinical effectiveness, reliability and professional accountability. The study highlighted ethical issues centred on documentation, user participation and consent, and found staff training was variable across the 10 hospices. The findings have informed the development of a post-bereavement service model which has been subsequently implemented across Marie Curie Cancer Care.

Microarray-based classifiers and prognosis models identify subgroups with distinct clinical outcomes and high risk of AML transformation of myelodysplastic syndrome

The diagnosis of myelodysplastic syndrome (MDS) currently relies primarily on the morphologic assessment of the patient's bone marrow and peripheral blood cells. Moreover, prognostic scoring systems rely on observer-dependent assessments of blast percentage and dysplasia. Gene expression profiling could enhance current diagnostic and prognostic systems by providing a set of standardized, objective gene signatures. Within the Microarray Innovations in LEukemia study, a diagnostic classification model was investigated to distinguish the distinct subclasses of pediatric and adult leukemia, as well as MDS. Overall, the accuracy of the diagnostic classification model for subtyping leukemia was approximately 93%, but this was not reflected for the MDS samples giving only approximately 50% accuracy. Discordant samples of MDS were classified either into acute myeloid leukemia (AML) or

Prospective Evaluation of Clinical and Ultrasound Findings in Ankle Disease in Juvenile Idiopathic Arthritis: Importance of Ankle Ultrasound

Objective. To prospectively compare clinical examination of the ankle structures with ultrasound (US) findings. Methods. In 42 children with juvenile idiopathic arthritis (JIA; 25 girls, 17 boys, mean age 11.3 yrs, range 2.3–22.3 yrs), a total of 61 swollen/painful ankles were assessed clinically and ultrasonographically. Accurate clinical examination of the entire ankle joint was performed, focusing especially on 3 regions — tibiotalar joint and medial and lateral tendons. Clinical and US findings were both scored 0–3 (normal-severe). Results. US demonstrated no signs of tibiotalar joint effusion in 14 out of 43 ankles considered clinically involved. For the medial tendons, US showed tenosynovitis in 13 ankles out of 31 thought to be clinically normal; and for the lateral tendons, of the 19 deemed to be clinically involved, less than 50% had involvement on US. Very poor agreement was observed comparing the clinical and US scores for the 3 regions: tibiotalar joint, kappa = 0.3; medial tendons, kappa = 0.24; lateral tendons, kappa = 0.25. With regard to other ankle structures, only 39% of the subtalar (talocalcaneal) joints considered clinically involved were deemed abnormal on US. Finally, of the 10 ankles with talonavicular US effusion, only 2 were considered clinically involved. Conclusion. Using US findings as the “gold standard,” clinical examination of the ankle in children with JIA was found to be inadequate in identifying the structures involved. US assessment prior to any glucocorticoid injection should be considered to improve the outcome. A prospective study comparing the outcome following clinical- versus US-guided ankle joint injection should be undertaken, to confirm our findings.

The level playing field: the impact of assessment practice on professional development

Context: The effects of assessment practice on students’ learning are unclear, particularly regarding professional development. Corralling in objective structured clinical examinations (OSCEs) is designed to reduce illicit passing of examination information. Candidates completing an examination are kept secluded until the next cohort of examinees has begun. We used the introduction of corralling as a context in which to explore social influences on examination misconduct, with the aims of improving understanding of the hidden effects of assessment, and evaluating the acceptability of corralling from the student perspective.

Methods: A questionnaire was administered to students corralled post-OSCE for the first time. Eleven semi-structured interviews were subsequently conducted. Questionnaire data were analysed for descriptive statistics and thematic analysis of interview transcripts was carried out.

Results: The questionnaire response rate was 95.4% (251/263). Before corralling, 80.9% (203/251) of students were aware of the sharing of information among peers and 78.5% (197/251) agreed that such misconduct was unprofessional. The majority were in favour of corralling (90.8%, 228/251). Four themes emerged from the semi-structured interviews: the student network versus the individual; assessment-driven culture; the deferring of professionalism, and the ‘level playing field’. Students saw interaction within the student network, on a background of assessment-driven culture, as the key driver in examination misconduct. Conforming to the rules of the social network was prioritised over individual agency, although the mismatch between the rules of the network and the dominant professional discourse caused some conflict for individuals. Deferred professionalism (described as the practice of taking on the norms of professional behaviour only when qualified) was a rationalisation used to minimise this conflict. Corralling provided a ‘level playing field’ in which the influences of the network were minimised.

Conclusions: Examination misconduct is thus a complex social construction with implications for individual learners in terms of professional development. Corralling is one mechanism for addressing misconduct that is acceptable to students, but assessment processes have important hidden effects which educators should acknowledge.

A Risky Business: An Examination of Irish Probation Officers Attitudes and Work Practices Regarding Risk Assessment

This article examines recent research on risk assessment and probation practice in Ireland and relates the findings to the ongoing debate regarding risk management practices in probation. The piece discusses current theoretical arguments on the influence of risk in criminal justice and outlines the impact of risk discourse on probation practice in Ireland and England and Wales. Using a mix of qualitative and quantitative methods, Irish probation officers’ attitudes are examined in order to highlight key issues facing probation officers when making risk decisions. These findings are compared and contrasted to other research results from England and Wales. All the conclusions identify both positive and negative consequences of adopting risk tools and point to the continued salience of clinical judgment over actuarial methods of risk assessment. It is argued that the research highlights the role of ‘resistance’ by criminal justice professionals in mediating the effects of the ‘new penology’ at the level of implementation. The idea of resistance holds particular relevance for probation practice in Ireland where professional discretion is maintained within the National Standards framework. Despite this, to date there has been an uncritical approach taken to risk assessment which may ignore the dangers of risk inflation/deflation and the need to take into account local factors in assessing risk of reoffending

Assessment of cell-mediated immunity in a British population using multiple skin test antigens

An in vivo method of assessing the competence of the cell-mediated immune system (Multitest CMI) was used in 200 healthy volunteers (age range 17-88 years). The profile of reactivity to seven individual antigens was determined. A positive reaction was obtained in 96.5% of the subjects who reacted positively to at least one antigen with 78% reacting to two or more antigens. The number of positive responses and the degree of reactivity was significantly reduced in elderly subjects and in females aged 17-65 years. The Multitest CMI system provides a rapid and convenient method of assessing cell-mediated immunity (CMI) in vivo and could have a wide range of applications in the investigation of immunological, infective and neoplastic conditions.

The geriatric minimum data set for clinical trials (GMDS)

To overcome the weak evidence base coming from often poor and insufficient clinical research in older people, a minimum data set to achieve harmonisation is highly advisable. This will lead to uniform nomenclature and to the standardisation of the assessment tools. Our primary objective was to develop a Geriatric Minimum Data Set (GMDS) for clinical research.

Fluoroscopic and electrical assessment of a series of defibrillation leads:prevalence of externalized conductors

Introduction : Insulation defects with externalized conductors have been reported in the St. Jude Riata(®) family of defibrillation leads (St. Jude Medical, Sylmar, CA, USA). The objective of the Northern Ireland Riata(®) lead screening program was to identify insulation defects and externalized conductors by systematic fluoroscopic and electrical assessment in a prospectively defined cohort of patients. We sought to estimate the prevalence, identify risk factors, and determine the natural history of this abnormality. Methods : All patients with a Riata(®) lead under follow-up at the Royal Victoria Hospital were invited for fluoroscopic imaging and implantable cardioverter-defibrillator lead parameter checks. Fluoroscopic images were read independently by two cardiologists and the presence of externalized conductors was classified as positive, negative, or borderline. Results: One hundred and sixty-five of 212 patients with a Riata lead were evaluated by fluoroscopy and lead parameter measurements. The mean duration after implantation was 3.98+/-1.43 years. After screening 25 (15%) patients were classified as positive, 137 (83%) negative, and three (1.8%) borderline. Time since implantation (P = 0.001), presence of a single coil lead (P = 0.042), and patient age (P = 0.034) were significantly associated with externalized conductors. The observed rate of externalized conductors was 26.9% for 8-French and 4.7% for 7-French leads. No leads that were identified prospectively with externalized conductors had electrical abnormalities. Seven of 25 (28%) patients had a defective lead extracted by the end of this screening period. Conclusion: A significant proportion (15%) of patients with a Riata lead had an insulation breach 4 years after implantation. High-resolution fluoroscopic imaging in at least two orthogonal views is required to identify this abnormality. (PACE 2012;35:1498-1504).

Issues of assessment of pain and discomfort in neonates

Pain assessment in neonates often presents problems. The problem of inadequate or inaccurate assessment is complicated by issues related to the nature, consistency, and variability of the infant's physiologic and behavioral responses; the reliability, validity, specificity, sensitivity, and practicality of existing neonatal pain measures or measurement approaches; ethical questions about pain research in infants; and uncertainty about the responsibilities of health care professionals in managing pain in clinical settings. Despite these many issues, neonates need to be comfortable and as free of pain as possible to grow and develop normally. Valid and reliable assessment of pain is the major prerequisite for attaining this goal. Issues embodied in neonatal pain responses, measurement, ethical, and clinical considerations are explored. Suggestions for resolving some of these problems are presented.

Depression associates with Mini Nutritional Assessment (MNA), Vitamin B12 and Folate status::Findings from Belfast Elderly Longitudinal Free-Living Ageing STudy (BELFAST)

Introduction: An association between depression and folate has been found in clinical studies. Depression and dementia can contribute to nutritional deficiency. This study clinical depression in in octo/nonagenarians from the BELFAST study.
Method: In the BELFAST study, 38 free-living octo/nonagenarians (mean age 82 years), who apparently well and cognitively intact were followed up at 5 years and assessed using the Geriatric Depression Scale (GDS), Folstein (30 point), Mini Nutritional Assessment Tool (MNA) together with serum folate and vitamin B12 levels.
Results: Mean GDS was 3.4 (SD 2.5), serum folate 7.1 umol/l (SD 5.3) and B12 553 umol/l (458). With mean MNA and Folstein -25.8 (SD 2.7) and 27.6 (SD 2.7) respectively with no sex difference (p = 0.78; p = 0.36). 25% of subjects showed a GDS >5 indicating risk of mild depression and 21% had compromised nutritional status. MNA associated with GDS in male (r2 = 0.56 p = 0.01), but not in female elderly subjects (r2 = 0.01; p = 0.44). GDS score and lower serum folate were associated (r2 = -0.23; p = 0.01).
Conclusion: Overall there was the suggestion that nutritional status and depression might be linked in male subjects at 5 year follow-up in octo/nonagenarians from the BEFLAST study. The lower folate in subjects categorised at risk of mild depression might suggest vitamin supplementation could be useful.

The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma:A systematic review and economic evaluation

Objectives: To assess whether open angle glaucoma (OAG) screening meets the UK National Screening Committee criteria, to compare screening strategies with case finding, to estimate test parameters, to model estimates of cost and cost-effectiveness, and to identify areas for future research. Data sources: Major electronic databases were searched up to December 2005. Review methods: Screening strategies were developed by wide consultation. Markov submodels were developed to represent screening strategies. Parameter estimates were determined by systematic reviews of epidemiology, economic evaluations of screening, and effectiveness (test accuracy, screening and treatment). Tailored highly sensitive electronic searches were undertaken. Results: Most potential screening tests reviewed had an estimated specificity of 85% or higher. No test was clearly most accurate, with only a few, heterogeneous studies for each test. No randomised controlled trials (RCTs) of screening were identified. Based on two treatment RCTs, early treatment reduces the risk of progression. Extrapolating from this, and assuming accelerated progression with advancing disease severity, without treatment the mean time to blindness in at least one eye was approximately 23 years, compared to 35 years with treatment. Prevalence would have to be about 3-4% in 40 year olds with a screening interval of 10 years to approach cost-effectiveness. It is predicted that screening might be cost-effective in a 50-year-old cohort at a prevalence of 4% with a 10-year screening interval. General population screening at any age, thus, appears not to be cost-effective. Selective screening of groups with higher prevalence (family history, black ethnicity) might be worthwhile, although this would only cover 6% of the population. Extension to include other at-risk cohorts (e.g. myopia and diabetes) would include 37% of the general population, but the prevalence is then too low for screening to be considered cost-effective. Screening using a test with initial automated classification followed by assessment by a specialised optometrist, for test positives, was more cost-effective than initial specialised optometric assessment. The cost-effectiveness of the screening programme was highly sensitive to the perspective on costs (NHS or societal). In the base-case model, the NHS costs of visual impairment were estimated as £669. If annual societal costs were £8800, then screening might be considered cost-effective for a 40-year-old cohort with 1% OAG prevalence assuming a willingness to pay of £30,000 per quality-adjusted life-year. Of lesser importance were changes to estimates of attendance for sight tests, incidence of OAG, rate of progression and utility values for each stage of OAG severity. Cost-effectiveness was not particularly sensitive to the accuracy of screening tests within the ranges observed. However, a highly specific test is required to reduce large numbers of false-positive referrals. The findings that population screening is unlikely to be cost-effective are based on an economic model whose parameter estimates have considerable uncertainty, in particular, if rate of progression and/or costs of visual impairment are higher than estimated then screening could be cost-effective. Conclusions: While population screening is not cost-effective, the targeted screening of high-risk groups may be. Procedures for identifying those at risk, for quality assuring the programme, as well as adequate service provision for those screened positive would all be needed. Glaucoma detection can be improved by increasing attendance for eye examination, and improving the performance of current testing by either refining practice or adding in a technology-based first assessment, the latter being the more cost-effective option. This has implications for any future organisational changes in community eye-care services. Further research should aim to develop and provide quality data to populate the economic model, by conducting a feasibility study of interventions to improve detection, by obtaining further data on costs of blindness, risk of progression and health outcomes, and by conducting an RCT of interventions to improve the uptake of glaucoma testing. © Queen's Printer and Controller of HMSO 2007. All rights reserved.

Comparison of two fast strategies, SITA fast and TOP, for the assessment of visual fields in glaucoma patients

Purpose: To compare two fast threshold strategies of visual field assessment; SITA Fast (HSF) and Tendency Orientated Perimetry (TOP), in detecting visual field loss in patients with glaucoma. Methods: Seventy-six glaucoma, ocular hypertensive and normal patients had HSF and TOP performed in random order. Quantitative comparisons for the global visual field indices - mean deviation and defect (MD) for HSF and TOP, and pattern standard deviation (PSD) for HSF and loss variance (LV) for TOP - were made using correlation coefficients. Humphrey global parameters were converted to Octopus equivalents, and method comparison analysis was used to determine agreement between the two strategies. Test duration times were compared using t-test. Sensitivity and specificity for these two algorithms were determined according to predetermined criteria. Results: High correlation coefficient values were obtained for MD measurements between HSF and TOP (r=-0.89, P

Comorbid motor deficits in a clinical sample of children with specific language impairment

The aim of the present study was to compare the motor function of a clinical sample of children with specific language impairment (SLI) to a language-matched comparison group that had not been referred for SLI assessment. A typical language comparison group with similar nonverbal IQ was also included. There were approximately 35 children in each group, aged 9- to 10-years-old, and the children completed a range of standardised language, motor and literacy measures. The results showed that the SLI group scored significantly lower than the language-matched and typical language comparison groups on all of the motor and literacy measures. We conclude that language factors alone are insufficient to explain the extensive comorbid motor and literacy deficits shown by the children with SLI in this study. We suggest that the clinical diagnosis of SLI may be influenced by the presence of additional developmental difficulties, which should be made explicit in assessment procedures, and that intervention strategies which address the broad range of difficulties experienced by children with a clinical diagnosis of SLI, should be prioritised.

Serial chimerism analyses indicate that mixed haemopoietic chimerism influences the probability of graft rejection and disease recurrence following allogeneic stem cell transplantation (SCT) for severe aplastic anaemia (SAA): indication for routine assessment of chimerism post SCT for SAA

Ninety-one patients were studied serially for chimeric status following allogeneic stem cell transplantation (SCT) for severe aplastic anaemia (SAA) or Fanconi Anaemia (FA). Short tandem repeat polymerase chain reaction (STR-PCR) was used to stratify patients into five groups: (A) complete donor chimeras (n = 39), (B) transient mixed chimeras (n = 15) (C) stable mixed chimeras (n = 18), (D) progressive mixed chimeras (n = 14) (E) recipient chimeras with early graft rejection (n = 5). As serial sampling was not possible in Group E, serial chimerism results for 86 patients were available for analysis. The following factors were analysed for association with chimeric status: age, sex match, donor type, aetiology of aplasia, source of stem cells, number of cells engrafted, conditioning regimen, graft-versus-host disease (GvHD) prophylaxis, occurrence of acute and chronic GvHD and survival. Progressive mixed chimeras (PMCs) were at high risk of late graft rejection (n = 10, P <0.0001). Seven of these patients lost their graft during withdrawal of immunosuppressive therapy. STR-PCR indicated an inverse correlation between detection of recipient cells post-SCT and occurrence of acute GvHD (P = 0.008). PMC was a bad prognostic indicator of survival (P = 0.003). Monitoring of chimeric status during cyclosporin withdrawal may facilitate therapeutic intervention to prevent late graft rejection in patients transplanted for SAA.