Pre-conception care : current practice and methods of provision

This thesis examines the present provisions for pre-conception care and the views of the providers of services. Pre-conception care is seen by some clinicians and health educators as a means of making any necessary changes in life style, corrections to imbalances in the nutritional status of the prospective mother (and father) and the assessment of any medical problems, thus maximizing the likelihood of the normal development of the baby. Pre-conception care may be described as a service to bridge the gap between the family planning clinic and the first ante-natal booking appointment. There were three separate foci for the empirical research - the Foresight organisation (a charity which has pioneered pre-conception care in Britain); the pre-conception care clinic at the West London Hospital, Hammersmith; and the West Midlands Regional Health Authority. The six main sources of data were: twenty five clinicians operating Foresight pre-conception clinics, couples attending pre-conception clinics, committee members of the Foresight organisation, staff of the West London Hospital pre-conception clinic, Hammersmith, District Health Education Officers working in the West Midlands Regional Health Authority and the members of the Ante-Natal Care Action Group, a sub-group of the Regional Health Advisory Group on Health Promotion and Preventive Medicine. A range of research methods were adopted. These were as follows: questionnaires and report forms used in co-operation with the Foresight clinicians, interviews, participant observation discussions and informal meetings and, finally, literature and official documentation. The research findings illustrated that pre-conception care services provided at the predominantly private Foresight clinics were of a rather `ad hoc' nature. The type of provision varied considerably and clearly reflected the views held by its providers. The protocol which had been developed to assist in the standardization of results was not followed by the clinicians. The pre-conception service provided at the West London Hospital shared some similarities in its approach with the Foresight provision; a major difference was that it did not advocate the use of routine hair trace metal analysis. Interviews with District Health Education Officers and with members of the Ante Natal Care Action Group revealed a tentative and cautious approach to pre-conception care generally and to the Foresight approach in particular. The thesis concludes with a consideration of the future of pre-conception care and the prospects for the establishment of a comprehensive pre-conception care service.

Articulating discursive and materialist conceptions of practice in the logics approach to critical policy analysis

In this article it is argued that while Glynos and Howarth’s logics of critical explanation (LCE) offers an important and promising contribution to critical policy analysis, it, along with other approaches that focus on the meaning of social action, faces a growing challenge in the form of a so-called new materialist turn in social and political theory. The article argues that there is much to be gained for the logics approach in paying closer attention to the materiality of practices in terms not only of lending greater clarity to the conception and role of social practices in the logics approach but also in enabling it fully to deliver on its critical ambition. The article explores an alternative materialist approach to the study of social practices, which hails from the post-actor–networktheory tradition and which has ontological affinities with post-structuralism. The article begins with a brief analysis of the new materialist turn in its various guises. It then critically examines the logics approach, and, in particular its conception of practice. It then explores an alternative materialist and ethnographic reading of practice, focusing on medical and care practices. It concludes with an examination of the implications for a more materialist conception of practices for the LCE’s broad deconstructive, psychoanalytic and onto-political ambitions.

Intern pharmacists as change agents to improve the practice of nonprescription medication supply: provision of salbutamol to patients with asthma

BACKGROUND: Earlier work established an evidence practice gap during provision of nonprescription salbutamol (albuterol). Pharmacist interns are hypothesized to be in a position to improve professional practice in the community pharmacy setting. OBJECTIVE: To explore the potential of intern pharmacists to improve the professional practice of community pharmacy staff in the provision of nonprescription salbutamol. METHODS: Intern pharmacists (n = 157) delivered an asthma intervention in 136 pharmacies consisting of an educational activity to pharmacy staff and a health promotion campaign to consumers. Post-intervention, simulated patients presented to 100 intervention and 100 control community pharmacies with a request for salbutamol. The appropriate outcome was medical referral for poor asthma control and correction of poor inhaler technique. Incidence and quantity of patient assessment and counseling provided during the visit were also assessed. Logistic regression was used to determine the predictors of medical referral. RESULTS: A doubling in the rate of medical referral was seen in the intervention group (19% vs 40%; p = 0.001). Assessment of reliever use frequency was the main predictor of medical referral (OR = 22.7; 95% CI 9.06 to 56.9). Correction of poor inhaler technique did not improve; however, a reduction in salbutamol supplied without patient assessment (23% vs 8%; p = 0.009) or counseling (75% vs 48%; p < 0.001) was noted. CONCLUSIONS: A doubling in the rate of medical referral showed a clear improvement in professional practice during the provision of nonprescription salbutamol. The improved patient outcome in the intervention group was due to increased assessment of reliever use frequency. Identification of poor inhaler technique remained near zero in both groups, which suggests that intern pharmacists were able to improve the current practice of community pharmacies yet were unable to establish a new practice behavior. This study provides evidence that intern pharmacists can act as change agents to improve pharmacy practice.

Indwelling catheters and medical implants with FXIIIa inhibitors:a novel approach to the treatment of catheter and medical device-related infections

Central venous catheters (CVCs) are being utilized with increasing frequency in intensive care and general medical wards. In spite of the extensive experience gained in their application, CVCs are related to the long-term risks of catheter sheath formation, infection, and thrombosis (of the catheter or vessel itself) during catheterization. Such CVC-related-complications are associated with increased morbidity, mortality, duration of hospitalization, and medical care cost [1]. The present study incorporates a novel group of Factor XIIIa (FXIIIa, plasma transglutaminase) inhibitors into a lubricious silicone elastomer in order to generate an optimized drug delivery system whereby a secondary sustained drug release profile occurs following an initial burst release for catheters and other medical devices. We propose that the incorporation of FXIIIa inhibitors into catheters, stents, and other medical implant devices would reduce the incidence of catheter sheath formation, thrombotic occlusion, and associated staphylococcal infection. This technique could be used as a local delivery system for extended release with an immediate onset of action for other poorly aqueous soluble compounds. © 2012 Elsevier B.V. All rights reserved.

Discovering the preferences of physicians with regards to rank-ordered medical documents

The practice of evidence-based medicine involves consulting documents from repositories such as Scopus, PubMed, or the Cochrane Library. The most common approach for presenting retrieved documents is in the form of a list, with the assumption that the higher a document is on a list, the more relevant it is. Despite this list-based presentation, it is seldom studied how physicians perceive the importance of the order of documents presented in a list. This paper describes an empirical study that elicited and modeled physicians' preferences with regard to list-based results. Preferences were analyzed using a GRIP method that relies on pairwise comparisons of selected subsets of possible rank-ordered lists composed of 3 documents. The results allow us to draw conclusions regarding physicians' attitudes towards the importance of having documents ranked correctly on a result list, versus the importance of retrieving relevant but misplaced documents. Our findings should help developers of clinical information retrieval applications when deciding how retrieved documents should be presented and how performance of the application should be assessed. © 2012 Springer-Verlag Berlin Heidelberg.

Optical in-fiber Bragg grating sensor systems for medical applications

Two in-fiber Bragg grating (FBG) temperature sensor systems for medical applications are demonstrated: (1) an FBG flow-directed thermodilution catheter based on interferometric detection of wavelength shift that is used for cardiac monitoring; and (2) an FBG sensor system with a tunable Fabry-Perot filter for in vivo temperature profiling in nuclear magnetic resonance (NMR) machines. Preliminary results show that the FBG sensor is in good agreement with electrical sensors that are widely used in practice. A field test shows that the FBG sensor system is suitable for in situ temperature profiling in NMR machines for medical applications.

Working with the public sector:SME medical device innovation and pre-procurement

Healthcare providers are under ever increasing pressure to deliver more technologically advanced care without increasing costs. Innovation is essential (Darzi, 2008), and for this healthcare providers rely on innovation within commercial companies. SMEs have an important part to play in this sector (NHS Supply Chain Parliamentary Brief, 2013). Collaboration between SME suppliers and the NHS for innovation forms the focus of this paper. We examine the academic literature on interorganizational innovation including academic insights from the areas of forward commitment procurement (Environmental Innovation Advisory Group, 2003-2008), pre-commercial procurement (Bos & Corvers, 2007), innovation and SMEs. We then explore practice, first from a policy and business sector perspective. Second, we present evidence from fifteen cases of interorganizational innovation projects involving SMEs and UK healthcare providers. Our findings show much effort is being put into creating opportunities for more interorganizational innovation of medical devices. Working across organizational boundaries presents added complexity to the innovation environment and process, and the challenge of developing high-quality cross-boundary group interaction.

Predicting binge-drinking behaviour using an extended TPB:examining the impact of anticipated regret and descriptive norms

Aims: To investigate the utility of an extended Theory of Planned Behaviour (TPB), including descriptive norms and anticipated regret, in predicting binge-drinking intentions and behaviour. Methods: A total of178 undergraduates completed a questionnaire containing measures of TPB variables, descriptive norms, anticipated regret, and previous binge-drinking behaviour. One week later, 104 students completed a measure of binge-drinking behaviour. Results: Hierarchical regression demonstrated that attitudes (beta = 0.30, P < 0.001) and anticipated regret (beta = 0.47, P < 0.001) were significant predictors of intentions, with the final equation accounting for 58% of the variance. Hierarchial regression found that intentions (beta = -0.21, P < 0.05) and previous binge-drinking behaviour (beta = 0.36, P < 0.01) predicted current drinking behaviour, accounting for 33% of the variance. Conclusions: The study suggests that modifying attitudes and inducing regret may be effective strategies for reducing binge-drinking intentions among undergraduates, which should reduce subsequent binge-drinking behaviour. © The Author 2006. Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved.

Classifying clinical decision making:interpreting nursing intuition, heuristics and medical diagnosis

This is the second of two linked papers exploring decision making in nursing. The first paper, 'Classifying clinical decision making: a unifying approach' investigated difficulties with applying a range of decision-making theories to nursing practice. This is due to the diversity of terminology and theoretical concepts used, which militate against nurses being able to compare the outcomes of decisions analysed within different frameworks. It is therefore problematic for nurses to assess how good their decisions are, and where improvements can be made. However, despite the range of nomenclature, it was argued that there are underlying similarities between all theories of decision processes and that these should be exposed through integration within a single explanatory framework. A proposed solution was to use a general model of psychological classification to clarify and compare terms, concepts and processes identified across the different theories. The unifying framework of classification was described and this paper operationalizes it to demonstrate how different approaches to clinical decision making can be re-interpreted as classification behaviour. Particular attention is focused on classification in nursing, and on re-evaluating heuristic reasoning, which has been particularly prone to theoretical and terminological confusion. Demonstrating similarities in how different disciplines make decisions should promote improved multidisciplinary collaboration and a weakening of clinical elitism, thereby enhancing organizational effectiveness in health care and nurses' professional status. This is particularly important as nurses' roles continue to expand to embrace elements of managerial, medical and therapeutic work. Analysing nurses' decisions as classification behaviour will also enhance clinical effectiveness, and assist in making nurses' expertise more visible. In addition, the classification framework explodes the myth that intuition, traditionally associated with nurses' decision making, is less rational and scientific than other approaches.

Using DEA to estimate potential savings at GP units at medical specialty level

The aim of this paper is to identify benchmark cost-efficient General Practitioner (GP) units at delivering health care in the Geriatric and General Medicine (GMG) specialty and estimate potential cost savings. The use of a single medical specialty makes it possible to reflect more accurately the medical condition of the List population of the Practice so as to contextualize its expenditure on care for patients. We use Data Envelopment Analysis (DEA) to estimate the potential for cost savings at GP units and to decompose these savings into those attributable to the reduction of resource use, to altering the mix of resources used and to those attributable to securing better resource 'prices'. The results reveal a considerable potential for savings of varying composition across GP units. © 2013 Elsevier Ltd.

Are community pharmacists prepared to work extended opening hours?

Focal points: A 5 per cent cross-sectional sample of the Royal Pharmaceutical Society's membership was targeted with a self-completion questionnaire Community pharmacy respondents were asked questions on their views on current pharmacy opening hours and their willingness to work extended opening hours Around one fifth of the community pharmacists sampled believed that patients should have access to at least one community pharmacy 24 hours a day Only 3.4 per cent of community pharmacists sampled were prepared to work at any time over a 24-hour period With the introduction of more 24-hour health care services (eg, NHS Direct), there may need to be a change in the attitudes of community pharmacists towards working extended opening hours

Medical students' personal experience of high-stakes failure:case studies using interpretative phenomenological analysis

Abstract (provisional): Background Failing a high-stakes assessment at medical school is a major event for those who go through the experience. Students who fail at medical school may be more likely to struggle in professional practice, therefore helping individuals overcome problems and respond appropriately is important. There is little understanding about what factors influence how individuals experience failure or make sense of the failing experience in remediation. The aim of this study was to investigate the complexity surrounding the failure experience from the student’s perspective using interpretative phenomenological analysis (IPA). Methods The accounts of 3 medical students who had failed final re-sit exams, were subjected to in-depth analysis using IPA methodology. IPA was used to analyse each transcript case-by-case allowing the researcher to make sense of the participant’s subjective world. The analysis process allowed the complexity surrounding the failure to be highlighted, alongside a narrative describing how students made sense of the experience. Results The circumstances surrounding students as they approached assessment and experienced failure at finals were a complex interaction between academic problems, personal problems (specifically finance and relationships), strained relationships with friends, family or faculty, and various mental health problems. Each student experienced multi-dimensional issues, each with their own individual combination of problems, but experienced remediation as a one-dimensional intervention with focus only on improving performance in written exams. What these students needed to be included was help with clinical skills, plus social and emotional support. Fear of termination of the their course was a barrier to open communication with staff. Conclusions These students’ experience of failure was complex. The experience of remediation is influenced by the way in which students make sense of failing. Generic remediation programmes may fail to meet the needs of students for whom personal, social and mental health issues are a part of the picture.

Paediatric prescribing practice and opinions of paediatric prescribers on ePrescribing

Objective The aim of this study was to provide an initial insight into current UK paediatric prescribing practice. Methods In 2012 focus groups were conducted at Birmingham Children's Hospital (UK specialist hospital) with both medical and non-medical prescribers and analysed using thematic analysis. Key findings Both sets of prescribers used a wide range of resources to support their prescribing decisions. Dosing information was most commonly checked, and a lack of specialist paediatric information was reported in existing resources. All groups had high expectations of the support functions that should be included in an electronic prescribing system and could see many potential benefits. Participants agreed that all staff should see the same drug alerts. The overwhelming concern was whether the current information technology infrastructure would support electronic prescribing. Conclusions Prescribers had high expectations of electronic prescribing, but lacked confidence in its delivery. Prescribers use a wide range of resources to support their decision making when prescribing in paediatrics.

Randomised trial of levonorgestrel intrauterine system compared to usual medical treatment for heavy menstrual bleeding:the ECLIPSE Trial

Objective: Heavy menstrual bleeding (menorrhagia) is a common problem, yet evidence is limited to inform therapeutic decisions.We compared the levonorgestrel-releasing intrauterine system(LNG-IUS) to usual medical treatment in a pragmatic randomised trial in primary care. Methods: We randomly assigned 571 women consulting their primary care providers with menorrhagia to LNG-IUS or to usual medical treatment as clinically appropriate (tranexamic acid, mefenamic acid, combined estrogen/progestogen or progestogen only). The primary outcome was a patient-reported measure ofimpact of menorrhagia, the validated Menorrhagia Multi-Attribute Scale (MMAS), assessed over 2 years. Secondary measures included generic quality of life (SF-36), sexual activity and surgical intervention.Results MMAS scores improved from baseline in both the LNG-IUS and usual medical treatment groups by 6 months (mean increases 32.7 points versus 21.4 points, respectively; P < 0.001for both) and were maintained over 2 years, but improvements were significantly greater with LNG-IUS (mean between-group difference 13.4 points, 95%CI, 9.9–16.9; P < 0.001).All domains of MMAS (practical difficulties, social life, family life,work/daily routine, psychological well being and physical health)improved significantly more with LNG-IUS, as were seven of the eight domains of SF-36. More women were still using LNG-IUSthan usual medical treatment at 2 years (64% versus 38%,P < 0.001). There were no significant between-group differences in surgical intervention rates or sexual activity scores. There were no serious adverse events in either group.Conclusions Among women presenting to primary care providers with menorrhagia, LNG-IUS was more effective than usual medical treatment at reducing the impact of this problem on their quality of life. In practice therefore, conventional treatments, such as tranexamic and mefenamic acid, remain helpful choices in women for whom LNG-IUS is considered unsuitable, or due to individual preference. For other women, LNG-IUS can be confidently recommended as an effective initial medical therapy for menorrhagia. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 02/06/02)

Measuring and managing liquidity risk in the Hungarian practice

The crisis that unfolded in 2007/2008 turned the attention of the financial world toward liquidity, the lack of which caused substantial losses. As a result, the need arose for the traditional financial models to be extended with liquidity. Our goal is to discover how Hungarian market players relate to liquidity. Our results are obtained through a series of semi-structured interviews, and are hoped to be a starting point for extending the existing models in an appropriate way. Our main results show that different investor groups can be identified along their approaches to liquidity, and they rarely use sophisticated models to measure and manage liquidity. We conclude that although market players would have access to complex liquidity measurement and management tools, there is a limited need for these, because the currently available models are unable to use complex liquidity information effectively.