Pelvic lymph node dissection in the context of radical cystectomy: a thorough insight into the connection between patient, surgeon, pathologist and treating institution

Pelvic lymph node dissection (PLND) in patients with bladder cancer varies widely in extent, technique employed, and pathological workup of specimens. The present paper provides an overview of the existing evidence regarding the effectiveness of PLND and elucidates the interactions between patient, surgeon, pathologist, and treating institution as well as their cumulative impact on the final postoperative lymph node (LN) staging. Bladder cancer patients undergoing radical cystectomy with extended PLND appear to have better oncologic outcomes compared to patients undergoing radical cystectomy and limited PLND. Attempts have been made to define and assess the quality of PLND according to the number of lymph nodes identified. However, lymph node counts depend on multiple factors such as patient characteristics, surgical template, pathological workup, and institutional policies; hence, meticulous PLND within a defined and uniformly applied extended template appears to be a better assurance of quality than absolute lymph node counts. Nevertheless, the prognosis of the patients can be partially predicted with findings from the histopathological evaluation of the PLND specimen, such as the number of positive lymph nodes, extracapsular extension, and size of the largest LN metastases. Therefore, particular prognostic parameters should be addressed within the pathological report to guide the urologist in terms of patient counseling.

Becoming a pharmacist : the role of curriculum in professional identity formation

Objective To understand how the formal curriculum experience of an Australian undergraduate pharmacy program supports students’ professional identity formation. Methods A qualitative ethnographic study was conducted over four weeks using participant observation and examined the ‘typical’ student experience from the perspective of a pharmacist. A one-week period of observation was undertaken with each of the four year groups (that is, for years one to four) comprising the undergraduate curriculum. Data were collected through observation of the formal curriculum experience using field notes, a reflective journal and informal interviews with 38 pharmacy students. Data were analyzed thematically using an a priori analytical framework. Results Our findings showed that the observed curriculum was a conventional curricular experience which focused on the provision of technical knowledge and provided some opportunities for practical engagement. There were some opportunities for students to imagine themselves as pharmacists, for example, when the lecture content related to practice or teaching staff described their approach to practice problems. However, there were limited opportunities for students to observe pharmacist role models, experiment with being a pharmacist or evaluate their professional identities. While curricular learning activities were available for students to develop as pharmacists e.g. patient counseling, there was no contact with patients and pharmacist academic staff tended to role model as educators with little evidence of their pharmacist selves. Conclusion These findings suggest that the current conventional approach to the curriculum design may not be fully enabling learning experiences which support students in successfully negotiating their professional identities. Instead it appeared to reinforce their identities as students with a naïve understanding of professional practice, making their future transition to professional practice challenging.

Bisphosphonates adherence for treatment of osteoporosis

Background: Osteoporosis is a disease of bone metabolism in which bisphosphonates (BPS) are the most common medications used in its treatment, whose main objective is to reduce the risk of fractures. The aim of this study was to conduct a systematic review on BPs adherence for treatment of osteoporosis. Methods. Systematic review of articles on BPs adherence for treatment of osteoporosis, indexed on MEDLINE (via PubMed) databases, from inception of databases until January 2013. Search terms were Adherence, Medication (MeSH term), Bisphosphonates (MeSH term), and Osteoporosis (MeSH term). Results: Of the 78 identified studies, 27 met the eligibility criteria. Identified studies covered a wide range of aspects regarding adherence and associated factors, adherence and fracture, adherence and BPs dosage. The studies are mostly observational, conducted with women over 45 years old, showing low rates of adherence to treatment. Several factors may influence adherence: socio-economic and cultural, participation of physicians when guidance is given to the patient, the use of bone turnover markers, and use of generic drugs. The monthly dosage is associated with greater adherence compared to weekly dosage. Conclusions: Considering the methodological differences between the studies, the results converge to show that adherence to treatment of osteoporosis with BPs is still inadequate. Further experimental studies are needed to evaluate the adherence and suggest new treatment options. © 2013 Vieira et al.; licensee BioMed Central Ltd.

Family satisfaction with critical care: measurements and messages

PURPOSE OF REVIEW: Family satisfaction in the ICU reflects the extent to which perceived needs and expectations of family members of critically ill patients are met by healthcare professionals. Here, we present recently developed tools to assess family satisfaction, with a special focus on their psychometric properties. Assessing family satisfaction, however, is not of much use if it is not followed by interpretation of the results and, if needed, consecutive measures to improve care of the patients and their families, or improvement in communication and decision-making. Accordingly, this review will outline recent findings in this field. Finally, possible areas of future research are addressed. RECENT FINDINGS: To assess family satisfaction in the ICU, several domains deserve attention. They include, among others, care of the patient, counseling and emotional support of family members, information and decision-making. Overall, communication between physicians or nurses and members of the family remains a key topic, and there are many opportunities to improve. They include not only communication style, timing and appropriate wording but also, for example, assessments to see if information was adequately received and also understood. Whether unfulfilled needs of individual members of the family or of the family as a social system result in negative long-term sequels remains an open question. SUMMARY: Assessing and analyzing family satisfaction in the ICU ultimately will support healthcare professionals in their continuing effort to improve care of critically ill patients and their families.

Nutrition knowledge and attitudes of physician assistants in Texas

Physician Assistants (PAs) are increasingly assuming more responsibilities as "front-line" health providers due to emphasis on primary care and cost-containment in the rapidly changing health care environment. Nutrition plays an important role in health promotion and disease prevention. Primary care providers, including PAs, have enormous potential as nutrition counselors and advocates. There have been no studies to date that address the PAs' adequacy of nutrition education or their attitudes toward the value of nutrition. Therefore, it was the purpose of the study to determine the nutrition knowledge and attitudes of PAs in Texas.^ All certified physician assistants in Texas were eligible for the study. A mailed survey was sent to 1,482 PAs in Texas with a response rate of 54.2%. The sample utilized for data analysis was 764 PAs.^ The study compared the nutrition knowledge mean scores for PAs who graduated from a PA program greater than 11 years ago with those who graduated less than 11 years ago. The study also examined Texas PAs' attitudes about their nutrition education training, the value of nutrition counseling, and their perceived ability to provide such nutrition counseling. Demographic and practice information was collected from the PAs. Demographically, PAs in Texas were found to be comparable to the national population of PAs surveyed in 1996.^ The overall mean level of nutrition knowledge was 70% correct. The mean level of nutrition knowledge was significantly related to the type of PA program that the PA graduated from (i.e., Certificate only or Master's degree level). No significant relationships were found between the mean nutrition knowledge score and age, year of graduation, length of practice, or the type of nutrition education provided in PA program.^ The majority of the PAs surveyed felt that diet and nutrition has an important role in disease prevention and felt that PA programs should place a greater emphasis on nutrition education. Many PAs surveyed were not satisfied with the amount of nutrition education they had received in their PA education programs and were not confident in their ability to provide nutrition counseling to patients.^ Suggestions are offered for improvement in PA nutrition education in the areas of both nutrition knowledge and patient counseling skills. In addition, this study recommends developing and strengthening partnerships between PAs and nutrition organizations. ^

Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs

CONTEXT Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times. OBJECTIVE To overview the use and key elements of ERAS pathways, and define needs for future clinical trials. EVIDENCE ACQUISITION A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms "postoperative period," "postoperative care," "enhanced recovery after surgery," "enhanced recovery," "accelerated recovery," "fast track recovery," "recovery program," "recovery pathway", "ERAS," and "urology" or "cystectomy" or "urologic surgery." EVIDENCE SYNTHESIS We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6h and perioperative liquid-carbohydrate loading up to 2h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters. CONCLUSIONS ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery. PATIENT SUMMARY This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials.

Biologic therapies and non-melanoma skin cancer rates in three chronic immune-mediated diseases

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Patient-practitioner relationships desired by overweight/obese adults

Objective: This study investigated the characteristics of the patient-practitioner relationship desired by overweight/obese individuals in weight management. The aim was to identify characteristics of the relationship which empower patients to make lifestyle changes. Methods: Grounded theory was used inductively to build a model of the patient-practitioner relationship based on the perspectives of 21 overweight/obese ¬adults. Results: Emerging from the match between patient and practitioner characteristics, collaboration was the key process explicitly occurring in the patient-practitioner relationship, and was characterised by two subcategories; perceived power dimensions and openness. Trust emerged implicitly from the collaborative process, being fostered by relational, informational, and credible aspects of the interaction. Patient trust in their practitioner consequently led to empowering outcomes including goal ownership and perceiving the utility of changes. Conclusion: An appropriate match between patient and practitioner characteristics facilitates collaboration which leads to trust, both of which appear to precede empowering outcomes for patients such as goal ownership and perceiving the utility of changes. Collaboration is an explicit process and precedes the patient trusting their practitioner. Practice implications: Practitioners should be sensitive to patient preferences for collaboration and the opportunity to develop trust with patients relationally, through information provision, and modelling a healthy lifestyle.

Perceived acceptability of home-based couples voluntary HIV counseling and testing in Northern Tanzania.

It is estimated that 5.6% of the Tanzanian population ages 15-49 are infected with HIV, but only 30% of adults have ever had an HIV test. Couples' testing has proven to increase testing coverage and introduce HIV prevention, but barriers include access to testing services and unequal gender dynamics in relationships. Innovative approaches are needed to address barriers to couple's testing and increase uptake of HIV testing. Using qualitative data collection methods, a formative study was conducted to assess the acceptability of a home-based couples counseling and testing (HBCCT) approach. Eligible study participants included married men and women, HIV-infected individuals, health care and home-based care providers, voluntary counseling and testing counselors, and community leaders. A total of 91 individuals participated in focus group discussions (FGDs) and in-depth interviews conducted between September 2009 and January 2010 in rural settings in Northern Tanzania. An HBCCT intervention appears to be broadly acceptable among participants. Benefits of HBCCT were identified in terms of access, confidentiality, and strengthening the relationship. Fears of negative consequences from knowing one's HIV status, including stigma, blame, physical abuse, or divorce, remain a concern and a potential barrier to the successful provision of the intervention. Lessons for implementation highlighted the importance of appointments for home visits, building relationships of confidence and trust between counselors and clients, and assessing and responding to a couple's readiness to undergo HIV testing. HBCCT should addresses HIV stigma, emphasize confidentiality, and improve communication skills for disclosure and decision-making among couples.

Patient safety and communication: A new assessment for doctors trained in countries where language differs from that of the host country: Results of a pilot using a domain-based assessment

Objective

Global migration of healthcare workers places responsibility on employers to comply with legal employment rights whilst ensuring patient safety remains the central goal. We describe the pilot of a communication assessment designed for doctors who trained and communicated with patients and colleagues in a different language from that of the host country. It is unique in assessing clinical communication without assessing knowledge.

A 14-station OSCE was developed using a domain-based marking scheme, covering professional communication and English language skills (speaking, listening, reading and writing) in routine, acute and emotionally challenging contexts, with patients, carers and healthcare teams. Candidates (n = 43), non-UK trained volunteers applying to the UK Foundation Programme, were provided with relevant station information prior to the exam.

The criteria for passing the test included achieving the pass score and passing 10 or more of the 14 stations. Of the 43 candidates, nine failed on the station criteria. Two failed the pass score and also the station criteria. The Cronbach's alpha coefficient was 0.866.

This pilot tested ‘proof of concept’ of a new domain-based communication assessment for non-UK trained doctors.

The test would enable employers and regulators to verify communication competence and safety in clinical contexts, independent of clinical knowledge, for doctors who trained in a language different from that of the host country.

How was patient empowerment portrayed in information leaflets describing the community pharmacy Medicines Use Review service in the UK?

Objective The Medicines Use Review (MUR) community pharmacy service was introduced in 2005 to enhance patient empowerment but the service has not been taken up as widely as expected. We investigated the depiction of the patient–pharmacist power relationship within MUR patient information leaflets. Methods We identified 11 MUR leaflets including the official Department of Health MUR booklet and through discourse analysis examined the way language and imagery had been used to symbolise and give meaning to the MUR service, especially the portrayal of the patient–pharmacist interactions and the implied power relations. Results A variety of terminology was used to describe the MUR, a service that aimed ultimately to produce more informed patients through the information imparted by knowledgeable, skilled pharmacists. Conclusion The educational role of the MUR overshadowed the intended patient empowerment that would take place with a true concordance-centred approach. Although patient empowerment was implied, this was within the boundaries of the biomedical model with the pharmacist as the expert provider of medicines information. Practice implications If patient empowerment is to be conveyed this needs to be communicated to patients through consistent use of language and imagery that portrays the inclusivity intended.

Cytogenomic characterization of an unexpected 17.6 Mb 9p deletion associated to a 14.8 Mb 20p duplication in a dysmorphic patient with multiple congenital anomalies presenting a normal G-banding karyotype

We describe a female patient with developmental delay, dysmorphic features and multiple congenital anomalies who presented a normal G-banded karyotype at the 550-band resolution. Array and multiplex-ligation probe amplification (MLPA) techniques identified an unexpected large unbalanced genomic aberration: a 17.6 Mb deletion of 9p associated to a 14.8 Mb duplication of 20p. The deleted 9p genes, especially CER1 and FREM1, seem to be more relevant to the phenotype than the duplicated 20p genes. This study also shows the relevance of using molecular techniques to make an accurate diagnosis in patients with dysmorphic features and multiple anomalies suggestive of chromosome aberration, even if on G-banding their karyotype appears to be normal. Fluorescence in situ hybridization (FISH) was necessary to identify a masked balanced translocation in the patient's mother, indicating the importance of associating cytogenetic and molecular techniques in clinical genetics, given the implications for patient management and genetic counseling. (C) 2012 Elsevier B.V. All rights reserved.

Sharing vs. caring--the relative impact of sharing decisions versus managing emotions on patient outcomes

To assess the relative impact of cognitive and emotional aspects of shared decision making (SDM) on patient outcomes.