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Taking things apart: ovario-hysterectomy--textbook knowledge and actual practice in veterinary surgery.

Veterinary surgery provides an interesting context in which to address important questions about the links between formal 'book' learning and actual, personal experience of the phenomena in question, and to examine the processes through which these links are forged. Participant observation of surgical procedures suggests that surgeons initially learn about anatomy from books, pictures and demonstrations, and become skilled 'operators' through the application of enhancement and reduction procedures that have the effect of transforming the living body into something more closely resembling anatomical pictures of it. Some of these procedures can be seen as a set of formalized 'rules' for performing operations, and like most rules, they appear to decrease in importance as a surgeon gains experience. They may, however, regain importance when a practitioner meets with an anatomical variant that he or she has not previously encountered. Other practices appear to be less formalized, requiring creative, constructive use of visual aids or language practices outside formal textbook knowledge. The links between actual bodies (and operations) and textbook representations of them are thus formed within a community of 'operators'.

Animals↗

Newark Information Sharing Project: lessons for Medical Audit Advisory Groups.

This article describes one method of professional performance review which relies heavily on confidentiality and comparability. For the Newark Information Sharing Project, an association of five practices collected data for two years on registrations, workload, prevention, referrals, prescribing, and disease prevalence. After central collation, the averages and ranges were returned to the individual practices with their position confidentially indicated. Unlike previous reports of inter-practice comparisons, this project involved no research funds or special assistance. The time and financial costs are quantified. This model is suitable for adoption by Medical Audit Advisory Groups.

Attitude of Health Personnel↗

Carotid endarterectomy in Great Britain and Ireland: practice between 1984 and 1992.

Of 356 questionnaires on carotid endarterectomy sent to all vascular surgeons in Great Britain and Ireland likely to undertake this procedure, 326 (92 per cent) were returned. Of those who replied 131 (40 per cent) performed at least one carotid endarterectomy in 1992; 57 (44 per cent) of these carried out ten or fewer operations and 74 (56 per cent) more than ten. The 131 surgeons were collectively responsible for 2628 operations in 1992, twice as many as were undertaken in either 1984 or 1989, years for which similar survey data are available. This sharp rise in the number of operations was accounted for by increased activity on the part of experienced operators, rather than any rise in the number of 'occasional' carotid surgeons. In 1992, although the neurologist remained a major source of patient referral, general practitioners (and others) were also referring patients in large numbers direct to the vascular surgeon; this represents a change in practice compared with previous years. Many of the technical aspects surrounding carotid endarterectomy remained unchanged over the years surveyed (1984, 1989, 1992) but by 1992 duplex scanning, intra-arterial (but not intravenous) digital subtraction angiography and transcranial Doppler ultrasonography had become established as clinically useful techniques.

Anesthesia↗

Three-dimensional electrical impedance tomography.

The electrical resistivity of mammalian tissues varies widely and is correlated with physiological function. Electrical impedance tomography (EIT) can be used to probe such variations in vivo, and offers a non-invasive means of imaging the internal conductivity distribution of the human body. But the computational complexity of EIT has severe practical limitations, and previous work has been restricted to considering image reconstruction as an essentially two-dimensional problem. This simplification can limit significantly the imaging capabilities of EIT, as the electric currents used to determine the conductivity variations will not in general be confined to a two-dimensional plane. A few studies have attempted three-dimensional EIT image reconstruction, but have not yet succeeded in generating images of a quality suitable for clinical applications. Here we report the development of a three-dimensional EIT system with greatly improved imaging capabilities, which combines our 64-electrode data-collection apparatus with customized matrix inversion techniques. Our results demonstrate the practical potential of EIT for clinical applications, such as lung or brain imaging and diagnostic screening.

Algorithms↗

Research and organizational issues for the implementation of family work in community psychiatric services.

BACKGROUND: The need for evidence-based practice (EBP) to guide and develop mental health services remains fundamental for modern services. Aim. To discuss issues that impact upon implementation of EBP and practice development using family work (FW) as an example. METHODS: A selection of the FW literature was reviewed drawing on sources including the Cochrane Library, Cinahl and Medline. Keywords used were FW, community mental health team and research design. FINDINGS: Centralized policy initiatives and guidelines that are themselves guided by evidence of randomized controlled trials predominantly risk alienating practitioners and clients/carers. Family work has some demonstrable clinical benefits although models differ and the active therapeutic agent remains unclear. Its adoption into routine care is also hindered by a productivity management outlook that seeks to maximize stretched resources and whose values are likely to be internalized by practitioners. The dichotomous position of previous research and practice development make implementation of EBP difficult and highlights the need for strategic planning that embraces both factors. CONCLUSION: The current drive to increase EBP requires a bi-directional process of influence that allows individual practitioners and clients/carers to become producers of evidence and not simply recipients. The authors support wider adoption of case study research designs to reflect the unpredictable nature of mental health care. Adoption of assertive community treatment models within community services is most likely to promote the excellence management model and accommodate EBP such as FW.

Community Health Nursing↗

Implications of the ionizing radiations regulations for typical nuclear medicine departments.

The application of the 1985 Ionizing Radiations Regulations and Approved Code of Practice to a typical Nuclear Medicine Department has been considered. References to the Regulations are given so that their implications in a given department may be examined. The radiopharmacy, radioisotope dispensary and injection room will need to be Controlled Areas. It will also be necessary to designate Controlled Areas if radiopharmaceuticals are injected in imaging rooms or on wards. Waiting rooms will need to be Controlled Areas. The area around individual patients will, however, not need to be Controlled except for some patients receiving therapeutic doses of 131I for thyrotoxicosis. It should not generally be necessary to designate employees as Classified persons. Major problems in implementing the Regulations are not envisaged in situations where the previous Code of Practice has been followed.

England↗

HIV risk behaviour among injecting drug users in Perth: the Australian National AIDS and Injecting Drug Use Study.

OBJECTIVE: This study was carried out in 1989 to examine behaviour involving risk of human immunodeficiency virus (HIV) infection and to measure the prevalence of HIV antibodies in a sample of injecting drug users (IDUs) in Perth. DESIGN: The study was a cross-sectional survey with a sample of convenience of 196 IDUs drawn from drug treatment (54%) and non-treatment (46%) populations. RESULTS: Sixty-five per cent of the sample were men and 35% women. Subjects were predominantly heterosexual, were in their late twenties, had not completed secondary school, and were on sickness, unemployment or pension benefits. The majority were poly-drug users, but heroin and amphetamines were the only drugs that had been injected by more than 20% of the sample more than once a month. Respondents reported injecting an average of 43.6 (SD 83.6) times a month and using 33.7 (SD 55.4) new needles a month. The majority (70%) had injected within weeks of the interview. Sixty-seven per cent had shared needles within months. Respondents claimed to pass on used needles more frequently than to accept them, and were most likely to share with close friends or lovers when clean needles were unavailable and/or when they were withdrawing. While most respondents cleaned used needles, few used bleach all or most of the time. Most (78%) respondents had been tested for HIV seropositivity at least once. Most had multiple sexual partners and 92.3% had engaged in at least one unsafe sexual practice during the previous six months. Sixty-four per cent had changed some aspect of drug using, and 38% some aspect of sexual behaviour since hearing about the acquired immunodeficiency syndrome (AIDS). HIV seroprevalence for the 179 respondents who were tested was 2.2%, but this figure should not be taken as an estimate of seroprevalence for the Perth IDU population. CONCLUSION: Respondents' behaviour placed them at a high level of risk for HIV infection. Based on reported behaviour, it is recommended that education for IDUs in Perth should emphasise, among other things: not passing on used needles; cleaning used needles and syringes with bleach; planning ahead so that sterile equipment is available; and further risk reduction, particularly the adoption of safer sexual practices.

Acquired Immunodeficiency Syndrome↗

Human rabies prevention--United States, 1999. Recommendations of the Advisory Committee on Immunization Practices (ACIP).

These revised recommendations of the Advisory Committee on Immunization Practices update the previous recommendations on rabies prevention (MMWR 1991;40[No.RR-3]:1-14) to reflect the current status of rabies and antirabies biologics in the United States. This report includes new information about a human rabies vaccine approved for U.S. use in 1997, recommendations regarding exposure to bats, recommendations regarding an observation period for domestic ferrets, and changes in the local administration of rabies immune globulin.

Contraindications↗

Patterns of knee injuries in wrestling: a six year study.

Data on knee injuries sustained by the University of Iowa wrestling team over a 6 year period were compiled. There were a total of 136 wrestlers during this time. Fifty-one different wrestlers sustained 136 injuries (64 knees). Multiple parameters were examined for each injury, including date of injury; days lost; diagnosis; side injured; mechanism; occurrence during competition or practice; whether the wrestler was in control, "on the bottom," or both wrestlers standing; type of move being made at the time of injury; how far into a match or practice the injury happened; initial versus recurrent injury; principal form of management; weight-bearing status; and presence of knee pads. Each wrestler's weight class, years of experience, rank on the team, lead leg, and compliance were noted. We found an incidence of 30 knee injuries per 100 wrestlers per year. There were 11.5 knee injuries per 100 wrestlers per year requiring a week or greater time loss. This comprises over one third of all serious wrestling injuries. Exposure data revealed injury rates in matches to be almost 40 times those of practice. Wrestlers with previous knee injuries were at high risk for reinjury. Early season competition is an extremely high risk period. The most frequent injuries were prepatellar bursitis, lateral and medial sprains, and lateral and medial meniscal tears. We noted a relatively higher rate of lateral versus medial meniscal tears compared to other sports and a somewhat common presentation of a meniscal tear resulting from minimal trauma. The lead leg was injured most often. The takedown was the most frequent situation where any injury occurred. Defensive wrestlers appeared to be at higher risk during takedowns. The wrestler "underneath" was also injured more often. Compliance correlated with decreased recurrence of injury. Approximately 50% of wrestlers were found to be noncompliant with medical recommendations. Junior varsity wrestlers lost significantly more time than varsity wrestlers with equivalent injuries. There was no correlation of injury rate with weight class, period of match, timing in practice, or years of experience.

Athletic Injuries↗

General dental practitioner referral patterns for minor oral surgery.

A questionnaire was sent to all general dental practitioners within Grampian region investigating the frequency of referral to hospital of medically fit patients for minor oral surgery. This was compared with their general dental practice experience and previous hospital employment. A 91.8% (n = 135) response rate was achieved. The responses indicated that practitioners refer if they believe specialist treatment is required, but less experienced practitioners were more likely to refer in the belief that general anaesthesia was necessary for treatment. A patient's request was a rare cause of referral, particularly with the more experienced practitioners. Referrals for the patient to avoid paying National Health Service (NHS) charges were rare, as were referrals due to lack of equipment. Inappropriate NHS fees for minor oral surgery treatment was a cause of referral by one third of practitioners.

Age Factors↗

Communication of research and practice knowledge in nursing literature.

BACKGROUND: Previous research did not indicate whether communication occurred between the research and practice components of nursing knowledge. OBJECTIVES: This study was designed to examine the extent of communication between or within the nursing-research and nursing-practice components of the nursing literature. METHODS: Specific citing/cited relationships from the Current Index to Nursing and Allied Health Literature (CINAHL) are analyzed using citation analysis. The sample was taken from the population of indexed documents that contained references, that had the subject code of nursing, and that were originally published in the United States or Canada in 1989. RESULTS: The results show that authors of research articles tend to cite research articles more often than practice articles, and that authors of practice articles tend to cite practice articles more often than research articles. Authors with research degrees publish research articles more often than would be expected by chance, and authors with clinical and undergraduate degrees publish practice articles more often than expected. Authors associated with research institutions tend to publish research articles, and those affiliated with service institutions tend to publish practice articles. Most cited documents (69.4%) are from disciplines other than nursing. CONCLUSIONS: The existence of communication between the research and the practice component of nursing knowledge was demonstrated and appears to be more prevalent than previously indicated. Further research on how the cited literature is used would enable us to know about the depth and quality of the communication event and to note variations as the body of nursing knowledge evolves.

Chi-Square Distribution↗

Bacterial aerosols in dental practice - a potential hospital infection problem?

Aerosols containing microbes from the oral cavity of the patient are created when using modern high-speed rotating instruments in restorative dentistry. How far these aerosols spread and what level of contamination they cause in the dental surgery has become a growing concern as the number of patients with oro-nasal meticillin-resistant Staphylococcus aureus colonization has increased. The present study aimed to determine how far airborne bacteria spread during dental treatment, and the level of contamination. Fall out samples were collected on blood agar plates placed in six different sectors, 0.5-2m from the patient. Restorative dentistry fallout samples (N=72) were collected from rooms (N=6) where high-speed rotating instruments were used, and control samples (N=24) were collected from rooms (N=4) used for periodontal and orthodontic treatment where rotating and ultrasonic instruments were not used. The collection times were 1.5 and 3 h. In addition, samples were taken from facial masks of personnel and from surfaces in the rooms before and after disinfection. After 48 h of incubation at 37 degrees C, colonies were counted and classified by Gram stain. The results showed significant contamination of the room at all distances sampled when high-speed instruments were used (mean 970 colony-forming units/m2/h). The bacterial density was found to be higher in the more remote sampling points. Gram-positive cocci, namely viridans streptococci and staphylococci, were the most common findings. The area that becomes contaminated during dental procedures is far larger than previously thought and practically encompasses the whole room. These results emphasize the need for developing new means for preventing microbial aerosols in dentistry and protection of all items stored temporarily on work surfaces. This is especially important when treating generally ill or immunocompromised patients at dental surgeries in hospital environments.

Aerosols↗

HIV prevalence and risk behaviour among intravenous drug users attending HIV counselling and testing centres in Paris.

This study was designed to analyse sexual and drug use behaviour, to determine whether increased awareness can lead to behaviour change, and to evaluate the association between HIV seropositivity and potential risk factors. A 4-month survey was carried out on 147 IVDUs attending three HIV counselling and testing centres, 98% of whom had been using heroin for an average of 7 years, 85% in association with other drugs. Two-thirds of injectors reported having used "safer" injecting practices in the previous year. Most of the IVDUs were heterosexual, and had had an average of three sexual partners in the previous year. More than half of them had had high risk partners. Condoms were used by only 25% of IVDUs, and were more likely to be used with seropositive partners (38% versus 12.7%, p = 0.02). Patients considering themselves to be well informed about HIV transmission shared syringes significantly less often, but had the same sexual behaviour patterns as other subjects. The HIV prevalence rate (8.2%) in our sample was not statistically related to any risk factor apart from drug use duration, the latter possibly reflecting a cumulative exposure to HIV risks. Since sexual risk appears to be a potential long-term hazard for IVDUs, it is important that more attention be paid to providing counselling to specifically address this issue.

AIDS Serodiagnosis↗

Attitudes to evidence on complementary medicine: the perspective of British healthcare purchasers.

OBJECTIVES: To determine the attitude of those who make decisions on the allocation of health-care resources (health-care purchasers/commissioners) towards the relative importance of different types of evidence on complementary medicine. DESIGN: Questionnaire study of GPs and Directors of Public Health. SETTING: General practices in the UK and Directors of Public Health of Health Authorities in the Greater London region. SUBJECTS: 500 randomly selected general practices in 10 randomly selected UK regions, 100 randomly selected general practices who had previously referred to the Royal London Homoeopathic Hospital and all 28 directors of public health of health authorities in the Greater London region. MAIN OUTCOME MEASURE: Importance of the following on a four point scale ranging from 0 (not important) to 3 (very important): randomized clinical trials, audit outcome data from homoeopathic hospitals, uncontrolled outcome studies, patient satisfaction, patient demand, economic evaluation, colleagues' views, expert opinion, theoretical understanding, laboratory research, safety and availability of literature. RESULTS: 462 general practitioners and 19 Directors of Health Authorities responded. Safety data and randomised clinical trials were considered very important, colleagues' views and patient demand as slightly important, uncontrolled outcome studies as not important. The remaining aspects were considered to be important. Differences between the categories of respondents were small. CONCLUSIONS: While randomized clinical trials remain very important, more emphasis should be placed on further substantiating the safety and value for money of complementary medicine in 'real world' clinical settings.

Attitude of Health Personnel↗

The development of laparoscopic surgical skills in pediatric urologists: longterm outcome of a mentorship-training model.

INTRODUCTION AND OBJECTIVES: We previously reported the successful attainment of laparoscopic skills in a group of practicing pediatric urologists without previous formal laparoscopic training. During the mentorship period, the four urologists (trainees A, B, C, and D) performed a number of renal retroperitoneal laparoscopic procedures (RRLP) under the tutelage of an expert mentor. Specifically, trainee A performed or assisted in 8 RRLP while trainees B, C, and D performed/assisted in 10, 7, or 18 RRLP, respectively. Herein we assessed the outcome of this training program and practice pattern of this same group of urologists. METHODS: Following the completion of the mentorship period, we reviewed the outcomes of all of the consecutive RRLP performed from September 2001 to March 2005 with respect to operative time, conversion rate, perioperative complications and length of hospital stay (LOS). Furthermore, we attempted to correlate the number of procedures each surgeon performed both during and subsequent to the mentorship period. RESULTS: Fifty-two ablative RRLP including nephrectomy (n=38), partial nephrectomy (n=12), or synchronous bilateral nephrectomy (n=2), were performed on 50 patients (19 males, 31 females) with a mean age of 5.5 years (range 4 months-14 years). Trainee A performed 16/40 procedures, trainees B and C each performed 2/40, while trainee D performed 20/40 procedures. Mean operative time was 2.4 hours (range 1.5-6.3 hours). Five patients required open conversion due to inability to obtain retroperitoneal access (n=3) or failure to progress (n=2). Two patients (one nephrectomy, one partial nephrectomy) developed retroperitoneal urinomas requiring temporary urinary diversion. There were no other perioperative complications and mean LOS was 1.2 days (range 1-4 days). More advanced reconstructive procedures have since been performed with the aid of laparoscopic exposure; trainee D has thus far successfully performed 12 laparoscopically assisted pyeloplasties. CONCLUSIONS: This series demonstrates the effectiveness of the mentorship-training model to introduce RRLP to a pediatric urology training program. It is evident that the post-mentorship practice is affected by the number of cases initially performed during the training period. The development of an "expert" laparoscopist is dependent not only on initial training experience, but continued education through ongoing case exposure.

Adolescent↗

A qualitative study of nurses' attitudes and practices regarding brief alcohol intervention in primary health care.

BACKGROUND: Excessive alcohol consumption causes significant mortality, morbidity, economic and social problems in the United Kingdom (UK). Despite strong evidence for the effectiveness of brief intervention to reduce excessive drinking in primary health care, there is little indication that such intervention routinely occurs. AIMS: This study aimed to explore primary health care nurses' attitudes and practices regarding brief alcohol intervention in order to understand why it is underexploited. METHODS: The study design was qualitative, using a grounded theory approach to data collection and analysis. Semi-structured in-depth interviews were conducted with 24 nurses from practices that had previously been involved in a General Practitioner (GP) led brief alcohol intervention trial in the North-east of England. A combination of convenience and purposive sampling was used to recruit subjects and gain a broad range of perspectives on issues emerging from ongoing data-analysis until data saturation occurred. RESULTS: It was clear that although primary health care nurses have many opportunities to engage in alcohol intervention, most have received little or no preparation for this work. This has left nurses at a disadvantage as alcohol consumption is a confusing and emotive area for both health professionals and patients. An analysis of factors influencing nurse involvement in alcohol intervention outlined a requirement for clear health messages about alcohol, training in intervention skills, facilitation to enhance confidence regarding intervention and support to help deal with negative patient reactions. CONCLUSIONS: As current health policy is to encourage, sustain and extend the health promotion and public health role of primary care nurses, more attention should be given to providing them with better preparation and support to carry out such work.

Adult↗

Anabolic steroids: interest among parents and nonathletes.

To determine the nature and extent of public interest in anabolic steroids, questionnaires were sent to 1290 family physicians and pediatricians in Texas. Of the 517 respondents, 55% reported being asked about steroids or seeing possible steroid users in their practices during the previous 5 years; 261 physicians (51%) reported 1682 inquiries. High school aged boys were the subject of 60% of all inquiries, 26% of which were made by parents and were exclusively related to sports. Football and athletics in general were the most common reasons for inquiry (62%), but 36% of the adolescents were interested in steroids for psychosocial reasons. Nearly 60% of the inquiries by adolescents and 36% of those by parents were considered to be serious, as opposed to casual. All inquiries regarding adolescents were for boys, and less than 1% were nonwhite. On hundred seventy-seven physicians (34%) reported 802 possible steroid users. Only 17 patients fit the stereotype of a steroid user (ie, competitive bodybuilders or professional and collegiate athletes); football players comprised 12.4% of the total. Those thought to be using steroids for psychosocial reasons equaled almost 10% of the total. All those identified as steroid users were male and only nine were nonwhite. The survey results suggest that interest in and use of anabolic steroids are common, rather than the exclusive purview of competitive athletes. This study is the first to demonstrate parental interest in anabolic steroids.

Adolescent↗

Women's experiences of general practitioner management of their vaginal symptoms.

BACKGROUND: Little is known about the management of vaginal symptoms despite their frequency. Most vaginal symptoms in non-menopausal women are managed as thrush, although bacterial vaginosis is commoner. AIM: The aim of this study was to measure the experiences of women attending their general practitioner with vaginal symptoms including self-reporting of symptoms, duration and severity, informal support, over-the-counter remedies, sources of information, gender of doctor, expected and actual vaginal examination, and explanations and knowledge of common vaginal infections. METHOD: A postal questionnaire survey was conducted of 490 patients presenting with vaginal symptoms aged between 18 and 48 years who had attended 10 general practices within the previous 3 months in the East Midlands of England. RESULTS: A total of 85% of patients had suffered a previous episode, with 39% having had three or more infections in the previous year. Overall, 68% consult with each episode, and most consult within 7 days of onset of symptoms (median = 4 days). In all, 68% discussed their symptoms with partners, families or friends, but 32% relied solely on their doctor. Some 33% bought over-the-counter remedies. A total of 65% informed themselves further from encyclopaedias, leaflets and women's magazines, but there was a strong request for more information. Out of those questioned, 75% expected a vaginal examination, whereas 57% had such an examination performed. Most were told their symptoms were caused by thrush (78%), but patients' ideas on causation were varied. Most believed sexual transmission played a role in transmission of symptoms. Women were socially embarrassed by their symptoms, with 46% admitting to having the condition on their minds all or most of the time. Twenty-eight per cent of women wished to see a female doctor, with gender being unimportant to the remainder. CONCLUSIONS: Vaginal symptoms were commonly recurrent, socially embarrassing and managed as candidiasis. Just over half the patients had a vaginal examination. There is a shortage of suitable information on vaginal infections available to patients, many of whom used over-the-counter medications.

Adolescent↗