An audit of dementia education and training in UK health and social care: a comparison with national benchmark standards.

BACKGROUND: Despite people living with dementia representing a significant proportion of health and social care users, until recently in the United Kingdom (UK) there were no prescribed standards for dementia education and training. This audit sought to review the extent and nature of dementia education and training offered to health and social care staff in the UK against the standards described in the 2015 Dementia Training Standards Framework, which describes the knowledge and skills required of the UK dementia workforce. METHODS: This audit presents national data concerning the design, delivery, target audience, length, level, content, format of training, number of staff trained and frequency of delivery within existing dementia training programmes offered to health and social care staff. The Dementia Training Standards Framework was used as a reference for respondents to describe the subjects and learning outcomes associated with their training. RESULTS: The findings are presented from 614 respondents offering 386 training packages, which indicated variations in the extent and quality of training. Many training packages addressed the subjects of 'person-centred care', 'communication', 'interaction and behaviour in dementia care', and 'dementia awareness'. Few training packages addressed subjects concerning 'pharmacological interventions in dementia care', 'leadership' and 'end of life care'. Fewer than 40% of The Dementia Training Standards Framework learning outcomes targeted to staff with regular contact with people with dementia or in leadership roles were covered by the reported packages. However, for training targeted at increasing dementia awareness more than 70% of the learning outcomes identified in The Dementia Training Standards Framework were addressed. Many training packages are not of sufficient duration to derive impact; although the majority employed delivery methods likely to be effective. CONCLUSIONS: The development of new and existing training and education should take account of subjects that are currently underrepresented and ensure that training reflects the Training Standard Framework and evidence regarding best practice for delivery. Lessons regarding the limitations of training in the UK serve as a useful illustration of the challenge of implementing national dementia training standards; particularly for countries who are developing or have recently implemented national dementia strategies.

Smoking cessation in the workplace.

BACKGROUND: The workplace is an important setting for reaching potentially large numbers of smokers. AIMS: To review the evidence about smoking cessation in the workplace. METHODS: Literature review including a synthesis of findings from recent systematic reviews and meta-analyses of workplace smoking cessation programmes, a separate review of the qualitative evidence, case studies and an expert panel assessment. RESULTS: We found advantages, identified or confirmed from the mixed methods used in this work to holding smoking cessation programmes in the workplace. These included: (i) easy access to large numbers of worker populations for large workplaces, (ii) the potential improved recruitment to such programmes given this, (iii) the opportunity to access young men, traditionally difficult to achieve, (iv) access to occupational health and other staff who can assist with support and delivery and (v) ability for workers to attend relatively easily. Evidence on the importance of developing peer support at work was mixed. The simple provision or availability of programmes and interventions was unlikely to provide any beneficial behaviour change. Interventions should target workers that actively want to stop smoking, use elements that workers have identified as useful or focus on altering beliefs about smoking and the need to stop. CONCLUSIONS: Smoking cessation programmes at work can provide useful support for workers wishing to stop smoking. They are only likely to be effective if participants have moved beyond the contemplation stage regarding smoking cessation, so that stopping smoking is a personal priority.

An insider's view of the lockdown at Moonbi during the Australian equine influenza outbreak.

Participants in the 1- and 2-day Tamworth Dressage Club (TDC) annual dressage championships arrived in Moonbi, New South Wales (NSW) as reports of the equine influenza outbreak surfaced on 25 August 2007. Three horses who had attended a competition in Maitland the weekend before had been showing flu-like symptoms and the next day the site was declared a suspect premise. On 27 August, infection was confirmed and the site was placed in total quarantine. Although most participants had travelled long distances to compete and did not have provisions for them or their horses, the quarantine was not lifted until 3 October, having a great social and personal impact on all those trapped in Moonbi.

FIB-SEM cathodoluminescence tomography: practical and theoretical considerations.

Focused ion beam-scanning electron microscope (FIB-SEM) tomography is a powerful application in obtaining three-dimensional (3D) information. The FIB creates a cross section and subsequently removes thin slices. The SEM takes images using secondary or backscattered electrons, or maps every slice using X-rays and/or electron backscatter diffraction patterns. The objective of this study is to assess the possibilities of combining FIB-SEM tomography with cathodoluminescence (CL) imaging. The intensity of CL emission is related to variations in defect or impurity concentrations. A potential problem with FIB-SEM CL tomography is that ion milling may change the defect state of the material and the CL emission. In addition the conventional tilted sample geometry used in FIB-SEM tomography is not compatible with conventional CL detectors. Here we examine the influence of the FIB on CL emission in natural diamond and the feasibility of FIB-SEM CL tomography. A systematic investigation establishes that the ion beam influences CL emission of diamond, with a dependency on both the ion beam and electron beam acceleration voltage. CL emission in natural diamond is enhanced particularly at low ion beam and electron beam voltages. This enhancement of the CL emission can be partly explained by an increase in surface defects induced by ion milling. CL emission enhancement could be used to improve the CL image quality. To conduct FIB-SEM CL tomography, a recently developed novel specimen geometry is adopted to enable sequential ion milling and CL imaging on an untilted sample. We show that CL imaging can be manually combined with FIB-SEM tomography with a modified protocol for 3D microstructure reconstruction. In principle, automated FIB-SEM CL tomography should be feasible, provided that dedicated CL detectors are developed that allow subsequent milling and CL imaging without manual intervention, as the current CL detector needs to be manually retracted before a slice can be milled. Due to the required high electron beam acceleration voltage for CL emission, the resolution for FIB-SEM CL tomography is currently limited to several hundreds of nm in XY and up to 650 nm in Z for diamonds. Opaque materials are likely to have an improved Z resolution, as CL emission generated deeper in the material is not able to escape from it.

Cryogenic EBSD on ice: preserving a stable surface in a low pressure SEM.

Naturally deformed ice contains subgrains with characteristic geometries that have recently been identified in etched surfaces using high-resolution light microscopy (LM). The probable slip systems responsible for these subgrain boundary types can be determined using electron backscattered diffraction (EBSD), providing the etch features imaged with reflected LM can be retained during EBSD data acquisition in a scanning electron microscope (SEM). Retention of the etch features requires that the ice surface is stable. Depending on the pressure and temperature, sublimation of ice can occur. The equilibrium temperature for a low pressure SEM operating at 1 × 10(-6) hPa is about -112°C and operating at higher temperatures causes sublimation. Although charging of uncoated ice samples is reduced by sublimation, important information contained in the etch features are removed as the surface sublimes. We developed a method for collecting EBSD data on stable ice surfaces in a low pressure SEM. We found that operating at temperatures of <-112°C reduced sublimation so that the original etch surface features were retained. Charging, which occurred at low pressures (<1.5 × 10(-6) to 2.8 × 10(-5) hPa) was reduced by defocusing the beam. At very low pressures (<1.5 × 10(-6) hPa) the spatial resolution with a defocused beam at 10 kV was about 3 µm in the x-direction at -150°C and 0.5 µm at -120°C, because at higher temperature charging was less and only a small defocus was needed to compensate it. Angular resolution was better than 0.7° after orientation averaging. Excellent agreement was obtained between LM etch features and EBSD mapped microstructures. First results are shown, which indicate subgrain boundary types comprised of basal (tilt and twist) and nonbasal dislocations (tilt boundaries).

Tomography of insulating biological and geological materials using focused ion beam (FIB) sectioning and low-kV BSE imaging.

Tomography in a focused ion beam (FIB) scanning electron microscope (SEM) is a powerful method for the characterization of three-dimensional micro- and nanostructures. Although this technique can be routinely applied to conducting materials, FIB-SEM tomography of many insulators, including biological, geological and ceramic samples, is often more difficult because of charging effects that disturb the serial sectioning using the ion beam or the imaging using the electron beam. Here, we show that automatic tomography of biological and geological samples can be achieved by serial sectioning with a focused ion beam and block-face imaging using low-kV backscattered electrons. In addition, a new ion milling geometry is used that reduces the effects of intensity gradients that are inherent in conventional geometry used for FIB-SEM tomography.

The Weighted Burgers Vector: a new quantity for constraining dislocation densities and types using electron backscatter diffraction on 2D sections through crystalline materials.

The Weighted Burgers Vector (WBV) is defined here as the sum, over all types of dislocations, of [(density of intersections of dislocation lines with a map) x (Burgers vector)]. Here we show that it can be calculated, for any crystal system, solely from orientation gradients in a map view, unlike the full dislocation density tensor, which requires gradients in the third dimension. No assumption is made about gradients in the third dimension and they may be non-zero. The only assumption involved is that elastic strains are small so the lattice distortion is entirely due to dislocations. Orientation gradients can be estimated from gridded orientation measurements obtained by EBSD mapping, so the WBV can be calculated as a vector field on an EBSD map. The magnitude of the WBV gives a lower bound on the magnitude of the dislocation density tensor when that magnitude is defined in a coordinate invariant way. The direction of the WBV can constrain the types of Burgers vectors of geometrically necessary dislocations present in the microstructure, most clearly when it is broken down in terms of lattice vectors. The WBV has three advantages over other measures of local lattice distortion: it is a vector and hence carries more information than a scalar quantity, it has an explicit mathematical link to the individual Burgers vectors of dislocations and, since it is derived via tensor calculus, it is not dependent on the map coordinate system. If a sub-grain wall is included in the WBV calculation, the magnitude of the WBV becomes dependent on the step size but its direction still carries information on the Burgers vectors in the wall. The net Burgers vector content of dislocations intersecting an area of a map can be simply calculated by an integration round the edge of that area, a method which is fast and complements point-by-point WBV calculations.

Electron backscattered diffraction as a tool to quantify subgrains in deformed calcite.

In this work, we investigated processing methods to obtain subgrain sizes from electron backscattered diffraction data using samples of experimentally deformed calcite (CaCO(3)) polycrystals. The domain boundary hierarchy method, based on area measurements of domains enclosed by boundaries larger than a given misorientation angle, was applied to these calcite samples and was found to be limited by: (i) topological problems; (ii) undersampling of large grains; and (iii) artefacts caused by nonindexing. We tested two alternative methods that may reduce the problems: (i) the measured linear intercept hierarchy method, based on measurements of linear intercept between boundaries having larger misorientations than a given minimum angle; and (ii) the calculated linear intercept hierarchy method, based on the total length of boundaries having misorientations larger than a given minimum angle. The measured linear intercept hierarchy method was found to produce results more representative for the microstructure than the calculated linear intercept hierarchy method, because the calculated linear intercept hierarchy method has a significant uncertainty related to the grid-based nature of the measurements. Preliminary results on calcite suggest that the measured linear intercept hierarchy method is related, in a complex way, to deformation conditions such as stress, strain and temperature as well as to the characteristics of subgrain rotation and grain boundary migration processes.

Low-angle subgrain misorientations in deformed NaCl.

The development of subgrain boundary misorientations with strain in NaCl polycrystals has been investigated. At low strains, a power law relationship exists between strain and average misorientations. The accuracy of this relationship is assessed in terms of material and electron backscattered diffraction (EBSD) processing parameters and is found to hold for a material of constant grain size deformed in compression, providing EBSD mapping and processing conditions were similar. Average misorientations are strongly influenced by grain orientation, suggesting that the misorientation-strain relationship may also be texture dependent in materials with high plastic anisotropy. A slight grain size dependency of the average misorientations was observed.

Misorientation distributions in hot deformed NaCl using electron backscattered diffraction.

EBSD orientation mapping has been used to derive subgrain boundary misorientation distributions in a series of hot deformed and etched NaCl samples. The main objective of this study has been to examine the influence of data processing, noise caused by angular resolution limits and step size on the subgrain misorientation distributions in hot deformed NaCl. Processing of non-indexed EBSD patterns increased the average misorientations in etched NaCl. Noise contributed significantly to low angle misorientation peaks for step sizes less than the minimum subgrain size. Orientation data collected using a step size larger than the average subgrain size cumulated misorientations across individual subgrains and effectively measured an orientation gradient between steps. Orientation gradient distributions were not influenced by noise. Average misorientation values calculated from large step data correlated well with average misorientation from small step size data, Average misorientations showed a power law relationship with strain. Three types of substructures were identified using scanning electron microscopy and EBSD mapping, equiaxed subgrains, long subgrain boundaries and a core-mantle subgrain arrangement.

Patients with cancer holding their own records: a randomised controlled trial.

BACKGROUND: The burden of cancer care in general practice is increasing. Patient-held records may facilitate effective, coordinated care, but no randomised controlled trials of their use in cancer care have been conducted, and concerns about possible negative effects remain. AIM: To evaluate the use of a supplementary patient-held record in cancer care. METHOD: Six hundred and fifty radiotherapy outpatients with any form of cancer were randomised either to hold a supplementary record or to receive normal care. It was explained to record holders that the supplementary record was intended to improve communication with health professionals and act as an aide memoire. After three months, patients' satisfaction with communication and with participation in their own care were assessed. Global health status, emotional functioning, and cognitive functioning were measured using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire. RESULTS: There were no significant differences between groups in any of the outcome measures. Patients in both groups expressed a high level of satisfaction with communication and participation in their care. Mean (SD) scores in the intervention and control groups were: global health status, 66.8 (24.2) and 65.3 (23.7); emotional functioning, 75.0 (24.6) and 77.4 (22.8); cognitive functioning, 84.5 (21.0) and 84.0 (21.3). CONCLUSION: A supplementary patient-held record for radiotherapy outpatients appears to have no effect on satisfaction with communication, participation in care, or quality of life.

Lipofection indirectly increases expression of endogenous major histocompatibility complex class I molecules on tumor cells.

Direct intratumoral injection of a lipid/DNA complex encoding an allogeneic major histocompatibility complex (MHC) class I molecule leads to regression of both an immunogenic murine tumor and also melanoma lesions in some patients. We have sought to understand the mechanism(s) for this augmentation of antitumor activity. While optimizing parameters for in vitro gene transfer into the D5 subclone of B16BL6, it was noted that lipofected tumors not only expressed the new alloantigen but also exhibited increased expression of endogenous MHC class I, both H-2 Kb and H-2 Db. This increase in expression was not restricted to the small percentage of cells that expressed the transfected gene, but appeared to affect the majority of cells in culture. Class I expression was not increased by lipopolysaccharide, DNA alone, lipid, or lipid/lipopolysaccharide mixtures. Enhanced class I expression required a DNA/lipid complex and was greatest when parameters optimized for gene transfer of the alloantigen were used. All DNA plasmids tested had this effect, including one plasmid whose DNA was not transcribed because it lacked an expression cassette. Because of the critical role that MHC class I antigens play in immune recognition, we propose that lipid complex-mediated gene transfer may provide immunological advantages beyond those that are attributable to expression of the specific gene transferred.

Pharmaceutical trials in general practice: the first 100 protocols. An audit by the clinical research ethics committee of the Royal College of General Practitioners.

OBJECTIVE: To assess the outcome of 100 general practice based, multicentre research projects submitted to the ethics committee of the Royal College of General Practitioners by pharmaceutical companies or their agents between 1984 and 1989. DESIGN: Analysis of consecutive submitted protocols for stated objectives, study design, and outcomes; detailed review of committee minutes and correspondence in relation to amendment and approval; assessment of final reports submitted at conclusion of studies. SUBJECTS: 82 finally approved protocols, embracing 34,523 proposed trial subjects and 1195 proposed general practice investigators. MAIN OUTCOME MEASURES: Success at enrolling subjects and investigators; commencement and completion data; validity of final report's assessment of efficacy, safety, tolerability, and acceptability; and method of use and dissemination of findings. RESULTS: 18 studies were not approved and 45 had to be amended. Randomised controlled trials comprised 46 of the original submissions. Remuneration considerations, inadequate information or consent sheets, pregnancy safety, the need to discontinue existing therapy, and suboptimal scientific content were major reasons for rejecting studies or asking for amendments. Of the 82 approved studies 8 were not started. Shortfalls of investigators (of 39%) and trial subjects (of 37%) and an overall 23% withdrawal rate were responsible for a significant incidence of inconclusive results. Within the six year follow up interval, only 19 of the studies had been formally published. CONCLUSIONS: This audit identified substantial ethical concerns in the process of approving multicentre general practice pharmaceutical research.

Timing of hard palatal closure: a critical long-term analysis.

The controversy about timing of cleft palate surgical procedures is focused on early palatoplasty for improved speech versus delayed hard palate repair for undisturbed facial growth. Timing and technique of palate repair are the most important influences on speech and facial growth, yet there is no consensus on the age or technique for surgery. The Oxford Cleft Palate Study was initiated to evaluate critically the long-term follow-up of 44 patients with early versus late closure of the hard palate. A multidisciplinary approach was used to determine the incidence of speech deficiencies, palatal fistulas, maxillofacial growth disturbances, and hearing abnormalities and to assess objectively the long-term effects of two different treatment modalities on the cleft palate patient. The 44 patients were selected randomly, interviewed, and examined by the multidisciplinary Oxford Cleft Palate Study team. The average age at follow-up in the early closure group was 17.0 years versus 18.2 years in the late closure group. There was a similar number of unilateral and bilateral clefts in both the early and late closure groups. The hard palate was closed in the early group at an average age of 10.8 months versus 48.6 months in the late closure group. All operative procedures in each group were performed by the same senior plastic surgery consultant. Both consultants have since retired and did not participate in the study. Each patient was evaluated by the same plastic surgeon, speech pathologist, orthodontist, and otologist. All examiners were blinded in that they were unaware of the type or timing of the surgical technique and had no prior knowledge of or access to the patient's medical records. Furthermore, none of the examiners participated in the initial care and surgery of these patients. Statistically significant greater speech deficiencies were noted with delayed hard palate closure, especially in articulation, nasal resonance, intelligibility, and substitution pattern assessment (overall intelligibility, p < 0.01). Likewise, the persistent palatal fistula rate in the late closure group was 35 percent in comparison with 5 percent for the early closure group (p <0.02). No significant differences in hearing or maxillofacial growth impairment were delineated in either group. Our data suggest that delaying hard palate closure results in significant speech impairment without a beneficial maxillofacial growth response.

Dominant situational determinants of sexual risk behaviour in gay men.

OBJECTIVE: To examine the interplay between situational, social and psychological factors in gay men's decisions about HIV risk behaviour, using multiple hypothetical situations. METHOD: The sample included 79 gay men from Sydney recruited through flyers, press advertisements or personal contact at gay venues. Subjects were presented with 20 hypothetical situations graphically on a computer, which included different levels of attraction to partner, intoxication, attractiveness to partner, condom availability, desire for anal sex by subject, insistence of partner on using a condom and time constraints in each situation. Subjects used a computerized graphic rating scale to indicate the likelihood of unprotected anal sex in each situation, the frequency with which they had experienced the hypothetical situation in real life and satisfaction with their response. The probability of having unsafe anal sex in any given situation was the dependent variable. All other variables were predictors. RESULTS: A vector of predictors accounted for 30% of the variance (r = 0.54). Ratings of the probability of anal sex increased with the frequency that subjects had experienced hypothetical situations in real life, attraction to partner, attractiveness to partner and time elapsed since real life experience similar to the hypothetical one. Ratings of the probability of anal sex decreased with condom availability. CONCLUSIONS: Our results suggest that interventions must address the way that individuals interact with their partner and their environment in order to be successful.

Effects of fluoxetine on the oral environment of bulimics.

The purpose of this study was to evaluate in a double-blind placebo-based study the effects of fluoxetine over a period of 16 weeks on the frequency of binging and purging and on fluctuations in the levels of cariogenic organisms and saliva secretion rate of patients (n = 30) with bulima nervosa. Profile analysis suggested that, over the course of the study, binging and purging frequency and Streptococcus sobrinus salivary levels decreased significantly in the fluoxetine group as compared with the placebo group. Our finding that S. sobrinus levels decreased 16 weeks after subjects were on medication suggests that the salivary levels of these organisms could serve as an objectively measured indicator of patient compliance with antibulimic therapy.