Microenvironmental topographic cues influence migration dynamics of nasopharyngeal carcinoma cells from tumour spheroids.

Tumour metastasis is a complex process that strongly influences the prognosis and treatment of cancer. Apart from intracellular factors, recent studies have indicated that metastasis also depends on microenvironmental factors such as the biochemical, mechanical and topographical properties of the surrounding extracellular matrix (ECM) of tumours. In this study, as a proof of concept, we conducted tumour spheroid dissemination assay on engineered surfaces with micrograting patterns. Nasopharyngeal spheroids were generated by the 3D culture of nasopharyngeal carcinoma (NPC43) cells, a newly established cell line that maintains a high level of Epstein-Barr virus, a hallmark of NPC. Three types of collagen I-coated polydimethylsiloxane (PDMS) substrates were used, with 15 µm deep "trenches" that grated the surfaces: (a) 40/10 µm ridges (R)/trenches (T), (b) 18/18 µm (R/T) and (c) 50/50 µm (R/T). The dimensions of these patterns were designed to test how various topographical cues, different with respect to the size of tumour spheroids and individual NPC43 cells, might affect dissemination behaviours. Spreading efficiencies on all three patterned surfaces, especially 18/18 µm (R/T), were lower than that on flat PDMS surface. The outspreading cell sheets on flat and 40/10 µm (R/T) surfaces were relatively symmetrical but appeared ellipsoid and aligned with the main axes of the 18/18 µm (R/T) and 50/50 µm (R/T) grating platforms. Focal adhesions (FAs) were found to preferentially formed on the ridges of all patterns. The number of FAs per spheroid was strongly influenced by the grating pattern, with the least FAs on the 40/10 µm (R/T) and the most on the 50/50 µm (R/T) substrate. Taken together, these data indicate a previously unknown effect of surface topography on the efficiency and directionality of cancer cell spreading from tumour spheroids, suggesting that topography, like ECM biochemistry and stiffness, can influence the migration dynamics in 3D cell culture models.

A preliminary ergonomic analysis of the MRI work system environment: Implications and recommendations for safety and design.

INTRODUCTION: The MRI work system environment in acute hospitals poses a significant risk of harm to patients, healthcare practitioners and others, but knowledge of hazards and potential design improvements are limited as safety research is lacking. The aim of this exploratory study was to understand how the discipline of Human Factors and Ergonomics (HFE) can support the understanding and improvement of safety and performance of MRI working environments. METHODS: A multi-method study of two MRI units in Scottish acute hospital settings based on Human Factors and Ergonomics (HFE) principles was undertaken in May 2016. Data collection sources included published literature, local and national safety incident data, site observations and staff interviews which were triangulated and subject to a content analysis. RESULTS: A diverse range of system-wide hazards were highlighted which impact on the complexity of MRI work, patient and staff safety and system performance (e.g. adequacy of training and procedures, interactions with equipment, organisation of work). Preliminary recommendations were made to improve system design related to national approaches to safety (e.g. equipment procurement; staff training and procedural standards); interaction design and standardisation (e.g. physical design and barriers, staff uniforms, checking processes); and introduction of MRI passports for patients. CONCLUSIONS: This exploratory study suggests the need for national co-ordination and standardisation of MRI safety management strategies, based on safety science and HFE evidence and approaches to improve system design and reduce risk to patients, staff and others. A series of provisional recommendations are offered for consideration.

Patient safety in dentistry: development of a candidate 'never event' list for primary care.

Introduction The 'never event' concept is often used in secondary care and refers to an agreed list of patient safety incidents that 'should not happen if the necessary preventative measures are in place'. Such an intervention may raise awareness of patient safety issues and inform team learning and system improvements in primary care dentistry.Objective To identify and develop a candidate never event list for primary care dentistry.Methods A literature review, eight workshops with dental practitioners and a modified Delphi with 'expert' groups were used to identify and agree candidate never events.Results Two-hundred and fifty dental practitioners suggested 507 never events, reduced to 27 distinct possibilities grouped across seven themes. Most frequently occurring themes were: 'checking medical history and prescribing' (119, 23.5%) and 'infection control and decontamination' (71, 14%). 'Experts' endorsed nine candidate never event statements with one graded as 'extreme risk' (failure to check past medical history) and four as 'high risk' (for example, extracting wrong tooth).Conclusion Consensus on a preliminary list of never events was developed. This is the first known attempt to develop this approach and an important step in determining its value to patient safety. Further work is necessary to develop the utility of this method.

A Brief Strengths Scale for individuals with mental health issues.

Using their strengths and virtues enables individuals to build resilience and alleviate mental health issues. However, most existing instruments for measuring strengths are too lengthy to provide effective assessment for clinical screening. A brief instrument with good factorial and ecological validity is needed to measure strengths, especially among individuals with mental health issues. In this study, the authors developed a brief inventory, the Brief Strengths Scale-12 (BSS-12), to assess 3 strengths: Temperance Strength, Intellectual Strength, and Interpersonal Strength. Two studies were conducted. Study 1 was conducted in Hong Kong. Service recipients (n = 149) from a psychiatric rehabilitation organization were recruited to establish the factor structure and construct validity of the BSS-12. In Study 2, 203 university undergraduates from mainland China were recruited to examine the factorial invariance of the BSS-12 in a different culture and population. Each factor demonstrated satisfactory internal consistency, content validity, and discriminant validity. The BSS-12 may be a useful tool for assessing strengths in clinical and nonclinical settings for service planning and the evaluation of intervention effectiveness. (PsycINFO Database Record

Role of virtues and perceived life stress in affecting psychological symptoms among Chinese college students.

OBJECTIVE: This study explored the relationship among virtues, self-perceived life stress, and psychological symptoms. PARTICIPANTS: A total of 235 undergraduates participated in the study in March 2013. METHODS: The participants were recruited to complete the Life Stress Rating Scale for College Students, the Chinese Virtues Questionnaire that measures 3 virtues (relationship, vitality, and conscientiousness), and the Symptom Checklist-90. RESULTS: Regression analyses indicated that the perceived stress from minor events explained approximately 35.00% of the variance of psychological symptoms. Both vitality and conscientiousness contributed to another 6.00% of psychological symptoms. Perceived stress from minor events mediated the relationship between vitality and psychological symptoms, whereas conscientiousness directly affected psychological symptoms regardless of the perceived stress level. CONCLUSION: This study clarified the positive role of virtues in stressful situations among Chinese undergraduates. The results benefit the college health professionals in attending strengths of their clients in practice both in Eastern and Western countries.

The development and psychometric evaluation of a safety climate measure for primary care.

INTRODUCTION: Building a safety culture is an important part of improving patient care. Measuring perceptions of safety climate among healthcare teams and organisations is a key element of this process. Existing measurement instruments are largely developed for secondary care settings in North America and many lack adequate psychometric testing. Our aim was to develop and test an instrument to measure perceptions of safety climate among primary care teams in National Health Service for Scotland. METHOD: Questionnaire development was facilitated through a steering group, literature review, semistructured interviews with primary care team members, a modified Delphi and completion of a content validity index by experts. A cross-sectional postal survey utilising the questionnaire was undertaken in a random sample of west of Scotland general practices to facilitate psychometric evaluation. Statistical methods, including exploratory and confirmatory factor analysis, and Cronbach and Raykov reliability coefficients were conducted. RESULTS: Of the 667 primary care team members based in 49 general practices surveyed, 563 returned completed questionnaires (84.4%). Psychometric evaluation resulted in the development of a 30-item questionnaire with five safety climate factors: leadership, teamwork, communication, workload and safety systems. Retained items have strong factor loadings to only one factor. Reliability coefficients was satisfactory (α = 0.94 and ρ = 0.93). DISCUSSION: This study is the first stage in the development of an appropriately valid and reliable safety climate measure for primary care. Measuring safety climate perceptions has the potential to help primary care organisations and teams focus attention on safety-related issues and target improvement through educational interventions. Further research is required to explore acceptability and feasibility issues for primary care teams and the potential for organisational benchmarking.

The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records.

BACKGROUND: A multi-method strategy has been proposed to understand and improve the safety of primary care. The trigger tool is a relatively new method that has shown promise in American and secondary healthcare settings. It involves the focused review of a random sample of patient records using a series of "triggers" that alert reviewers to potential errors and previously undetected adverse events. AIM: To develop and test a global trigger tool to detect errors and adverse events in primary-care records. METHOD: Trigger tool development was informed by previous research and content validated by expert opinion. The tool was applied by trained reviewers who worked in pairs to conduct focused audits of 100 randomly selected electronic patient records in each of five urban general practices in central Scotland. RESULTS: Review of 500 records revealed 2251 consultations and 730 triggers. An adverse event was found in 47 records (9.4%), indicating that harm occurred at a rate of one event per 48 consultations. Of these, 27 were judged to be preventable (42%). A further 17 records (3.4%) contained evidence of a potential adverse event. Harm severity was low to moderate for most patients (82.9%). Error and harm rates were higher in those aged > or =60 years, and most were medication-related (59%). CONCLUSIONS: The trigger tool was successful in identifying undetected patient harm in primary-care records and may be the most reliable method for achieving this. However, the feasibility of its routine application is open to question. The tool may have greater utility as a research rather than an audit technique. Further testing in larger, representative study samples is required.

Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross-sectional study.

BACKGROUND AND AIMS: There is variation in the identification, analysis and reporting of significant events in general practice. Consistency is desired to optimise learning from, and reporting of, patient safety incidents. We examined levels of agreement among different groups of general practitioners (GPs) on the grading, analysis and reporting of selected significant event scenarios. METHOD: Cross-sectional postal questionnaire survey of 162 GPs split into five professional groups in the west of Scotland. Differences in grading severity and willingness to formally analyse and report seven significant event scenarios were examined using analysis of variance (ANOVA). Differences in proportions were calculated together with 95% confidence intervals. RESULTS: 122 GPs responded (77%). No difference was found in the grading severity of significant events by GP groups. Increased grading severity was linked to the willingness of GP groups to analyse and report that event (p<0.05). A preference to anonymously report all event scenarios to a national educational body was reported (p<0.05). The majority of respondents were not willing to involve patients in relevant event analyses (83-100%). CONCLUSIONS: The strong levels of agreement suggest that GPs can prioritise relevant significant events for formal analysis and reporting. Focused guidance should be developed to encourage their engagement with the patient safety agenda, optimise learning from safety-relevant events and increase reporting opportunities. Exploration is required of the reasons why GPs may prefer an educational body as a potential reporting source or may be unwilling to include patients in relevant event analyses.

Development and testing of an assessment instrument for the formative peer review of significant event analyses.

AIM: To establish the content validity and specific aspects of reliability for an assessment instrument designed to provide formative feedback to general practitioners (GPs) on the quality of their written analysis of a significant event. METHODS: Content validity was quantified by application of a content validity index. Reliability testing involved a nested design, with 5 cells, each containing 4 assessors, rating 20 unique significant event analysis (SEA) reports (10 each from experienced GPs and GPs in training) using the assessment instrument. The variance attributable to each identified variable in the study was established by analysis of variance. Generalisability theory was then used to investigate the instrument's ability to discriminate among SEA reports. RESULTS: Content validity was demonstrated with at least 8 of 10 experts endorsing all 10 items of the assessment instrument. The overall G coefficient for the instrument was moderate to good (G>0.70), indicating that the instrument can provide consistent information on the standard achieved by the SEA report. There was moderate inter-rater reliability (G>0.60) when four raters were used to judge the quality of the SEA. CONCLUSIONS: This study provides the first steps towards validating an instrument that can provide educational feedback to GPs on their analysis of significant events. The key area identified to improve instrument reliability is variation among peer assessors in their assessment of SEA reports. Further validity and reliability testing should be carried out to provide GPs, their appraisers and contractual bodies with a validated feedback instrument on this aspect of the general practice quality agenda.

A pilot study of the feasibility of trainee hospital doctors undertaking significant event analysis.

Participating in significant event analysis is proposed as an important method of reflective learning that can enhance patient care and safety. Peer review is one way of making informed judgments on the ability of participants to apply the technique.

A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment.

OBJECTIVES: To explore the influences and perceived benefits behind general practitioners' willingness to participate in significant event analysis (SEA) and educational peer assessment. DESIGN: Qualitative analysis of focus group transcripts. SETTING: Greater Glasgow Primary Care Trust. PARTICIPANTS: Two focus group sessions involving 21 principals in general practice (GPs). MAIN OUTCOME MEASURES: GPs' perceptions of the reasons for and benefits of participating in SEA and associated educational peer assessment. RESULTS: Pressure from accreditation bodies and regulatory authorities makes SEA compulsory for most participants who believe more in-depth event analyses are undertaken as a result. Some believed SEA was not an onerous activity while others argued that this depended on the complexity of the event. SEA that is linked to a complaint investigation may provide credible evidence to patients that their complaint is taken seriously. Writing up an event analysis is viewed as an educational process and may act as a form of personal catharsis for some. Event analyses are submitted for peer assessment for educational reward but are highly selective because of concerns about confidentiality, litigation, or professional embarrassment. Most participants disregard the opportunities to learn from "positive" significant events in favour of problem ones. Peer assessment is valued because there is a perception that it enhances knowledge of the SEA technique and the validity of event analyses, which participants find reassuring. CONCLUSIONS: This small study reports mainly positive feedback from a select group of GPs on the merits of SEA and peer assessment.

Awareness and analysis of a significant event by general practitioners: a cross sectional survey.

OBJECTIVES: To determine the extent to which general practitioners (GPs) were aware of a recent significant event and whether a structured analysis of this event was undertaken to minimise the perceived risk of recurrence. DESIGN: Cross sectional survey using a postal questionnaire. SETTING: Greater Glasgow primary care trust. PARTICIPANTS: 466 principals in general practice from 188 surgeries. MAIN OUTCOME MEASURES: GPs' self-reported personal and practice characteristics, awareness of a recent significant event, participation in the structured analysis of the identified significant event, perceived chance of recurrence, forums for discussing and analysing significant events, and levels of primary care team involvement. RESULTS: Four hundred and sixty six GPs (76%) responded to the survey. GPs from single handed practices were less likely to respond than those in multi-partner training and non-training practices. 401 (86%) reported being aware of a recent significant event; lack of awareness was clearly associated with GPs from non-training practices. 219 (55%) had performed all the necessary stages of a structured analysis (as determined by the authors) of the significant event. GPs from training practices were more likely to report participation in the structured analysis of the recent event, to perceive the chance of this event recurring as "nil" or "very low", and to report significant event discussions taking place. CONCLUSIONS: Most GPs were aware of a recent significant event and participated in the structured analysis of this event. The wider primary care team participated in the analysis process where GPs considered this involvement relevant. There is variation in the depth of and approach to significant event analysis within general practice, which may have implications for the application of the technique as part of the NHS quality agenda.

Unnecessary out-of-hours biochemistry investigations--a subjective view of necessity.

OBJECTIVE: To investigate the extent to which pre-registration house officers (PRH0s) admit to requesting 'unnecessary' out-of-hours biochemistry tests and assess the reasons why this occurs. DESIGN: Semi-structured interviews conducted over a 2-year period covering 1998/99. SETTING: Inverclyde Royal District General Hospital SUBJECTS: 79 PRHOs. RESULTS: Seventy-nine PRHOs were interviewed. Eighty-seven percent admitted requesting 'unnecessary' out-of-hours tests in between 5% and 50% of cases. The reasons cited include uncertainty about the diagnosis (80%), the need for medico-legal protection (79%), to avoid leaving work for colleagues (66%), and to prevent criticism from consultant staff and others (71%). Seventy six percent of PRHOs indicated that ordering 'unnecessary' tests helped to lessen anxiety and reduce stress levels associated with their work. Seventy one percent agreed an attempt should be made to reduce 'unnecessary' tests. CONCLUSIONS: This study has shown that a significant proportion of PRHOs admits to requesting 'unnecessary' out-of-hours tests. A better understanding of why these tests are requested has been established. The need for self-protection and a fear of criticism from senior staff are prominent factors affecting stress levels amongst junior medical staff in the hospital workplace.

Young dyspeptic patients: with a test-and-treat policy, are the benefits of decreased symptom severity and oesophago-gastric-duodenoscopy workload sustained?

OBJECTIVES: To examine the symptom severity and requirement for oesophago-gastro-duodenoscopy (OGD) in young dyspeptic patients 2 years after serological testing for Helicobacter pylori, and to compare the outcomes of seronegative patients with those of seropositive patients. DESIGN: Long-term follow-up study of 232 participants from our previous trial. METHODS: Telephone assessment of patients' symptom severity, scored using a previously validated questionnaire; return of patients for OGD determined using local patient administration system (PAS); and review of medical case notes. RESULTS: Dyspepsia symptom severity of both seronegative and seropositive patients remained reduced compared with initial scores at time of trial recruitment. Symptom severity of seropositive patients was significantly lower than that of seronegative patients (P< 0.001). Seventeen additional patients returned for OGD between six months and two years after the start of the serological study. As 61 of the original 232 study patients returned for OGD within the first six month follow-up period, a total of 78 individuals (34%) had OGD during the two years following the study. Thus, 66% of the original participants avoided OGD. CONCLUSIONS: This study of non-invasive testing for H. pylori in young dyspeptic patients has demonstrated an improvement in symptom severity and a substantial reduction in OGD workload over a 2-year period.

Audit and non-principals: reported experiences in general practice.

OBJECTIVES: To determine respondents reported levels of exposure to audit during their medical career and as a general practice non-principal. To assess and identify audit education and training needs. DESIGN: Postal questionnaire survey. SETTING: The West of Scotland. SUBJECTS: Two hundred GP non-principals. RESULTS: A response rate of 79% was achieved. The mean age of respondents was 35 years and 121 (77%) were female. One hundred and thirty respondents (83%) reported involvement in three or less audit projects during a mean career length of 12.1 years. Of 378 audit projects claimed to have been undertaken, 287 (76%) involved setting measurable standards, and 181 (48%) failed to be completed. One hundred and six respondents (68%) had yet to take part in audit during their time as a non-principal (median length of time was 1 year). Thirty nine respondents (25%) were currently involved in an on-going audit project. One hundred and twelve (71%) claimed that they were not expected to participate in audit as part of their current or previous non-principal post. One hundred and one respondents (64%) indicated that they require further education and training in audit method. CONCLUSIONS: Non-principals' experience of audit and exposure to it are poor. Many lack knowledge of audit method and appear to be uninvolved in audit and excluded from local audit programmes. Integration into the primary care team, access to a co-ordinated programme of audit and training in audit method are required. Otherwise non-principals may continue to struggle with the audit demands of clinical governance and impending revalidation.

First-line management of menorrhagia: findings from a survey of general practitioners in Forth Valley.

This study was undertaken to determine local GPs' current management of menorrhagia, prior to the release of the Royal College of Obs tetricians and Gynaecologists' (RCOG) guideline on the initial management of menorrhagia. A postal questionnaire was sent to 204 GPs in the Forth Valley area. An 84% (n = 173) response rate was recorded. Responses were compared with RCOG guideline recommendations after its release. Fifty-two percent of respondents measured a full blood count and 56% performed a pelvic examination. Two thirds of GPs chose the recommended treatments (mefenamic acid or tranexamic acid) as their first or second choice of treatment in women not requiring contraception. One third chose cyclical progestogens. Only 10% of GPs selected an ineffective treatment (cyclical progestogens) as their first or second choice of treatment in women requiring contraception. This survey demonstrates that the majority of GPs are already prescribing the treatments recommended in the RCOG guidelines. There is a need for education amongst a minority to improve their practice. Half of the GPs reported compliance with the recommended investigations of full blood count and pelvic examination. The point at which these investigations are performed in the initial management of menorrhagia may need further discussion between primary and secondary care clinicians to clarify their purpose.

The quality of residential and nursing-home care for people with dementia.

OBJECTIVES: to determine the environmental quality of community-based residential and nursing care for people with dementia. DESIGN: survey of a stratified random sample of care homes. SETTINGS: forty-six registered residential and nursing homes in a single health district. MAIN OUTCOME MEASURES: scales for the assessment of environments for people with dementia, including care practices, social activities, social facilities, reality orientation cues, physical condition and space availability. RESULTS: over 90% of the homes had high quality scores on at least two measures. Provision of reality orientation cues was usually poor. Nursing homes catering specifically for 'the elderly mentally infirm' had more restrictive care practices, whilst local-authority residential homes had a better provision of recreational facilities. Private sector homes were in much better condition than public sector homes but their care practices were more institutional--this may be related to the provision of nursing and elderly mentally infirm care almost exclusively by the private sector. CONCLUSIONS: the environmental quality of community-based residential care is generally good, but improvements could be made, particularly with reality orientation cues.

Methicillin-resistant Staphylococcus aureus colonization in nursing home residents: a prevalence study in Northamptonshire.

A prevalence study of methicillin-resistant Staphylococcus aureus (MRSA) colonization was carried out in 17 nursing homes in Northamptonshire over a 20-month period. Thirteen of 275 residents swabbed (4.7%) were found to be colonized and six of the 17 homes (35%) had colonized residents. Only two homes had more than one colonized resident. Individual risk factors for colonization were gender (male) and the presence of skin ulcers and sores. There were no significant risk factors identified for homes. Spread may have occurred in the two homes which had more than one colonized resident. Both these homes had the epidemic strain EMRSA-15 whereas three of the four homes with a single colonized resident had EMRSA-16. It is suggested that homes with residents colonized with EMRSA-16 may be able to prevent spread by adherence to good infection control procedures but that this may not be adequate to prevent spread of EMRSA-15.

Should the Mini Mental State Examination be used to monitor dementia treatments?

The test-retest and inter-rater reliabilities of the Mini Mental State Examination were found inadequate for detecting small changes in cognition, making this test inappropriate for assessing treatment response in Alzheimer's disease.

Midazolam sedation to produce complete amnesia for bronchoscopy: 2 years' experience at a district general hospital.

Patients may find bronchoscopy without sedation unpleasant. There is some evidence that patient satisfaction correlates with amnesia for the procedure. For several years we have used doses of midazolam sufficient to put patients lightly asleep hoping to produce complete amnesia. We looked at practical aspects of this technique over a 2-year period. We studied 337 consecutive patients. They were 219 men and 118 women of mean age 63 +/- 12.4 (SD). Sixty-seven patients were aged 75 years or over and the eldest was 86. Sixty-three patients were already hospital inpatients but the remainder were seen as day cases. Midazolam was given by slow i.v. injection over several minutes until the patient was judged to be lightly asleep. Patients were given supplemental oxygen (3 l min-1) and monitored by ECG and pulse oximetry. A note was made of the time at which they awakened, defined as when nursing staff felt the patients were awake enough to have a cup of tea and toast. Patients were asked if they had any memory of the procedure both on awakening and when seen a few days later to discuss the results. The procedures were carried out in a well-staffed Day Case Unit with a recovery area. The mean dose of midazolam used was 10.8 mg (mean +/- SD = 0.16 +/- 0.095 mg kg-1). The midazolam was given over a median of 4 min (range 1-15 min). Patients took 59 +/- 45 min (mean +/- SD) to wake up. Twenty-eight patients were given flumazanil to reverse the sedation (11 for concern over bleeding following biopsies, three for desaturation during and three after procedure, four as they were frail, two as they were restless, two as they were hypotensive after procedure and three for miscellaneous reasons). Only nine patients could remember any part of the procedure. Incremental doses of midazolam given slowly until patients are lightly asleep almost invariably produce complete amnesia for bronchoscopy. This is a safe technique but patients need careful monitoring and may require reversal of sedation with flumazanil.