Facilitating successful implementation of a person-centred intervention to support family carers within palliative care: a qualitative study of the Carer Support Needs Assessment Tool (CSNAT) intervention.

BACKGROUND: An understanding of how to implement person-centred interventions in palliative and end of life care is lacking, particularly for supporting family carers. To address this gap, we investigated components related to successful implementation of the Carer Support Needs Assessment Tool (CSNAT) intervention, a person-centred process of carer assessment and support, using Promoting Action on Research Implementation in Health Services (PARIHS) as a theoretical framework. This study identifies how the PARIHS component of 'facilitation' and its interplay with the components of 'context' and 'evidence' affect implementation success. METHODS: MRC Framework Phase IV study to evaluate implementation of the CSNAT intervention at scale, over six months, in 36 UK palliative care services. 38 practitioners acting as internal facilitators in 35/36 services were interviewed. Field notes were collected during teleconference support sessions between the external and internal facilitators. RESULTS: Successful implementation was associated with internal facilitators' 'leverage' including their positioning within services, authority to change practice, and having a team of supportive co-facilitators. Effective facilitation processes included a collaborative approach, ongoing communication, and proactive problem solving to address implementation barriers. Facilitators needed to communicate the evidence and provide legitimacy for changing practice. Contextual constraints on facilitation included having to adjust recording systems to support implementation, organisational changes, a patient-focused culture and lack of managerial support. CONCLUSIONS: The CSNAT intervention requires attention to both facilitation processes and conducive organisational structures for successful implementation. These findings are likely to be applicable to any person-centred process of assessment and support within palliative care.

A large-scale, rapid public health response to rabies in an organ recipient and the previously undiagnosed organ donor.

This article describes and contrasts the public health response to two human rabies cases: one organ recipient diagnosed within days of symptom onset and the transplant donor who was diagnosed 18 months post-symptom onset. In response to an organ-transplant-related rabies case diagnosed in 2013, organ donor and recipient investigations were conducted by multiple public health agencies. Persons with potential exposure to infectious patient materials were assessed for rabies virus exposure. An exposure investigation was conducted to determine the source of the organ donor's infection. Over 100 persons from more than 20 agencies spent over 2700 h conducting contact investigations in healthcare, military and community settings. The 564 persons assessed include 417 healthcare workers [5.8% recommended for post-exposure prophylaxis (PEP)], 96 community contacts (15.6% recommended for PEP), 30 autopsy personnel (50% recommended for PEP), and 21 other persons (4.8% recommended for PEP). Donor contacts represented 188 assessed with 20.2% recommended for PEP, compared with 5.6% of 306 recipient contacts recommended for PEP. Human rabies cases result in substantial use of public health and medical resources, especially when diagnosis is delayed. Although rare, clinicians should consider rabies in cases of encephalitis of unexplained aetiology, particularly for cases that may result in organ donation.

Successful use of the TandemHeart percutaneous ventricular assist device as a bridge to recovery for acute cellular rejection in a cardiac transplant patient.

In this report, we presented a patient who benefited from hemodynamic support with the TandemHeart percutaneous ventricular assist device (pVAD; Cardiac Assist, Inc) implantation in the setting of early acute graft rejection 2 months after orthotopic heart transplant. The TandemHeart initially had been used for temporary hemodynamic assistance during postcardiotomy heart failure and high-risk coronary interventions. More recently, its use in patients with cardiogenic shock from acute myocardial infarction, fulminant myocarditis, and critical aortic stenosis has been reported. To our knowledge, this is one of the first reported cases in which the TandemHeart pVAD served as a successful device for support during acute cardiac transplant rejection.

Selective sweeps for recessive alleles and for other modes of dominance.

A selective sweep describes the reduction of linked genetic variation due to strong positive selection. If s is the fitness advantage of a homozygote for the beneficial allele and h its dominance coefficient, it is usually assumed that h=1/2, i.e. the beneficial allele is co-dominant. We complement existing theory for selective sweeps by assuming that h is any value in [0, 1]. We show that genetic diversity patterns under selective sweeps with strength s and dominance 0 < h < 1 are similar to co-dominant sweeps with selection strength 2hs. Moreover, we focus on the case h=0 of a completely recessive beneficial allele. We find that the length of the sweep, i.e. the time from occurrence until fixation of the beneficial allele, is of the order of √(N/s) generations, if N is the population size. Simulations as well as our results show that genetic diversity patterns in the recessive case h=0 greatly differ from all other cases.

Informal carer bereavement outcome: relation to quality of end of life support and achievement of preferred place of death.

This study investigated (a) whether carer bereavement outcome is affected by the achievement of the patient's and/or carers' preferred place of death and (b) the relationship between carer satisfaction with end of life care and bereavement outcome. Participants were 216 carers of patients referred to hospice at home (H@H). Prospective recording of preferred and actual place of death were obtained from H@H records. Carers' level of grief and mental health and assessment of end of life care were obtained through postal survey three to four months post-bereavement. Fulfilment of carer preference for place of death only related to post-bereavement mental health at P < 0.1. Adequacy of psychological support showed the clearest relationship with bereavement outcome both in univariate and multivariate analyses. The level of support, particularly psychological, may be more important for carers' bereavement outcome than achievement of the preferred place of death for the patient.

DNA surveillance: web-based molecular identification of whales, dolphins, and porpoises.

DNA Surveillance is a Web-based application that assists in the identification of the species and population of unknown specimens by aligning user-submitted DNA sequences with a validated and curated data set of reference sequences. Phylogenetic analyses are performed and results are returned in tree and table format summarizing the evolutionary distances between the query and reference sequences. DNA Surveillance is implemented with mitochondrial DNA (mtDNA) control region sequences representing the majority of recognized cetacean species. Extensions of the system to include other gene loci and taxa are planned. The service, including instructions and sample data, is available at http://www.dna-surveillance.auckland.ac.nz.

A critical review of ion mobility spectrometry for the detection of explosives and explosive related compounds.

Ion mobility spectrometry has become the most successful and widely used technology for the detection of trace levels of nitro-organic explosives on handbags and carry on-luggage in airports throughout the US. The low detection limits are provided by the efficient ionization process, namely, atmospheric pressure chemical ionization (APCI) reactions in negative polarity. An additional level of confidence in a measurement is imparted by characterization of ions for mobilities in weak electric fields of a drift tube at ambient pressure. Findings from over 30 years of investigations into IMS response to these explosives have been collected and assessed to allow a comprehensive view of the APCI reactions characteristic of nitro-organic explosives. Also, the drift tube conditions needed to obtain particular mobility spectra have been summarized. During the past decade, improvements have occurred in IMS on the understanding of reagent gas chemistries, the influence of temperature on ion stability, and sampling methods. In addition, commercial instruments have been refined to provide fast and reliable measurements for on-site detection of explosives. The gas phase ion chemistry of most explosives is mediated by the fragile CONO(2) bonds or the acidity of protons. Thus, M(-) or M.Cl(-) species are found with only a few explosives and loss of NO(2), NO(3) and proton abstraction reactions are common and complicating pathways. However, once ions are formed, they appear to have stabilities on time scales equal to or longer than ion drift times from 5-20 ms. As such, peak shapes in IMS are suitable for high selectivity and sensitivity.

Self-report of delivery of clinical preventive services by U.S. physicians. Comparing specialty, gender, age, setting of practice, and area of practice.

OBJECTIVES: To summarize national survey results for key clinical preventive services provided by primary care physicians, characterize the results by demographic and practice attributes of the respondents, and compare the results to those obtained in other studies. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 3881 clinicians who provided primary care at least 50% of their time, randomly sampled from the professional associations representing family practitioners, pediatricians, internists, and OB-GYNs. MEASURES: The Primary Care Providers Survey instrument of 1992, administered through the Office of Disease Prevention and Health Promotion, designed to assess the provision of clinical preventive services by primary caregivers. MAIN RESULTS: Few of the physicians surveyed reported providing most indicated clinical preventive services more than 80% of the time. For the purposes of this paper, > 80% provision of preventive services is considered adequate. Female physicians reported providing more preventive services involving exercise, diet, alcohol/drugs, seatbelts, sexual activity, family planning, immunizations, and screening procedures. Physicians aged < 50 reported providing more preventive services involving smoking, alcohol/drugs, seatbelts, sexual activity, and family planning. Older physicians generally reported more delivery of vaccines and screening procedures. Practitioners from big metropolitan areas reported more preventive services involving alcohol/drugs and family planning while respondents in rural areas reported less immunizations and screening procedures. When analyzed by specialty, physicians reporting the most preventive care varied by type of preventive care. CONCLUSIONS: Small differences in the self-report of provision of clinical preventive services between specialties and demographic subgroups did exist. At the time of this survey, however, no group of primary care physicians reported providing clinical preventive services to their patients at adequate levels.

Absorption Anomalies in Ratio and Subtraction FT-IR Spectroscopy.

Subtraction and ratioing of strong absorption bands in Fourier transform infrared (FT-IR) spectroscopy produces anomalous absorption errors. One source of error is the instability in the wavenumber scale of the FT-IR spectra. The possible causes of this error are explored. The thermal expansion and contraction of the cavity of the HeNe reference laser from a typical commercial instrument was found to produce changes in the laser wavenumber of ±0.034 cm(-)(1). Changes of this size are shown to introduce errors into the wavenumber scales of FT-IR spectra which are sufficient to produce the observed anomalies. The dependence of the error on instrumental and spectroscopic parameters is explored. Solutions to the problem are proposed.

The bases of differences between American and Canadian cities.

The author presents a reanalysis of multivariate data used in a 1986 study by Goldberg and Mercer entitled "The myth of the North American city: continentalism challenged", which examined differences between U.S. and Canadian cities. He concludes that "if one factors out that part of the variance in these 34 variables associated with metropolitan population, racial composition, and variations in the boundaries delimiting central municipalities, and in the criteria used to delimit metropolitan areas in the two countries, then the apparent national urban differences they find are considerably muted."

The effect of maternal fluid intake on breast milk supply: a pilot study.

To examine the effect of increased and decreased fluids on breast milk supply, a pilot study using a cross-over design with 10 mother-infant pairs was completed. Baseline measures of milk supply were determined over a 3-day period of normal fluid intake based on body weight. Subjects were studied over 3-day periods when fluid intake was alternately 50% more and 50% less than normal level. Milk supply was calculated by averaging breast milk intake, determined by test weighing the infants with electronic scales, and milk yield, measured either by total breast expression with an electric breast pump or a combination of expression and test weighing. Although milk supply decreased with decreased fluids and increased with increased fluids, this change was not statistically significant. Recommendations for further research include replication using subjects' usual fluid intake as a baseline and replication using mothers suspected of insufficient milk syndrome.

Energy expenditure in early infancy.

The measurement of energy expenditure has wide applications in clinical and scientific studies. Ethical and practical problems, however, have limited the acquisition of information on total energy expenditure in infancy. The doubly-labelled-water technique, recently validated for use in infants, has now been used to measure, non-invasively, total energy expenditure in a cohort of forty-one normal, full-term infants at or close to 1.5, 3 and 6 months of age. Mean total energy expenditure was 270, 280 and 330 kJ/kg per d at these ages. Centiles for total energy expenditure in early infancy are presented; it is suggested such data are most appropriately expressed as kJ/square root (kg body-weight per d). These findings will be of importance in the re-evaluation of energy requirements in infancy and in the study of lesions in energy metabolism in disease states at this age.

The nursing preparation of stoma patients for self-care.

The changes brought about by stoma surgery require that patients re-learn self-care skills with regard to elimination. This is accomplished as an integral part of postoperative nursing care. In this paper, some of the findings of a study are presented on the nursing preparation of stoma patients for self-management of their appliance. The observations made showed that, even at the end of their postoperative period in hospital, the patients in the study was receiving considerable nursing assistance in the management of their appliance and had not demonstrated new self-care skills for all aspects of the physical care of the stoma. It is concluded that these findings highlight a need to examine the methods of preparation for self-care of stoma patients in hospital, as containment rather than control of elimination remains a key issue in their rehabilitation.

Paradoxical priorities in breastfeeding research: challenges for new directions.

In recent years there has been a greater amount of research on infant feeding by medical and nutritional scientists than by behavioural and social scientists. The consequences of this imbalance of research focus is an extensive amount of information about breast milk with a lack of knowledge about breastfeeding. If we wish to increase the rate and duration of breastfeeding, greater attention needs to be paid to the art of nursing by resetting research priorities to take account of the mother's perspective.

The bowel habit of milk-fed infants.

A prospective study of the bowel habits of 240 infants aged 2-20 weeks was performed. Half of the infants were breast fed and half were fed cow's milk formula (CMF). Breast-fed infants had a higher mean frequency of defaecation than did CMF-fed infants at 2, 4 and 8 weeks (p less than 0.02). By 16 weeks the mean frequency of bowel actions per day of infants of both feeding groups was 2. With increasing age, infants produced fewer stools of greater firmness (p less than 0.05) though the breast fed tended to pass larger, softer stools than did the CMF-fed infants until the introduction of weaning foods (p less than 0.05). Stool colour was uniformly yellow in both feeding groups until the introduction of weaning foods, when it changed to brown. Weaning foods were introduced at an earlier age in the CMF-fed infants (p less than 0.05), though by 20 weeks 93% of all infants had received some. These data define the normal range of the bowel habits of milk-fed infants and may reflect differences in gastrointestinal function between those fed on the breast and with CMF.

Effect of weaning on accuracy of doubly labeled water method in infants.

Variations in background 2H and 18O abundances in body water influence the accuracy and precision of the 2H218O method for determination of energy expenditure. To investigate the effect of weaning during infancy on background 2H and 18O abundances, urine samples from 44 breast- or formula-fed infants aged 5-16 wk were analyzed. 2H and 18O abundances were significantly higher (P less than 0.001) in breast- than in formula-fed infants. The relationship between 2H and 18O abundances was linear and independent of diet [slope, 4.16 +/- 0.43 (SE)]. By use of this information, the effect of weaning on the accuracy of the 2H218O method was evaluated, taking into account the effect of 2H-18O abundances in the isotope loading dose. In infants weaned completely from breast milk to formula during the measurement, energy expenditure can be overestimated by 18.0%, even if 2H-18O abundances in the isotope dose equal the ratio of naturally occurring background changes. However, this error can be reduced to less than 3.0% by manipulating the study duration and isotope dose. During gradual weaning, the overestimation of energy expenditure is only 0.3-2.0%.