The influence of the patient's health-state compared with time to surgery on the outcomes following hip fracture surgery: a longitudinal study of 4,791 patients.

INTRODUCTION: This study investigated whether the health-state of hip fracture patients or the time to surgery had a greater effect on outcomes. METHODS: Of the 5,120 patients admitted with a fragility hip fracture, 4,791 (93.6%) were included in the analysis. Patients operated after 36 hours were initially group by length of delay (36-48 hours and >48 hours) and then regrouped by delay cause (medical and administrative). Patients operated within 36 hours were the comparative group. Data were collected at admission, discharge, 120 days and 365 days post discharge. RESULTS: Multivariate logistic regression analysis revealed that the patients who were delayed over 36 hours, owing to medical causes, had a higher mortality at all studied time points, but the patients who were delayed owing to administrative causes had no increase in mortality. Analysis by time to surgery revealed that patients operated after 36 and 48 hours had a higher mortality at discharge only. Medically delayed patients were less likely to return to their premorbid level of residence at discharge. Older, male patients had a higher risk of inferior outcomes. Postoperative length of stay was significantly greater in the >48-hour delay group and the medical delay group. All delay groups had a significantly higher rate of reoperation within 30 days compared with the no-delay group. CONCLUSIONS: The health-state of the hip fracture patient had a greater impact on the outcome in contrast to time to surgery. This study concurs that hip fracture patients should receive surgery within the timeframe of current guidelines, but medically unwell patients have relatively worse outcomes and should receive enhanced clinical attention.

Multicentre survey of radiologically inserted gastrostomy feeding tube (RIG) in the UK.

AIMS: To evaluate the variance in current UK clinical practice and clinical outcomes for direct percutaneous radiologically inserted gastrostomy (RIG). MATERIALS AND METHODS: A prospective UK multicentre survey of RIG performed between October 2008 and August 2010 was performed through the British Society of Gastrointestinal and Abdominal Radiology (BSGAR). RESULTS: Data from 684 patients were provided by 45 radiologists working at 17 UK centres. Two hundred and sixty-three cases (40%) were performed with loop-retained catheters, and 346 (53%) with balloon-retained devices. Sixty percent of all patients experienced pain in the first 24 h, but settled in the majority thereafter. Early complications, defined as occurring in the first 24 h, included minor bleeding (1%), wound infection (3%), peritonism (2%), and tube misplacement (1%). Late complications, defined as occurring between day 2 and day 30 post-procedure, included mild pain (30%), persisting peritonism (2%), and 30 day mortality of 1% (5/665). Pre-procedural antibiotics or anti-methicillin-resistant Staphylococcus aureus (MRSA) prophylaxis did not affect the rate of wound infection, peritonitis, post-procedural pain, or mortality. Ninety-three percent of cases were performed using gastropexy. Gastropexy decreased post-procedural pain (p < 0.001), but gastropexy-related complications occurred in 5% of patients. However, post-procedure pain increased with the number of gastropexy sutures used (p < 0.001). The use of gastropexy did not affect the overall complication rate or mortality. Post-procedure pain increased significantly as tube size increased (p < 0.001). The use of balloon-retention feeding tubes was associated with more pain than the deployment of loop-retention devices (p < 0.001). CONCLUSION: RIG is a relatively safe procedure with a mortality of 1%, with or without gastropexy. Pain is the commonest complication. The use of gastropexy, fixation dressing or skin sutures, smaller tube sizes, and loop-retention catheters significantly reduced the incidence of pain. There was a gastropexy-related complication rate in 5% of patients. Neither pre-procedural antibiotics nor anti-MRSA prophylaxis affected the rate of wound infection.

hCG beta expression by cervical squamous carcinoma--in vivo histological association with tumour invasion and apoptosis.

AIMS: To investigate the correlation of beta-subunit of human chorionic gonadotrophin (hCG beta) expression by cervical carcinomas with measures of tumour apoptosis. METHODS AND RESULTS: Eighty-nine cervical carcinoma patients' samples were subject to hCG beta immunohistochemistry and scored with respect to intensity of immunopositivity and percentage of positive cells. Apoptosis was evaluated by three independent parameters: morphological characteristics [haematoxylin and eosin (H&E)], terminal deoxynucleotidyl transferase biotin-dUTP nick end labelling (TUNEL) and poly (ADP-ribose) polymerase (PARP) immunopositivity. Of the 12 adenocarcinomas, only one (8%) was hCG beta+. However, 87% (61/70) of the squamous cell and 100% (7/7) of adenosquamous cell carcinomas were hCG beta+. hCG beta reactivity and intensity was predominantly confined to peripheral tumour cells at the stromal-epithelial interface. Correlation analysis showed that H&E and PARP apoptotic immunopositivity negatively correlated with hCG beta expression (P < 0.001 and P = 0.028 respectively), whereas TUNEL did not (P = 0.12). However, immunopositivity for apoptotic cells by TUNEL was significantly less in tumours where hCG beta expression was greater (scoring >or= 6) and vice versa. hCG beta immunopositivity was also observed in newly formed blood vessels, as well as tumour cells within lymphatic vessels. When tumour vascularization was taken into account, samples with noted vascularization positively correlated with hCG beta scoring. CONCLUSIONS: hCG beta expression correlates with reduced tumour cell apoptosis and may be involved in tumour vascularization and dissemination.

Addressing prescription discrepancies in renal patients: a prospective audit.

Background Management of chronic renal failure requires complex medication regimens to manage hypertension, hyperlipidaemia, diabetes, phosphate, anaemia and acidosis. Patient engagement in medicine management is essential to avoid potential harm. Methods We prospectively audited the rate of discrepancies between our hospital record of patient medications and their current prescription. We investigated whether changes to appointment letters reduced the number of discrepancies. Results The proportion of patients attending renal outpatient clinics failing to bring a list or unable to recall their medications fell over a 3-year period following changes to appointment letters (median proportion: 0.45 in 2014, 0.36 in 2015, 0.30 in 2016, Chi-sq = 46.94, p < 0.001); percentage of patients forgetting to bring a list with significant prescription discrepancies fell from 10.9% in 2014 to 3.9% in 2016). Conclusion Changes to appointment letters can potentially improve prescribing safety in an outpatient setting.

Helping students use nursing models to guide research.

This article describes a teaching-learning strategy that was used to help third-year undergraduate BSN students understand the importance of situating nursing research questions within a nursing theoretical framework. Examples of student-generated research questions and their transformation into questions that reflect explicit nursing frameworks are provided. Common difficulties encountered by the students are also discussed.

Residence of incident cohort of psychotic patients after 13 years of follow up.

OBJECTIVE: To establish the residential history of an incident cohort of psychotic patients 13 years after their first contact with the psychiatric services. DESIGN: Tracing of all patients admitted to the WHO study on determinants of outcome of severe mental disorders in Nottingham between 1978 and 1980. Patients were assessed using standardised and comparable instruments, and extra information was obtained from key informants and medical records. SETTING: Catchment area of Nottingham psychiatric services. MAIN OUTCOME MEASURES: Main place of residence over the previous two years and residential history over 13 years in terms of homelessness, imprisonment, and use of high dependency psychiatric facilities. RESULTS: 95 patients were traced. At the point of follow up no patients were in long stay psychiatric wards, two were in supervised residence, none was homeless, and none was in prison or a high security hospital. 85 patients were living either independently alone or with their family or friends in the community. Of these, 44 had had no contact with the psychiatric services at the point of follow up. CONCLUSIONS: Although many patients experienced a difficult early course of illness, the longer term outcome of the disorder was associated with remarkably low periods of homelessness and imprisonment and low use of intensive care facilities. These findings offer some reassurance, given the concerns about the effectiveness of community oriented care for this potentially most vulnerable group of psychiatric patients.

A common variant in myosin-18B contributes to mathematical abilities in children with dyslexia and intraparietal sulcus variability in adults.

The ability to perform mathematical tasks is required in everyday life. Although heritability estimates suggest a genetic contribution, no previous study has conclusively identified a genetic risk variant for mathematical performance. Research has shown that the prevalence of mathematical disabilities is increased in children with dyslexia. We therefore correlated genome-wide data of 200 German children with spelling disability, with available quantitative data on mathematic ability. Replication of the top findings in additional dyslexia samples revealed that rs133885 was a genome-wide significant marker for mathematical abilities (P(comb) = 7.71 × 10(-10), n = 699), with an effect size of 4.87%. This association was also found in a sample from the general population (P = 0.048, n = 1080), albeit with a lower effect size. The identified variant encodes an amino-acid substitution in MYO18B, a protein with as yet unknown functions in the brain. As areas of the parietal cortex, in particular the intraparietal sulcus (IPS), are involved in numerical processing in humans, we investigated whether rs133885 was associated with IPS morphology using structural magnetic resonance imaging data from 79 neuropsychiatrically healthy adults. Carriers of the MYO18B risk-genotype displayed a significantly lower depth of the right IPS. This validates the identified association between rs133885 and mathematical disability at the level of a specific intermediate phenotype.

A genome-wide association study identifies multiple loci associated with mathematics ability and disability.

Numeracy is as important as literacy and exhibits a similar frequency of disability. Although its etiology is relatively poorly understood, quantitative genetic research has demonstrated mathematical ability to be moderately heritable. In this first genome-wide association study (GWAS) of mathematical ability and disability, 10 out of 43 single nucleotide polymorphism (SNP) associations nominated from two high- vs. low-ability (n = 600 10-year-olds each) scans of pooled DNA were validated (P < 0.05) in an individually genotyped sample of (*)2356 individuals spanning the entire distribution of mathematical ability, as assessed by teacher reports and online tests. Although the effects are of the modest sizes now expected for complex traits and require further replication, interesting candidate genes are implicated such as NRCAM which encodes a neuronal cell adhesion molecule. When combined into a set, the 10 SNPs account for 2.9% (F = 56.85; df = 1 and 1881; P = 7.277e-14) of the phenotypic variance. The association is linear across the distribution consistent with a quantitative trait locus (QTL) hypothesis; the third of children in our sample who harbour 10 or more of the 20 risk alleles identified are nearly twice as likely (OR = 1.96; df = 1; P = 3.696e-07) to be in the lowest performing 15% of the distribution. Our results correspond with those of quantitative genetic research in indicating that mathematical ability and disability are influenced by many genes generating small effects across the entire spectrum of ability, implying that more highly powered studies will be needed to detect and replicate these QTL associations.

Capillary electrophoresis of human follicular fluid.

Some of the major serum proteins that are also found in follicular fluid, including transferrin, alpha-macroglobulin and albumin, are thought to play a role in oocyte maturation. This study set out to identify proteins in human follicular fluid by capillary zone electrophoresis and to investigate their relationship to follicular/oocyte maturity and fertility outcome. 176 individual follicular fluid samples, from 30 women undertaking in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), were run using an optimized capillary zone electrophoresis method that gave a good separation of sixteen peaks in most samples. Nine of the peaks were identified and quantified but seven remain unknown and require further proteomic identification. Of the identified protein peaks, levels of each were corrected for follicular volume and total content calculated. No significant difference in protein levels was found with regard to oocyte recovery and fertilization. Protein concentrations tended to decrease as the follicular sphere increased whilst total content in follicular fluid increased in proportion to size. This is consistent with simple transudation across a sphere surface area which does not increase in proportion to the follicular fluid. This is not true of the concentration and content pattern of other proteins/biomolecules which are produced by follicular cells locally. In conclusion, neither concentration nor absolute levels of nine major proteins identified in follicular fluids correlated with oocyte presence and fertility outcome. Future work to remove more concentrated proteins (e.g. albumin) would enhance separation of smaller peaks and identification of the unknown molecules.

Interviewing children.

The focus in health-related research on children has shifted from seeking information about children to seeking information directly from them. Children, even as young as three years old, can give graphic descriptions and have excellent recall of experiences related to adverse events, such as illness and hospitalization. Children use scripts as the primary means of anticipating, comprehending, and re-creating real-life experience. The content, timing, number, and structure of interviews will influence the completeness, accuracy, and consistency of children's recall of events. Although at times conflicting, the findings from recent scholarship on children's narrative competence will assist researchers to select the interviewing strategies most likely to yield faithful representations of experience.

Focus on qualitative methods. Qualitative metasynthesis: issues and techniques.

There has been an accumulation of qualitative studies in recent years, but little cumulation of the understandings gained from them. Qualitative research appears endangered both by efforts to synthesize studies and by the failure to do so. Techniques used have included reciprocal translations of key metaphors and concepts and qualitative and quantitative comparative analyses to produce narrative and theoretical integrations. The major problem yet to be resolved is developing usable and communicable systematic approaches to conducting metasynthesis projects that maintain the integrity of individual studies.

Survey of the information given to patients about blood transfusion and the need for consent before transfusion.

There is no current requirement in the United Kingdom to provide patients with information about blood transfusion or to seek their written consent to transfusion. To study patients' attitudes to these questions, a questionnaire survey was carried out on 51 patients during an admission to hospital in which they received a blood transfusion. The patients in this survey, although mostly satisfied about the information they were given before they were transfused, would have welcomed more general information about transfusion, mainly because of concerns about the risk of viral infections. Nearly 40% of patients thought that written consent should be obtained before transfusion, but the ethical and practical aspects of this issue are complex. Further debate would be required before implementation of written consent to transfusion could be considered as a routine policy.

African American mothers' responses to hospitalization of an infant with serious health problems.

PURPOSE: To describe African American mothers' experiences related to the hospitalization of an infant with serious health problems. DESIGN: Retrospective descriptive. SAMPLE: 19 African American mothers with premature and term infants who were hospitalized at birth for serious health problems related to sequelae of prematurity or birth defect. MAIN OUTCOME VARIABLE: African American mothers' recollections about the hospitalization of their seriously ill infant. RESULTS: The mothers worried primarily about when the baby could go home. Their greatest source of stress was separation from the infant. Seeing their sick infant was also stressful and evoked shock, fear, denial, guilt, and helplessness. Mothers sought hope by seeking information and cues from the infant and by praying to God. Mothers established a relationship with their infant by visiting regularly and by learning how to care for him. Some mothers feared getting attached to an infant who might die. Mothers' highest source of satisfaction was support from the health care team.

The temporary anatomical structures prominent in the first trimester may be fulfilling exchange functions assigned to the placenta in the second and third trimester.

The extra-embryonic coelom (EEC) and secondary yolk sac are prominent structures in the gestational sac during the first trimester of human pregnancy, at a time before the definitive placental circulation becomes established. We propose that the EEC and yolk sac play a critical role in the nutrition of early pregnancy, fulfilling exchange functions which are assumed by the placenta at a later stage.

Developmental outcomes of infants with bronchopulmonary dysplasia: comparison with other medically fragile infants.

The purpose of this study was to compare the developmental outcomes and mother-infant interactions of infants with bronchopulmonary dysplasia (BPD) and those of other medically fragile infants. One-hour behavioral observations were made of the interactions of mothers with two groups of infants (23 with BPD, 39 medically fragile without BPD or neurological problems) at enrollment, every 2 months during hospitalization, 1 month after discharge, and at 6 months' and 12 months' corrected age. Assessment of the home environment also was done at 6 and 12 months. Multiple regressions were calculated separately for child mental, adaptive, language, and motor outcomes. Predictors were: home environment assessment, measures of maternal interactive behaviors (positive attention, expression of negative affect, medicalized caregiving), infant group membership, and presence of intraventricular hemorrhage (IVH) in the infant. There were no significant differences between the two groups in any of the developmental outcomes or interactive variables, and the presence of IVH had no effect on these variables. Maternal positive attention and the home environment were correlated with mental development, and mother negative affect was related to adaptive behavior for both groups. Differences in developmental and interactive behaviors between infants with BPD and other prematurely born infants found in other studies appear to be a result of chronic health problems and, thus, are not unique to infants with BPD.