Peer-enabled staff training in residential care settings as means for promoting person-centred dementia care.

Background: Person-centred care (PCC) is regarded as best practice within dementia care, however there is a gap between the understanding and the implementation of this type of care practice. The Peer Enablement Program (PEP) incorporates a group problem solving model for promoting PCC of residents with moderate to advanced dementia living in care facilities.Objective: Trained PEP facilitators introduced the program to selected staff from an organisation with 99 facilities across Australia. The objective of this study was to identify what particular aspects of the PEP these facilitators valued for advancing PCC and care culture change.Method: An embedded mixed methods study design guided this investigation. The qualitative component of the study focussed on the insights of the nine PEP facilitators who presented the workshops. This information was supported and contrasted with descriptive data generated from 322 workshop feedback forms by attendees over the course of the three workshops presented nationally.Results: Facilitators identified peer support as the most valued aspect of the PEP. It promoted collaboration among attendees; supported development of their occupational identities as transformational leaders; and created communities of practice with potential to sustain advances in PCC.Conclusions: The PEP has the potential to advance PCC. Further research is needed to evaluate the long-term sustainability of these advances and to determine if this program can be utilised more widely, both in a national and international context.

Silent and suffering: a pilot study exploring gaps between theory and practice in pain management for people with severe dementia in residential aged care facilities.

BACKGROUND: Pain is common in older people, particularly those in residential aged care facilities (RACF) and those with dementia. However, despite 20 years of discourse on pain and dementia, pain is still undetected or misinterpreted in people with dementia in residential aged care facilities, particularly those with communication difficulties. METHODS: A topical survey typology with semistructured interviews was used to gather attitudes and experiences of staff from 15 RACF across Northern Sydney Local Health District. RESULTS: While pain is proactively assessed and pain charts are used in RACF, this is more often regulatory-driven than patient-driven (eg, prior to accreditation). Identification of pain and need for pain relief was ill defined and poorly understood. Both pharmacological and non-pharmacological regimes were used, but in an ad hoc, variable and unsystematic manner, with patient, staff, and attitudinal obstacles between the experience of pain and its relief. CONCLUSION: A laborious "pain communication chain" exists between the experience of pain and its relief for people with severe dementia within RACF. Given the salience of pain for older people with dementia, we recommend early, proactive consideration and management of pain in the approach to behaviors of concern. Individualized pain measures for such residents; empowerment of nursing staff as "needs interpreters"; collaborative partnerships with common care goals between patients where possible; RACF staff, doctors, and family carers; and more meaningful use of pain charts to map response to stepped pain protocols may be useful strategies to explore in clinical settings.

Vulvar carcinoma presenting during pregnancy, associated with recurrent bone marrow hypoplasia: a case report and literature review.

BACKGROUND: Carcinoma of the vulva has predominantly been a disease of the elderly. Although occasionally it occurs in women under the age of 40 years, carcinoma of the vulva has been rarely diagnosed in pregnancy. Bone marrow hypoplasia can occur as a transient, pregnancy-related event; however, the recurrence of this pathology in future pregnancies is quite rare in the literature. CASE: A 29-year-old woman in her second pregnancy that was complicated by bone marrow hypoplasia had developed a squamous vulvar carcinoma. Each of these two conditions are quite rare in pregnancy, they may have occurred by chance, but there is a hypothetical possibility that bone marrow hypoplasia is an autoimmune disorder, with vulvar carcinoma occurring as a further complication in this immunoimpaired individual. CONCLUSION: This case also emphasizes the need to consider malignancy as a differential diagnosis in vulvar ulcers occurring in young women.

Obstetric cholestasis with elevated gamma glutamyl transpeptidase: incidence, presentation and treatment.

BACKGROUND: Obstetric cholestasis (OC) may cause severe pruritus in the mother and lead to fetal distress and stillbirth. The etiology of OC is multifactorial, but includes inherited dysfunction of bile canalicular transporters. One of these, multidrug resistant protein 3 (MDR3), a phospholipid transporter, when dysfunctional is associated with elevated levels of gamma glutamyl transpeptidase (GGT). The aim of the present study was to assess the incidence of OC associated with elevated GGT. We compared the natural history of a cholestatic pregnancy and the efficacy of ursodeoxycholic acid (URSO) in OC patients grouped according to a normal or raised GGT level. METHODS: Eighty-one patients with OC were analyzed. OC was diagnosed in patients with pruritus and elevated serum bile acids (SBA). Fifty-seven consenting volunteer patients (70%) were treated with URSO. RESULTS: Elevated GGT at presentation was found in 21 patients (30%) and was associated with significantly higher serum levels of aspartate transaminase (AST), bilirubin (BIL) and SBA. OC presented at approximately the same gestation week in both groups of patients. In patients not treated with URSO, liver function tests (LFT) showed no significant change from the time of diagnosis to delivery. Patients from both groups responded to URSO with significant improvement in their AST and alanine aminotransferase (ALT) levels, but SBA fell significantly only in the normal GGT group. CONCLUSIONS: An elevated GGT occurs in less than one-third of patients with OC in the UK and, when present, is associated with greater impairment of LFT, but no difference in gestational age at onset. Treatment with URSO appears to be safe and significantly improves LFT in patients with OC, with the exception of SBA in the high GGT group.