Expectations of therapeutic radiography students in Wales about transitioning to practice during the Covid-19 pandemic as registrants on the HCPC temporary register.

INTRODUCTION: The Covid-19 crisis continues to profoundly impact on radiotherapy practice in the UK. We explore the views of therapeutic radiographer students on entering their first post in unique circumstances as a means to evaluate the support that may minimise negative impacts on their transition to practitioners. METHOD: Focus groups were conducted outside of students' final year educational programme and immediately prior to them starting work. Qualitative data were analysed using a framework analysis. RESULTS: Emergent themes from the eleven participants were: Covid-19 as a layer on top of underlying anxieties; Degree of readiness for imminent psychological, emotional and practical challenges; Feeling valued as a health professional/radiographer at this time; A mixed student and qualified staff professional identity as HCPC temporary registrants. CONCLUSION: Uncertainties related to Covid-19 were seen to add a destabilising component to existing anxieties and challenges. In this context, there are significant risks of impaired professional socialisation due to incongruence between students' expectations and the reality in clinical departments. IMPLICATIONS FOR PRACTICE: Informed academic support and flexible clinical preceptorship that address anxieties and congruence barriers are vital to guide new practitioners through a health crisis that presents significant challenges but also opportunity for professional development.

Pre-market approval and post-market direct-to-consumer advertising of medical devices in Australia: a case study of breast cancer screening and diagnostic devices.

While research investigating direct-to-consumer advertising of therapeutic goods in Australia has historically focused on prescription medicines, recent action taken by regulators against companies promoting medical devices has placed the industry into the spotlight. Despite the need to effectively regulate direct-to-consumer advertising of medical devices due to its potential harms, inadequacies in the current regulatory system have been noted. Under the present system, devices with a questionable evidence base may enter the Australian marketplace without an evaluation of their effectiveness, and regulators are reliant on industry self-regulation and consumer complaints to draw attention to cases of advertising misconduct. Although some successes in the present system have been observed, we argue that the outlined inadequacies continue to enable the promotion of medical devices to consumers without thorough or sufficient examination of evidence.

Vancomycin-resistant enterococcal bloodstream infections on a hematopoietic stem cell transplant unit: are the sick getting sicker?

Patients with hematologic malignancies and hematopoietic stem cell transplant (HSCT) recipients are at high risk for bacterial bloodstream infections (BSI) owing to resistant organisms. Data describing the outcomes of vancomycin-resistant enterococcal (VRE) BSI in this patient population are limited. We performed a retrospective cohort study of all cases of VRE BSI that occurred between February 1996 and December 2002 on the Leukemia/HSCT unit at Barnes-Jewish Hospital. There were 68 episodes of VRE BSI in 60 patients with acute (53%) or chronic (8%) leukemia, non-Hodgkin's lymphoma (22%) or other malignant hematologic disorders (17%). A total of 13, 32 and 32% were recipients of autologous, related and matched-unrelated transplants, respectively. Forty-two of allograft recipients had active acute graft-versus-host disease (GVHD) and 32% chronic GVHD. Only 57% were neutropenic, 52% had refractory/relapsed malignancy and 60% had end organ dysfunction with a median APACHE II score of 17. Median survival after VRE BSI was 19 days. Pneumonia, receipt of anti-fungal drugs and low APACHE II score at the time of the VRE BSI remained significant risk factors for death on multivariable analysis. Our analysis suggests that in patients with hematological malignancies or HSCT, VRE may not have the behavior of a virulent pathogen. VRE BSI may simply be a marker of these patients' already existing critical medical condition.

Systematic review of endovenous laser treatment for varicose veins.

BACKGROUND: The safety and effectiveness of endovenous laser treatment (EVLT) for varicose veins are not yet fully evaluated. METHODS: Medical bibliographic databases, the internet and reference lists were searched from January 1966 to September 2004. Only case series were available for inclusion in the review. RESULTS: : Thirteen studies met the inclusion criteria. Self-limiting features, such as pain, ecchymosis, induration and phlebitis, were commonly encountered after treatment. Deep vein thrombosis and incorrect placement of the laser in vessels were uncommon adverse events. No study has yet assessed the effectiveness of laser therapy in comparison to saphenofemoral junction ligation with saphenous vein stripping. Occlusion of the saphenous vein and abolition of venous reflux occurred in 87.9-100 per cent of limbs, with low rates of re-treatment and recanalization. CONCLUSION: From the low-level evidence available it seems that EVLT benefits most patients in the short term, but rates of recanalization, re-treatment, occlusion and reflux may alter with longer follow-up. The lack of such data, in addition to the small numbers of patients in the available studies, demonstrates the need for a randomized clinical trial of EVLT versus conventional surgery.

Systematic review of safety and effectiveness of an artificial bowel sphincter for faecal incontinence.

BACKGROUND: The aim was to determine the safety and effectiveness of the implantation of an artificial bowel sphincter for the treatment of severe faecal incontinence. METHOD: Medical bibliographic databases, the internet and reference lists were searched from January 1966 to January 2003. Only the lowest level of evidence was available for inclusion in this systematic review. Case series and case reports were selected to assess safety, whereas only case series were selected to assess effectiveness. RESULTS: Fourteen studies met the inclusion criteria. A number of safety issues were reported, including high explantation rates, and rates of adverse events owing to infection, device malfunction, ulceration and pain. Results in published reports were not analysed on an intention-to-treat basis. Continence, quality of life and manometry scores were reported for patients with a functioning device at the end of follow-up. These patients experienced a significant improvement in their level of continence. As no outcome data were presented for those with a non-functioning or explanted device, it is possible that such patients may have a worsened degree of incontinence or decreased quality of life. CONCLUSION: Implantation of an artificial bowel sphincter is of uncertain benefit and may possibly harm many patients. Patient selection is therefore critical and should be enhanced by higher-quality research.

Women with HIV infection: a model of university-based care, training and research.

The growth of human immunodeficiency virus type-1 (HIV) infection among women in the USA has been coincident with an international momentum to better address the specific health care needs of women. This paper provides an overview of a demonstration model for comprehensive HIV care of adolescent and adult women in an academic setting. The paper contains a descriptive summary of a university-based demonstration model of comprehensive care for women with HIV infection. During 1997-1998, there were 279 urban and rural Midwest adolescent and adult women with HIV infection in care at this model programme. Medical care encompassed subspecialty HIV care, obstetrical and gynaecological care, primary care of non-HIV comorbidities, mental health assessments and family planning in a safe, university-based environment. For 279 women during the two-year period, health services included the detection and treatment of sexually transmitted diseases (56%) and cervical dysplasia (35%), perinatal care (12%) and screening and referral for substance abuse treatment (30%). There was no mother-to-child HIV transmission among 33 pregnant women enrolled in the Center prior to delivery, and transmission by three of nine women enrolled after delivery. Only 167 (60%) women were compliant with biannual medical visits during 1997-1998. Integral to the health services delivery was the provision of ancillary support services intended to enhance optimal medical care for this cohort of women. This university-based model of care also incorporated HIV provider training and formative HIV research. Structured medical and public health experiential learning opportunities occurred for medical and social work students, medicine residents, infectious diseases fellows, nurses and other professional health care workers. Clinical investigations of adolescent and adult women have complemented care and training, with funded research in HIV medication adherence and health services research. In follow-up, 71% of these women remained active in care in 1999. Retention of vulnerable populations in care may be a big challenge over the next decade, despite the availability of potent antiretroviral therapies.

Environmental control to reduce transmission of Clostridium difficile.

Restrictive antibiotic policies and infection control measures have been shown to reduce the incidence of Clostridium difficile-associated diarrhea (CDAD) among hospitalized patients. To date, the role of environmental disinfectants in reducing nosocomial CDAD rates has not been well studied. In a before-and-after intervention study, patients in 3 units were evaluated to determine if unbuffered 1:10 hypochlorite solution is effective as an environmental disinfectant in reducing the incidence of CDAD. Among 4252 patients, the incidence rate of CDAD for bone marrow transplant patients decreased significantly, from 8.6 to 3.3 cases per 1000 patient-days (hazard ratio, 0.37; 95% confidence interval, 0.19-0.74), after the environmental disinfectant was switched from quaternary ammonium to 1:10 hypochlorite solution in the rooms of patients with CDAD. Reverting later to quaternary ammonium solution increased the CDAD rate to 8.1 cases per 1000 patient-days. No reduction in CDAD rates was seen among neurosurgical intensive care unit and general medicine patients, for whom baseline rates were 3.0 and 1.3 cases per 1000 patient-days, respectively. Unbuffered 1:10 hypochlorite solution is effective in decreasing patients' risk of developing CDAD in areas where CDAD is highly endemic. Presumed mechanisms include reducing the environmental burden and the potential for C. difficile transmission among susceptible patients.

A comparison of efficacy of sargramostim (yeast-derived RhuGM-CSF) and filgrastim (bacteria-derived RhuG-CSF) in the therapeutic setting of chemotherapy-induced myelosuppression.

A randomized, double-blind, multicenter study in 181 afebrile cancer patients with ANC levels < 500/microL receiving myelosuppressive chemotherapy was undertaken to compare sargramostim (yeast-derived recombinant human granulocyte-macrophage colony-stimulating factor, RhuGM-CSF) and filgrastim (bacteria-derived recombinant human granulocyte colony-stimulating factor, RhuG-CSF) in the treatment of chemotherapy-induced myelosuppression. Patients received daily subcutaneous (SC) injections of either agent until ANC levels reached at least 1500/microL. There was no statistical difference between treatment groups in the mean number of days to reach an ANC of 500/microL, but the mean number of days to reach ANC levels of 1000/microL and 1500/microL was approximately one day less in patients receiving filgrastim. Fewer patients in the sargramostim arm were hospitalized, and they had a shorter mean length of hospitalization, mean duration of fever, and mean duration of i.v. antibiotic therapy compared with patients who received filgrastim. Both growth factors were well tolerated. No patient was readmitted to the hospital after growth factor was discontinued. Sargramostim and filgrastim have comparable efficacy and tolerability in the treatment of standard-dose chemotherapy-induced myelosuppression in community practice.

Detection of toxin production by Bacteroides fragilis: assay development and screening of extraintestinal clinical isolates.

Strains of Bacteroides fragilis that produce an extracellular 20-kD heat-labile toxin have been epidemiologically associated with diarrheal disease. To standardize detection of the B. fragilis toxin (BFT), a detailed description of the methods for identifying BFT production by B. fragilis strains is reported. To further study the role of toxigenic strains of B. fragilis in clinical disease, extraintestinal clinical isolates that were recovered at an urban east-cost hospital were evaluated. Four (6.2%) of 65 isolates produced BFT. Three cases in which BFT-producing B. fragilis were isolated from extraintestinal sites are reported. In contrast to studies from Japan that have reported BFT production by 23.4% of extraintestinal B. fragilis isolates, we conclude that BFT-producing strains of B. fragilis are infrequently associated with extraintestinal B. fragilis disease at our institution. Additional study will be necessary to better define the importance of BFT production in human disease due to B. fragilis.

Tuberculin skin test reactivity, anergy, and HIV infection in hospitalized patients. Longcope Firm of the Osler Medical Housestaff.

PURPOSE: Detection of latent tuberculosis infection is an important step in the control of tuberculosis because high-risk persons may be given preventive therapy. The value of tuberculin skin testing in individuals with human immunodeficiency virus (HIV) infection, however, is limited by anergy. We evaluated the prevalence of tuberculin skin test reactivity, anergy, and HIV infection in a group of hospitalized patients in an area where both tuberculosis and HIV infection are prevalent. PATIENTS AND METHODS: Three hundred fifty-one patients consecutively admitted to a medical service of a large urban teaching hospital were enrolled in the study. All those with no documented history of a positive tuberculin skin test were evaluated on admission with purified protein derivative (PPD) by the Mantoux test, and with anergy testing using a multiple-puncture device. HIV testing was offered to all patients who did not have a known history of HIV infection, and was performed when informed consent was obtained. RESULTS: Forty-one patients (12%) had a documented history of a positive PPD. Of the remaining 310 patients, 62 (20%) had a PPD response of > or = 10 mm induration. Fifty-two (15%) of the 351 patients were HIV positive. None of the HIV-infected patients was PPD positive. Anergy was found in 63% of the HIV-infected patients and 28% of the HIV-seronegative patients. Independent risk factors for a positive PPD included age > 55, male sex, and hypertension. HIV infection, current steroid use, and a history of cancer were associated with a negative PPD. Independent risk factors for anergy included HIV infection, current corticosteroid use, renal failure pneumonia, and a history of cancer. Of the 62 new PPD-positive patients, 30 (48%) were candidates for chemoprophylaxis. Additionally, 30 (63%) of 48 HIV-seropositive patients who were completed testing were anergic and might be candidates for chemoprophylaxis. Almost all of the patients eligible for chemoprophylactic therapy would have been detected if only patients at increased risk for developing tuberculosis were screened. CONCLUSIONS: Tuberculosis infection, HIV infection, and anergy were common in patients admitted to this medical service. Interpretation of PPD reactivity was confounded by a high prevalence of anergy, particularly in HIV-infected patients. A large proportion of patients tested were candidates for chemoprophylaxis. Routine tuberculin skin testing with anergy testing for high-risk patients on admission to the hospital is useful for identifying patients who might benefit from prophylaxis to help control the spread of tuberculosis.

Evaluation of intense renal parenchymal activity ("hot kidneys") on bone scintigraphy.

The bone scintigrams of 600 patients performed over a 12-month period were reviewed. Thirty-six demonstrated abnormalities of the urinary tract of which six cases of intense renal parenchymal activity ("hot kidneys") were found. Two cases were related to treatment with the new antineoplastic agent mitoxantrone. In one patient it was related to treatment with calcitonin. Neither of these associations has been previously reported. Recognized causes of hypercalcemia and recent radiotherapy were present in two patients. No cause could be found in the final patient.

Fate of small diameter cervical veins grafted into the common carotid arteries of growing rabbits.

Autogenous cervical veins were grafted into the common carotid arteries of rabbits during their active growing period. A patency rate of 58.8% was achieved but the thin-walled vein grafts underwent massive dilatation. This dilatation is likely to severely limit the usefulness of these veins as a source of bridging grafts in clinical practice, particularly for use within the intracranial cavity.