Improving access to optometry services for people at risk of preventable sight loss: a qualitative study in five UK locations.

BACKGROUND: Reducing preventable sight loss is an increasing priority for public health and health care providers. We examined the factors affecting people's use of optometry services in population groups at increased risk of sight loss. METHODS: This is a qualitative study in five UK locations. In England, participants were from the Pakistani and Black Caribbean communities; in Scotland from the Pakistani community; and in Northern Ireland and Wales from white socio-economically deprived communities. Thirty-four focus groups were conducted (n = 289). The study included people who attend optometry services and people not engaged with services. RESULTS: Barriers to access included limited awareness of eye health and eye disease, concern about the cost of spectacles and the appropriateness of optometry in a commercial setting. Attendance at the optometrist was primarily symptom led. A positive previous experience or continuing relationship with the optometrist helped to alleviate the barriers and promote attendance. CONCLUSION: Addressing the disparity between the broader messages about eye health and the current perception of the function of optometry could help improve access to services. Uptake may be improved through the co-production of interventions that better resonate with local communities. Non-retail service delivery options should be explored.

Availability of manufacturers' information on efficacy and compatibility of detergents used for cleaning dental instruments.

AIM: To review physico-chemical data supplied for commercially available detergents marketed for manual and/or ultrasonic cleansing of reusable dental instruments. METHOD: Manufacturers/suppliers of commercially available detergents for manual or ultrasonic cleaning of dental instruments within primary dental care were invited to supply product information. A structured questionnaire requested details on a range of physical and chemical properties for each detergent. RESULTS: Seventeen detergent manufacturers/suppliers, encompassing 31 commercially available detergents were identified. Ten of the 17 manufacturers provided information on 23 (74%) of the detergent formulations. Nine detergents were of neutral pH, ten mild alkalis (pH 7.5-10.5) and four strong alkalis (pH >10.5). Sixteen detergents were recommended for ultrasonic and manual cleaning, four stated ultrasonic use and three manual only. Ten detergents cited enzymatic activity as their main mode of action, but only six manufacturers provided detailed information. Four detergents recommended by manufacturers as suitable for manual washing had a strong alkaline pH (>10.5), presenting chemical hazards to users. Two strong alkaline detergents did not warn users of potential adverse effects of such alkaline solutions (corrosion) upon aluminium containing instruments. Only one detergent had investigated the potential toxicity of detergent residuals remaining on instruments after reprocessing. CONCLUSION: It has proven challenging to collate physico-chemical data on detergents suitable for use in manual and/or ultrasonic cleaning of dental instruments in general dental practice. Standardisation of information on the nature and efficacy of dental detergents in a readily accessible form would be beneficial to dental practice.

Design of dental surgeries in relation to instrument decontamination.

Recent guidelines advise that the decontamination of dental instruments should be undertaken outwith the treatment area. The aim of this study was to determine the physical area of rooms in dental surgeries that decontaminate instruments within and outwith the treatment area respectively, and other factors relating to practice layout and ventilation. Data were collected by interview and observation of dental healthcare workers in dental practice in Scotland, UK. Room layouts were recorded and measured at floor, benchtop and above benchtop heights. Thirteen surgeries with instrument decontamination processes occurring in the treatment area and seven surgeries with instrument decontamination outwith the treatment area were selected at random for detailed analysis of room dimensions. Of the 179 dental surgeries surveyed, 55% were located in converted residential premises and most practitioners (91%) did not share premises with other healthcare providers. The median number of rooms in the practices was 8 (range: 2-21) and the median number of surgeries present was 3 (range: 1-6). Regardless of whether instrument decontamination facilities were housed within the treatment area or not, the average treatment area room size for both was 15.8m(2) (range: 7.3-23.9) (P=0.862), with 20% of the room area available as work surfaces. The median size of the seven instrument decontamination rooms (local decontamination units) was 7.6m(2) (range: 2.9-16.0), with, on average, 63% of the room used for work surfaces. This survey suggests that the historical location of dental surgeries in converted residential properties places many restrictions on appropriate design for healthcare premises.

Evaluation of a course on the operation and management of a local decontamination unit for undergraduate dental students.

OBJECTIVE: Describe the formulation of learning outcomes and evaluate a new course for undergraduate dental students in managing a local decontamination unit (LDU). DESIGN, SAMPLE AND SETTING: This was a retrospective analysis of questionnaire data from the first cohort of dental students completing the LDU managers course in a UK dental school. METHODS: All final year dental students were invited to complete a course evaluation. Data were collated via an anonymous semi-structured questionnaire distributed at a post-course session. RESULTS: A response rate of 95% was achieved. The majority (89%) improved their knowledge of decontamination and felt that the course material was relevant (81%) to their future role as a dental practitioner. Students stated that the practical elements of the course provided a valuable educational experience, while tutorials on health and safety and quality management systems proved less popular. The use of an e-learning programme to support the lectures and practical sessions was also useful in achieving the learning outcomes. The one-week intensive course proved challenging for both students and staff. We identified short comings both locally and nationally in the availability of appropriately trained staff to teach this core topic. CONCLUSION: We describe a series of learning outcomes to support competencies in instrument decontamination for dental undergraduates and a purpose built training facility. The evaluation of the course suggests this model meets current and future General Dental Council (GDC) requirements for training of dental undergraduates. We identified a shortage of appropriately qualified teachers in this subject area and recommend that these deficiencies are addressed as part of a coordinated national strategy.

Survey of the decontamination and maintenance of dental handpieces in general dental practice.

OBJECTIVES: To determine how dental handpieces are decontaminated and maintained in general dental practice. DESIGN: Observational survey. SETTING: The survey was carried out in general dental practice in Scotland. Survey visits ran from January 2003 until the end of March 2004. METHODS: Data were collected by interview and observation in 179 dental surgeries in Scotland. RESULTS: In virtually all surgeries, handpieces were cleaned before disinfection or autoclaving (99%; n = 177), most commonly by wiping the external surface with a cloth impregnated with disinfectant. Most surgeries lubricated their handpieces after cleaning and before sterilisation (91%; n = 162), although a number of surgeries (24%; n = 42) also lubricated their handpieces after sterilisation. In the majority (97%; n = 174) of dental surgeries, all handpieces were autoclaved after use, most frequently (89%; n = 160) in a bowl and instrument steriliser. In 38 surgeries (21%), handpieces were being wrapped (paper pouches) before sterilisation in bowl and instrument sterilisers. A minority of surgeries (20%; n = 36) had a dedicated handpiece for surgical procedures. CONCLUSIONS: The majority of dental handpieces are manually cleaned externally with a disinfectant impregnated cloth and processed in a type N (bowl and instrument) bench top steam steriliser. Handpieces are lubricated with non-water soluble lubricants at different stages of reprocessing, indicating clarification is required in this area. More work is required by manufacturers to establish a validated cleaning and lubrication process to facilitate the sterilisation of handpieces.

Management of infection control in dental practice.

This was an observational study in which the management policies and procedures associated with infection control and instrument decontamination were examined in 179 dental surgeries by a team of trained surveyors. Information relating to the management of a wide range of infection control procedures, in particular the decontamination of dental instruments, was collected by interview and by examination of practice documentation. This study found that although the majority of surgeries (70%) claimed to have a management policy on infection control, only 50% of these were documented. For infection control policies, 79% of surgeries had access to the British Dental Association Advice Sheet A12. Infection control policies were claimed to be present in 89% of surgeries, of which 62% were documented. Seventy-seven per cent of staff claimed to have received specific infection control training, but for instrument decontamination this was provided mainly by demonstration (97%) or observed practice (88%). Many dental nurses (74%) and dental practitioners (57%) did not recognise the symbol used to designate a single-use device. Audit of infection control or decontamination activities was undertaken in 11% of surgeries. The majority of surgeries have policies and procedures for the management of infection control in dental practice, but in many instances these are not documented. The training of staff in infection control and its documentation is poorly managed and consideration should be given to development of quality management systems for use in dental practice.

Sterilization of re-usable instruments in general dental practice.

OBJECTIVE: To examine the methods used for sterilisation of re-usable instruments in general dental practice, including the installation, commissioning and testing of benchtop steam sterilisers. MATERIALS AND METHODS: This was an observational study in which the policies and procedures for sterilising instruments were viewed directly by trained surveyors at practice premises. Information relating to the installation, commissioning and testing of benchtop steam sterilisers was also collected by interview and observation of records. Data were recorded onto a standardised data collection form prepared for automated reading. RESULTS: Data were available fom 179 surgeries surveyed. Dental practices reprocess a range of instruments from critical to non-critical. The most common type of benchtop steam steriliser is a type N, or bowl and instrument (B&I) steriliser (88%). The remainder were type B, or vacuum sterilisers, though one surgery had access to a hot air steriliser. Sterilisers were usually installed by manufactures or suppliers (69%). Only 51% of sterilisers were tested on installation and 26% were commissioned, of which 38% were tested to SHTM 2010 standard. In most cases it was difficult to determine from the documentation available whether daily, weekly, quarterly or annual testing was undertaken in accordance with recognised standards. Written instructions for the operation of the steriliser were unavailable in 61% of practices. Insurance cover for pressure vessels was available in 79% of the surgeries with a B&I steriliser. In many instances there was inadequate separation of clean and dirty areas for segregating processed from unprocessed instruments. Ninety-six percent of surgeries did not have a procedure for the identification and traceability of instruments used on patients. There was no documentation of staff training in the use of sterilisers in 90% of surgeries. CONCLUSION: There has been significant uptake of the use of steam sterilisation to reprocess used dental instruments. However, there are significant shortcomings at various stages of the process, including installation, commissioning and periodic testing of sterilisers. These potentially compromise safety and the time, money and effort currently put into sterilising dental instruments. Complicit in these deficiencies are the manufacturers and suppliers of equipment that is inadequately installed and tested. There is a need for enhanced education and training in the use of sterilisers and the management of the process at all levels, from supplier to user. Improved access to appropriate technical advice on decontamination would also be a major benefit for the profession.

Pre-sterilisation cleaning of re-usable instruments in general dental practice.

OBJECTIVE: This study examined the policies, procedures, environment and equipment used for the cleaning of dental instruments in general dental practice. MATERIALS AND METHODS: A total of 179 surgeries were surveyed. This was an observational based study in which the cleaning processes were viewed directly by a trained surveyor. Information relating to surgery policies and equipment was also collected by interview and viewing of records. Data were recorded onto a standardised data collection form prepared for automated reading. RESULTS: The BDA advice sheet A12 was available in 79% of surgeries visited. The most common method for cleaning dental instruments was manual washing, with or without the use of an ultrasonic bath. Automated washer disinfectors were not used by any surgery visited. The manual wash process was poorly controlled, with 41% of practices using no cleaning agent other than water. Only 2% of surgeries used a detergent formulated for manual washing of instruments. When using ultrasonic baths, the interval that elapsed between changes of the ultrasonic bath cleaning solution ranged from two to 504 hours (median nine hours). Fifty-eight percent of surgeries claimed to have a dedicated area for instrument cleaning, of which 80% were within the patient treatment area. However, in 69% of surgeries the clean and dirty areas were not clearly defined. Virtually all cleaning of dental instruments was undertaken by dental nurses. Training for this was provided mainly by demonstration and observed practice of a colleague. There was little documentation associated with training. Whilst most staff wore gloves when undertaking manual cleaning, 51% of staff did not use eye protection, 57% did not use a mask and 7% used waterproof overalls. CONCLUSIONS: In many dental practices, the cleaning of re-usable dental instruments is undertaken using poorly controlled processes and procedures, which increase the risk of cross infection. Clear and unambiguous advice must be provided to the dental team, especially dental nurses, on appropriate equipment, chemicals and environment for cleaning dental instruments. This should be facilitated by appropriate training programmes and the implementation of quality assurance procedures at each stage of the cleaning process.

A method for surveying instrument decontamination procedures in general dental practice.

OBJECTIVE: This paper describes an objective method for assessing the decontamination procedures used for reprocessing dental instruments in primary dental care facilities. MATERIALS AND METHODS: The study population comprised all general dental practitioners in Scotland with an NHS list number. A two-stage process was used to identify which surgeries were to be surveyed, using a proportional stratified random sampling method. First, practices were randomly selected in proportion to the distribution of practices within each of the health boards. Then, if there were more than one dentist within a selected practice, simple random sampling was used to identify a single dentist within the selected practice to be approached. The surgery that the dentist worked from and its associated decontamination facilities were the subject of the survey. A set of data collection forms provided questions designed to investigate compliance with extant guidance documents on decontamination. Specific training for the survey team members was provided during a three day course, to ensure consistency of approach. The data collection forms were piloted in 20 dental surgeries. RESULTS: A methodology was developed, which utilised both staff interviews and direct observation of decontamination processes. Data were collected on a set of 28 standard forms, which could be machine read. Three hundred and seventy-three dentists were selected at random from the dental practitioners list held by Practitioner Services, Scotland. One hundred and eighty-nine practitioners either declined to participate or could not be contacted at the address supplied. One hundred and eighty-four surgeries were surveyed, data were available for analysis from 179 sites. Data from five sites were rejected because of illegibility (three) and incomplete data (two). Each surgery survey was undertaken by a team of two surveyors, comprising one infection control/decontamination expert and one experienced dental practitioner. The survey team interviewed the dental practitioner and dental nurse, reviewed documentation relevant to the survey, directly observed decontamination practices and recorded the physical layout of the premises. CONCLUSION: The use of machine readable data collection forms, trained survey staff and direct observation of decontamination protocols provides a workable method for accurate collection of decontamination practice in primary care facilities.

Uterine tumour resembling ovarian sex cord tumour is an immunohistochemically polyphenotypic neoplasm which exhibits coexpression of epithelial, myoid and sex cord markers.

AIMS: To describe the clinicopathological and immunohistochemical findings in four cases of uterine tumour resembling ovarian sex cord tumour (UTROSCT). METHODS: Four UTROSCTs were stained with a wide range of antibodies, including epithelial (AE1/3, epithelial membrane antigen), myoid (desmin, alpha smooth muscle actin, h-caldesmon), sex cord (alpha inhibin, calretinin, melan A, CD99) and neuroendocrine (chromogranin, CD56) markers as well as hormone receptors (oestrogen receptor, progesterone receptor, androgen receptor), vimentin, CD10, WT1 and HMB45. RESULTS: The tumours ranged from 0.8 to 19.5 cm. Three were relatively well circumscribed intramural myometrial lesions; the other was a pedunculated mass attached to the uterine serosa. The tumours were variably composed of solid, corded, trabecular, nested, glandular and retiform arrangements of tumour cells. In three cases, cells with eccentric nuclei and abundant eosinophilic cytoplasm, resulting in a rhabdoid appearance, were a prominent feature. Three cases were diffusely positive with AE1/3 and all with epithelial membrane antigen. Positivity with myoid markers was common with 3, 4 and 1 case respectively staining with desmin, alpha smooth muscle actin and h-caldesmon; 2, 4, 1 and 2 cases respectively were positive with alpha inhibin, calretinin, melan A and CD99. All were chromogranin negative and exhibited diffuse strong staining with CD56. All were diffusely positive with oestrogen receptor, progesterone receptor, vimentin and WT1. Three cases were androgen receptor positive and all were CD10 and HMB45 negative. CONCLUSIONS: UTROSCT exhibits a polyphenotypic immunophenotype with coexpression of markers of epithelial, myoid and sex cord lineage as well as hormone receptors.

Infarct size determination by technetium 99m sestamibi single-photon emission computed tomography predicts survival in patients with chronic coronary artery disease.

BACKGROUND: The prognostic value of infarct size quantification by technetium 99m sestamibi single-photon emission computed tomography (SPECT) in patients with chronic coronary artery disease (CAD) has not been established. Methods And Results Between September 1994 and May 1995, 1323 patients with known or suspected CAD were referred for perfusion imaging for clinical reasons and had infarct size determined by quantitative SPECT imaging. Patients underwent exercise stress (61%), pharmacologic stress (37%), and rest imaging (3%). Patients were excluded if they had cardiomyopathy, valvular heart disease, or myocardial infarction within 3 weeks of the SPECT study. There were 1224 patients who formed the study group. Follow-up was 94% complete at a median of 1.9 +/- 0.4 years. Sixty-five percent of patients had no measurable infarct. Among the patients with measurable infarcts, the mean infarct size by sestamibi imaging was 15.0% +/- 14.5% of the left ventricle (25% of infarcts /=19% of the left ventricle). By using stepwise regression analysis, age, diabetes, and hypercholesterolemia were all clinical predictors of overall death (P <.05). For cardiac death, only age and diabetes were significant. After adjusting for these clinical variables, infarct size remained an independent predictor of overall death (P =. 001) and survival free of cardiac death (P =.0002). However, when first-pass left ventricular ejection fraction was added to the models, infarct size was no longer significant. CONCLUSIONS: Infarct size determination by SPECT (99m)Tc sestamibi can predict subsequent death in patients with chronic CAD, although ejection fraction appears to have greater prognostic value.

Assessment of right atrial pressure with 2-dimensional and Doppler echocardiography: a simultaneous catheterization and echocardiographic study.

OBJECTIVE: To derive a clinically useful, noninvasive determination of right atrial pressure. Noninvasive assessment of right ventricular systolic pressure from Doppler-derived tricuspid regurgitant velocity requires an accurate assumption of right atrial pressure. PATIENTS AND METHODS: Seventy-one patients were studied in the cardiac catheterization laboratory, comparing right atrial pressure (measured at mid systole) with simultaneous 2-dimensional echocardiographic measurement of inferior vena cava diameter and Doppler recordings of hepatic vein systolic, diastolic, and atrial reversal velocities. The initial 28 patients were used to derive a clinical algorithm to predict right atrial pressure, which was tested in the subsequent 43 patients. RESULTS: Inferior vena cava dimension correlated directly with right atrial pressure (r2=0.74; P<.001). The systolic filling fraction of the hepatic vein velocity curves correlated poorly with right atrial pressure. However, the correlation between the hepatic vein Doppler sum of systolic forward flow velocity and atrial reversal velocity and right atrial pressure was inverse (r2=0.32; P=.002). With a combination of variables from both inferior vena cava diameter and hepatic vein velocity curves, patients can be divided into those with normal right atrial pressure, mildly increased right atrial pressure, and severely increased right atrial pressure. CONCLUSION: The combined information from inferior vena cava diameter and hepatic vein velocity curves can be used to assess right atrial pressure.

Reversible perfusion defects on exercise tomographic thallium imaging in patients with and without collateral flow.

A consecutive series of patients underwent exercise thallium imaging and coronary angiography that identified single-vessel right coronary artery disease. Redistribution in the left anterior descending territory was significantly associated with the presence of left-to-right collaterals, whereas collaterals were significantly less frequent in individuals who did not exhibit redistribution.

Short deceleration time of mitral inflow E velocity: prognostic implication with atrial fibrillation versus sinus rhythm.

The present study retrospectively identified 367 patients who had restrictive physiology as defined by deceleration time < or = 130 msec; 293 were in sinus rhythm (SR) (194 men and 99 women; mean age 64 +/- 14 years) and 74 were in atrial fibrillation (AF) (51 men and 23 women; mean age 72 +/- 11 years; p < 0.001). Both groups had similar underlying diagnoses and no significant difference in Doppler indices (E wave, 96 +/- 23 vs 99 +/- 22 cm/sec in SR and AF, respectively; deceleration time, 116 +/- 12 vs 116 +/- 13 msec; and left ventricular outflow tract time velocity integral, 14.8 +/- 4.8 vs 14.5 +/- 4.4 cm). Left ventricular ejection fraction was significantly lower in SR patients (29% +/- 16% vs 39% +/- 20%; p = 0.0003). There were 120 deaths (41%) in the SR group and 35 (47%) in the AF group (median follow-up for both groups, 2.2 years). Restrictive physiology as defined by Doppler echocardiography (deceleration time < or = 130 msec) appears to predict a similar poor prognosis with AF as with SR.

Echocardiography in the invasive laboratory: utility of two-dimensional echocardiography in performing transseptal catheterization.

OBJECTIVE: To evaluate the potential utility of transthoracic two-dimensional echocardiography as an aid in the technique of transseptal catheterization. DESIGN: We performed a prospective study of 58 patients (29 men and 29 women; mean age, 64.2 years) referred for cardiac catheterization, in whom a systematic approach was used with selective application of two-dimensional echocardiography. MATERIAL AND METHODS: The study group of 58 patients had the following diagnoses: mitral stenosis in 17, hypertrophic cardiomyopathy in 13, dilated cardiomyopathy in 13, aortic stenosis in 13, and prosthetic valve dysfunction and pulmonary hypertension in 1 each. With use of only fluoroscopic guidance, initial gentle pressure on the dilator alone was attempted for left atrial access. If the catheter resisted entry into the left atrium, two-dimensional echocardiography was performed to assess the catheter's position relative to the atrial septum, and adjustments were made accordingly. Transseptal puncture with a Brockenbrough needle was performed only after confirmation of the catheter position at the region of the fossa ovalis with two-dimensional echocardiography. RESULTS: The catheterization procedure was performed without complication in all 58 patients; the mean time to catheter placement was 5.6 +/- 3.5 minutes (range, 3 to 20). Two-dimensional echocardiography was used in 33 patients (57%) when left atrial access was not obtained. On the basis of echocardiographic images, the transseptal catheter had to be repositioned in 16 of these 33 patients (48%). CONCLUSION: Two-dimensional echocardiography offers value in demonstrating catheter position during transseptal catheterization and may be used in some patients to ensure transseptal puncture at the region of the fossa ovalis.

Utility of preload alteration in assessment of left ventricular filling pressure by Doppler echocardiography: a simultaneous catheterization and Doppler echocardiographic study.

OBJECTIVES: The aim of this study was to demonstrate the usefulness of preload alterations in assessing left ventricular filling pressures with transmitral Doppler velocity curves. BACKGROUND: Doppler mitral inflow velocities, used to estimate left ventricular filling pressures noninvasively, are limited in predicting left ventricular filling pressures, especially in patients with normal systolic function and a "pseudonormal" mitral filling pattern. METHODS: Forty-nine patients were studied in the cardiac catheterization laboratory with simultaneous Doppler echocardiography using high fidelity catheters to compare left ventricular diastolic filling pressures (pre-A wave left ventricular pressure) and Doppler mitral inflow at baseline and during reduction of preload during the strain phase of the Valsalva maneuver (n = 27) or sublingual nitroglycerin (n = 36), or both (n = 14). Doppler measurements consisted of E (initial peak velocity), A (velocity at atrial contraction), deceleration time (time from E velocity to deceleration of flow extrapolated to baseline) and absolute A wave velocity (A' [peak A wave velocity minus velocity at onset of atrial contraction]). RESULTS: In patients with high pre-A wave pressure (> or 15 mm Hg), there was a greater change in the E/A' ratio during the Valsalva maneuver than in patients with a normal pre-A wave pressure (-1.22 +/- 1.1 vs. -0.35 +/- 0.17; p = 0.02). A similar change was seen when comparing the change in the E/A' ratio after administration of nitroglycerin in patients with a high versus a normal pre-A wave pressure (0.81 +/- 0.49 vs. 0.18 +/- 0.17; p < 0.001). These differences were present in patients with a normal E/A ratio at baseline. CONCLUSIONS: Alterations in preload during assessment of Doppler echocardiographic indexes may be useful in noninvasively assessing left ventricular filling pressures.