An exploration of factors involved in the roll out of a digital application in breast services: A case study approach.

INTRODUCTION: Acceptance of new technologies in health care, by those who use them as part of their role, is challenging with confounding contextual factors surrounding the acceptance of technology. As healthcare is rapidly digitising, stakeholder groups should be included in each stage of evaluation and implementation to allow opportunities to influence and contribute to digital health policies. This research employed a case study methodology to initiate an exploration into the factors associated with implementing a digital application into a mammography service. It examined the initial implementation and subsequent impact of the rollout of a digital application (VA) within a breast service in South Australia. METHODS: Stakeholders' opinions on team performance and feedback mechanisms of the digital application were evaluated through a staff questionnaire distributed through an online survey JISC. RESULTS: The incorporation of digitised technology into a service is evidently met with challenges. Although there is potential value in utelising automated feedback for workflow improvement and patient services, it appears imperative to provide targeted and developmental resources for educational development and staff well-being during the implementation phase. CONCLUSION: This case study approach delves into key discussion areas and serves as the initial insight into the implementation of a digital application. It could be regarded as a foundational reference for future evaluations of digital applications. IMPLICATIONS FOR PRACTICE: Research around digital fluency within the radiography profession requires further consideration. Under-utilisation or resistance may result in missed opportunities to enhance patient experiences and care outcomes and support staff wellbeing. Therefore, continued engagement and the encouragement of user feedback during the implementation phase are crucial to demonstrate future acceptance of digital applications in clinical settings.

A bioavailable strontium (87Sr/86Sr) isoscape for Aotearoa New Zealand: Implications for food forensics and biosecurity.

As people, animals and materials are transported across increasingly large distances in a globalized world, threats to our biosecurity and food security are rising. Aotearoa New Zealand is an island nation with many endemic species, a strong local agricultural industry, and a need to protect these from pest threats, as well as the economy from fraudulent commodities. Mitigation of such threats is much more effective if their origins and pathways for entry are understood. We propose that this may be addressed in Aotearoa using strontium isotope analysis of both pests and products. Bioavailable radiogenic isotopes of strontium are ubiquitous markers of provenance that are increasingly used to trace the origin of animals and plants as well as products, but currently a baseline map across Aotearoa is lacking, preventing use of this technique. Here, we have improved an existing methodology to develop a regional bioavailable strontium isoscape using the best available geospatial datasets for Aotearoa. The isoscape explains 53% of the variation (R2 = 0.53 and RMSE = 0.00098) across the region, for which the primary drivers are the underlying geology, soil pH, and aerosol deposition (dust and sea salt). We tested the potential of this model to determine the origin of cow milk produced across Aotearoa. Predictions for cow milk (n = 33) highlighted all potential origin locations that share similar 87Sr/86Sr values, with the closest predictions averaging 7.05 km away from their true place of origin. These results demonstrate that this bioavailable strontium isoscape is effective for tracing locally produced agricultural products in Aotearoa. Accordingly, it could be used to certify the origin of Aotearoa's products, while also helping to determine if new pest detections were of locally breeding populations or not, or to raise awareness of imported illegal agricultural products.

Patency of superficial femoral vein employed as a crossover femoral artery bypass conduit.

This study assesses the patency of superficial femoral vein used as a crossover femoral artery bypass conduit in patients presenting either with localized groin sepsis, generalized sepsis or in patients with occluded or heavily diseased superficial femoral artery outflow. Twenty patients were followed prospectively with femoral crossover grafts constructed of superficial femoral vein. Twelve patients presented with sepsis and 8 with chronic ischemia from iliac artery occlusion and severely diseased superficial femoral artery outflow. Graft patency was assessed with regular duplex ultrasound examination. There was one perioperative death. Six patients died during the follow-up period. Mean follow-up time was 24.3 months. No graft occluded or required revision. There was no limb loss, graft infection, or graft hemorrhage. Superficial femoral vein offers an effective femoral crossover bypass graft in patients with either localized/generalized sepsis or disadvantaged outflow tracts.

Advised best practice for the use of emollients in eczema and other dry skin conditions.

The recent Dermatological Care Working Group report highlighted important deficiencies in the dermatology service in the UK and recommended that care should move closer to the patient. The report stated that 'expert patients' could become 'sharers in their care' and are best placed to improve their own self management. One area that could benefit greatly from increased patient education and participation is the use of emollients. Emollients are frequently prescribed for patients with eczema and other dry skin conditions. Although the benefits of emollient therapy are widely accepted, prescribing practices vary considerably, often according to physicians' individual preferences. Patients can receive confusing or conflicting treatment advice, leading to frustration, non-compliance, and difficulty in following an effective regimen. To promote the effective use of emollients it is important for patients and health professionals to understand the functions of the skin and the principles of emollient use and application. We propose a set of simple guidelines for emollient therapy in eczema care to improve day-to-day management by health professionals in the community and to promote consistent practices by patients. These guidelines form the ABC dry skin and eczema management programme supported by the National Eczema Society and accredited by the British Skin Foundation.

Predicting death from ruptured abdominal aortic aneurysms.

BACKGROUND: We have previously reported preoperative and immediate postoperative formulae to estimate mortality in patients with ruptured abdominal aortic aneurysms (rAAA). In this study, we prospectively compared these formulae in patients with rAAA with their actual outcomes. METHODS: Information was collected on 134 patients from two centers over a 3-year period. Preoperative mortality risk was estimated using coefficients for age, level of consciousness, and cardiac arrest. Mortality risk in the immediate postoperative state was based on the presence of coagulopathy, ischemic colitis, prolonged requirement for inotropes, time from arrival at hospital to surgery, patient age, perioperative myocardial infarction, renal failure, and pre-operative hemoglobin level. RESULTS: The average age was 73 years (range 30 to 92 y) and 20 of 134 (15%) patients were women. Sixty-three patients (47%) survived. For patients with a calculated preoperative mortality risk of >90%, the sensitivity, specificity, and positive and negative predictive values were 25%, 98%, 95%, and 54%, respectively. For a mortality risk >80%, these values were 37%, 94%, 87%, and 57%, respectively. For patients with an estimated immediate postoperative mortality risk > or = 90%, the sensitivity, specificity, and positive and negative predictive values were 17%, 87%, 60%, and 49%, respectively. For a predicted mortality > or = 80%, these values were 22%, 84%, 60%, and 50%, respectively. CONCLUSIONS: Our formula for predicting mortality for preoperative rAAA patients may be useful for patients with an estimated mortality risk >/=90%, based on the high positive predictive value. The formula for immediate postoperative rAAA patients was not useful in predicting death.

Benzoporphyrin derivative monacid ring A (Verteporfin) alone has no inhibitory effect on intimal hyperplasia: in vitro and in vivo results.

Benzoporphyrin derivative monoacid ring A (Verteporfin, BPD-MA), a photosensitizing drug, has been suggested as having inhibitory effects on smooth muscle cell (SMC) proliferation in rabbit aortic intimal injuries. The effect of BPD-MA on vascular SMCs in the absence of light stimulation in vitro and in vivo was studied using models of intimal hyperplasia. Human SMCs were incubated with BPD-MA for 4 h in darkness. A small (20%) but significant decrease in viability (n =42,p < .05) was noted for BPD-MA concentrations above 15 microg/mL. This was an all-or-none phenomenon with no further decrease in viability at higher concentrations. Treatment with BPD-MA was also carried out in vivo using a balloon injury model of intimal hyperplasia in rabbit aortas. Thirty-three rabbits were randomized into five groups and given intravenous BPD-MA (2 mg/kg) according to the following schedule: Group 1 (n = 8), BPD-MA 25 min prior to injury; Group 2 (n = 8), BPD-MA 25 min prior to injury plus a second dose 4 weeks later; Group 3 (n = 4), BPD-MA immediately postinjury; Group 4 (n = 7), BPD-MA immediately postinjury plus a second dose 4 weeks later; or Group 5 (n = 6), no drug (control group). No statistically significant difference was seen in the amount of intimal hyperplasia that developed in the five groups.

Assessment of patient waiting times for vascular surgery.

OBJECTIVES: To assess patient waiting times for vascular surgery and to determine if complications of the disease develop while the patients are awaiting surgery. DESIGN: Prospective cohort study. SETTING: A university-affiliated tertiary care institution. PATIENTS: All 554 patients who underwent scheduled vascular surgical procedures between April 1995 and October 1996. OUTCOME MEASURES: A literature review carried out to develop guidelines for acceptable waiting times for surgery associated with various vascular disorders based on their natural history (benchmark target); actual waiting times, defined as the interval from the date each patient was booked for surgery to the date of admission to hospital for the procedure; the proportion of patients admitted within the benchmark targets; and whether prolonged waiting time placed patients at risk for complications of their disease. RESULTS: Of the 554 patients, 382 (69%) were admitted within the benchmark waiting times. Of 84 patients having an abdominal aortic aneurysm, the aneurysm ruptured during the waiting period in 6, and 4 of them died, for a complication rate of 7% and a death rate of 5%. Two of the 6 aneurysms ruptured after the patient had waited longer than the target time. Three of 100 patients with symptomatic carotid artery stenosis awaiting admission for carotid endarterectomy suffered ischemic stroke, for a 3% complication rate; all had waited longer than the target period. One patient suffered occlusion of a femoropopliteal bypass graft while awaiting revision of a stenosed bypass graft. CONCLUSIONS: This study suggests that although most patients are admitted for operation within the benchmark time, one-third are admitted late and may suffer serious complications of their disease while awaiting admission for the procedure.

Effect of endothelial and adventitial injury on somatostatin receptor expression.

BACKGROUND: The somatostatin analog, angiopeptin, inhibits intimal hyperplasia formation; although the specific somatostatin receptor (SSTR) subtypes transducing this effect are unknown. The purpose of this study was to determine the expression of SSTR subtypes in rat iliac arteries after balloon catheter endothelial injury and perivascular dissection. METHODS: Male rats received balloon endothelial injury to their left common and external iliac arteries with or without circumferential arterial dissection. The right arteries served as controls. At 1 and 2 months after intimal injury, animals were killed and their iliac arteries harvested and studied for SSTR expression by using immunocytochemical and molecular techniques. Quantitative polymerase chain reaction was used to determine the level of SSTR expression. RESULTS: Normal rat iliac arteries expressed only SSTR2 and 3. After balloon endothelial injury, there was significant upregulation of SSTR2 messenger RNA at 1 and 2 months after injury as compared with controls (1 month, 1.8 +/- 0.3 vs 0.4 +/- 0.1 zmol, P < .001; 2 months, 2.7 +/- 0.5 vs 1.1 +/- 0.2 zmol, P < .001). The addition of adventitial dissection to endothelial injury also showed a significant increase in SSTR2 expression (1 month, 2.4 +/- 0.4 vs 0.8 +/- 0.2, P < .05; 2 months, 1.3 +/- 0.3 vs 0.7 +/- 0.3, P < .05), but not significantly greater than that seen after balloon endothelial injury alone. Immunocyto-chemical studies also demonstrated an increase in SSTR2 immunoreactivity on the luminal surface of the endothelial cells in the balloon catheter-injured arteries. CONCLUSIONS: These findings show that SSTR2 is the primary SSTR that is upregulated after injury and likely mediates the effects of somatostatin analogs on intimal hyperplasia.

Mutagenesis of E477 or K505 in the B' domain of human topoisomerase II beta increases the requirement for magnesium ions during strand passage.

A type II topoisomerase is essential for decatenating DNA replication products, and it accomplishes this task by passing one DNA duplex through a transient break in a second duplex. The B' domain of topoisomerase II contains three highly conserved motifs, EGDSA, PL(R/K)GK(I/L/M)LNVR, and IMTD(Q/A)DXD. We have investigated these motifs in topoisomerase II beta by mutagenesis, and report that they play a critical role in establishing the DNA cleavage-religation equilibrium. In addition, the mutations E477Q (EGDSA) and K505E (PLRGKILNVR) increase the optimal magnesium ion concentration for strand passage, without affecting the Mg(2+) dependence of ATP hydrolysis. It is likely that the binding affinity of the magnesium ion(s) specifically required for DNA cleavage has been reduced by these mutations. The crystal structure of yeast topo II indicates that residues E477 and K505 may help to position the three aspartate residues of the IMTD(Q/A)DXD motif for magnesium ion coordination, and we propose two possible locations for the magnesium ion binding site(s). These observations are consistent with a previous model in which the B' domain is positioned such that these acidic residues lie next to the active site tyrosine residue. A magnesium ion bound by these aspartate residues could therefore mediate the DNA cleavage-religation reaction.

Carbamate analogues of amsacrine active against non-cycling cells: relative activity against topoisomerases IIalpha and beta.

PURPOSE: Methyl N-(4'-(9-acridinylamino)-phenyl)carbamate hydrochloride (AMCA) and methyl N-(4'-(9-acridinylamino)-2-methoxyphenyl)carbamate hydrochloride (mAMCA) are analogues of the topoisomerase II (topo II) poison amsacrine, and are distinguished from amsacrine by their high cytotoxicity towards non-cycling cells. Since mammalian cells contain two forms (alpha and beta) of topo II and the alpha isoform is down-regulated in non-cycling cells, we have considered whether these carbamate analogues target topo IIbeta selectively. METHODS: A drug permeable yeast strain (JN394 top2-4) was transformed using a shuttle vector containing either human top2alpha, human top2alpha or yeast top2 under the control of a GAL1 promoter. The strain was analysed at a non-permissive temperature, where only the plasmid-borne topo II was active. RESULTS: AMCA and mAMCA produced comparable levels of cell killing with human DNA topo IIalpha, human DNA topo IIbeta and yeast DNA topo II. Two other acridine derivatives N-[2-(dimethylamino)ethyl]acridine-4-carboxamide (DACA) and its 7-chloro derivative, which like AMCA and mAMCA are able to overcome multidrug resistance mechanisms, were much more active against human DNA topo IIalpha than against human DNA topo IIbeta and yeast DNA topo II. A series of mutant Chinese hamster and human lines with defined topo lesions, including the HL60/MX2 line that lacks topo IIbeta expression, was also used to compare resistance to amsacrine, AMCA and etoposide. Loss of topo IIbeta activity had a greater effect on amsacrine and AMCA than on etoposide. Resistance of murine Lewis lung cultures in exponential and plateau phase was also measured. Loss of topo IIalpha activity, as measured in both mutant cells expressing lower amounts of enzyme and in cells in plateau phase, resulted in concomitant acquisition of resistance that was greatest for etoposide and least for AMCA. CONCLUSION: We conclude that the carbamate analogues of amsacrine recognize both topo IIalpha and beta in cells.

Successful innominate thromboembolectomy of a paradoxic embolus.

A 54 year-old man had symptoms of acute right hemispheric cerebral ischemia. He was initially considered for participation in a trial of early thrombolysis in stroke, but an innominate artery embolus was found with no apparent arterial source. The embolus was removed by means of a combined brachial and carotid bifurcation approach to protect the cerebral vasculature from embolic fragmentation during extraction. Further investigation revealed deep venous thrombosis, evidence of pulmonary emboli, and a patent foramen ovale, supporting a diagnosis of paradoxic embolus. Additional treatment included anticoagulation and placement of an inferior vena caval filter. The unusual condition of paradoxic embolus is reviewed, and the management of this patient is discussed.

Brown snakes (Pseudonaja genus): venom yields, prothrombin activator neutralization and implications affecting antivenom usage.

The recent high prevalence of fatal bites by Brown snakes (Pseudonaja genus) has led to this study of venom yields from 66 brown snake milkings over 15 months. The amount of venom obtained from all species was higher than reported previously. Electrophoretic and Western blotting analyses of their venoms showed significantly lower avidity of Brown snake antivenom (BS-AV) for the prothrombin activator (PA) component (190 kD) than for other venom components, including the neurotoxins. The LD50 of P. inframacula has been determined for the first time. SDS-PAGE (sodium dodecyl sulphate-polyacrylamide gel electrophoresis) and Western blotting studies have shown that the Pseudonaja venoms contained proportionately more PA component than venoms of the Taipan (Oxyuranus scutellatus) or the Fierce snake (O. microlepidotus). Neutralization of the prothrombin activator of the Common Brown snake (P. textilis) (Pt-PA) by BS-AV was found to be time dependent and 40% remained unneutralized after 30 minutes incubation. Adult rats administered quantities of Pt-PA (IV) died with acute disseminated intravascular coagulation. Rats were made resistant to Pt-PA by preheparinization or by induction of tolerance to increasing quantities of Pt-PA. There is no evidence that Pt-PA has intrinsic toxicity apart from being a procoagulant. The improvement of BS-AV by addressing its deficiencies should be canvassed.

Isolation and amino acid sequence of a new long-chain neurotoxin with two chromatographic isoforms (Aa el and Ae e2) from the venom of the Australian death adder (Acanthophis antarcticus).

The amino acid sequence of a previously undescribed toxin from Australian death adder venom (Acanthophis antarcticus) has been elucidated. It appears to exist in two forms which are separated by reverse-phase high-performance liquid chromatography, but which have the same sequence and mol. wt. It has 79 amino acid residues and is therefore longer than other long postsynaptic neurotoxins. It shows homology with the conserved regions of the other long postsynaptic neurotoxins except for three unique substitutions of conserved residues, which are Arg-29 instead of Trp or Phe, Leu-33 instead of Arg and Thr-43 instead of Ala.

Hemodynamic changes and gut barrier function in sequential hemorrhagic and endotoxic shock.

Multisystem organ failure (MSOF) is the major cause of late death following trauma. The gut is hypothesized to be the source of an ongoing systemic inflammatory response that drives MSOF. It has also been suggested that while a single physiologic insult might not reliably cause MSOF, the addition of a delayed second stress will. This is known as the "two-hit" theory. The purpose of this study was to investigate the two-hit theory by observing the hemodynamic and bacteriologic response to a second stress in a subacute pig model of hemorrhagic and endotoxic shock. Swine (n = 18, 30-40 kg) were fed an antibiotic-free diet for 14 days. During instrumentation and experimentation on days 1 and 3, all animals were anesthetized (ketamine, isofluorane). On day 1, all animals had placement of central venous and arterial catheters, a portal venous catheter, and superior mesenteric artery flow probe. Group E (n = 6) underwent instrumentation on day 1, then infusion of endotoxin (25 mcg/kg E. coli lipopolysaccharide) on day 3. Group HE (n = 7) underwent instrumentation then hemorrhagic shock (mean arterial pressure = 40 mm Hg for 4 hours) on day 1, then infusion of endotoxin on day 3. Group H (n = 5) were instrumented and hemorrhaged on day 1, and underwent anesthesia only on Day 3. Between periods of anesthesia the animals were allowed food and water ad lib and systemic blood was sampled for culture every 12 hours. On day 5, the animals were euthanized prior to organ sampling for bacterial culture. One animal from group HE died during endotoxic shock on day 3.(ABSTRACT TRUNCATED AT 250 WORDS)

Benzydamine Hydrochloride (Tantum) in the management of oral inflammatory conditions.

Benzydamine HCL (Tantum) is a topical nonsteroidal anti-inflammatory drug (NSAID) with anti-inflammatory, analgesic, antipyretic and local anesthetic activity. This paper reviews the pharmacology of benzydamine and surveys the existing literature relating to its applications in medicine and dentistry. Guidelines for its use in dentistry are offered.