Objective

We aimed to identify facilitators of and barriers to healthcare professionals' motivation in a diabetes centre in the United Arab Emirates (UAE).

Design

A qualitative research approach was employed using semistructured interviews to assess perception of and attitudes regarding healthcare professionals' motivation in providing good quality diabetes care.

Setting

A diabetes centre located in Abu-Dhabi, UAE.

Participants

Healthcare professionals including specialist physicians, dieticians, podiatrists, health educators and nurses were recruited through purposive sampling.

Main outcome measures

After data collection, the audiotaped interviews were transcribed verbatim and subjected to content analysis.

Results

Nine semistructured interviews were conducted with healthcare professionals of various professional backgrounds. Important facilitators and barriers related to patient, professional, organization and cultural factors were identified. Barriers that related to heavy workload, disjointed care, lack of patient compliance and awareness, and cultural beliefs and attitudes about diabetes were common. Key facilitators included the patient's role in achieving therapeutic outcomes as well as compliance, cooperation and communication.

Conclusion

This qualitative study provides some unique insights about factors affecting healthcare professionals' motivation in providing good quality care. To improve the motivation of healthcare professionals in the management of diabetes and therefore the quality of diabetes care, several steps are needed. Importantly, the role of primary care should be reinforced and strengthened regarding the management of type 2 diabetes mellitus, privacy of the consultation time should be highly protected and regulated, and awareness of the Emirate culture and its impact on health should be disseminated to the healthcare professionals providing care to Emirates with diabetes. Also, greater emphasis should be placed on educating Emiratis with diabetes on, and involving them in, the management of their condition.

Botulinum toxin (Botox) is an exotoxin produced from Clostridium botulinum. It works by blocking the release of acetylcholine from the cholinergic nerve end plates leading to inactivity of the muscles or glands innervated. Botox is best known for its beneficial role in facial aesthetics but recent literature has highlighted its usage in multiple non-cosmetic medical and surgical conditions. This article reviews the current evidence pertaining to Botox use in the head and neck. A literature review was conducted using The Cochrane Controlled Trials Register, Medline and EMBASE databases limited to English Language articles published from 1980 to 2012. The findings suggest that there is level 1 evidence supporting the efficacy of Botox in the treatment of spasmodic dysphonia, essential voice tremor, headache, cervical dystonia, masticatory myalgia, sialorrhoea, temporomandibular joint disorders, bruxism, blepharospasm, hemifacial spasm and rhinitis. For chronic neck pain there is level 1 evidence to show that Botox is ineffective. Level 2 evidence exists for vocal tics, trigeminal neuralgia, dysphagia and post-laryngectomy oesophageal speech. For stuttering, ‘first bite syndrome’, facial nerve paresis, Frey's syndrome, oromandibular dystonia and palatal/stapedial myoclonus the evidence is level 4. Thus, the literature highlights a therapeutic role for Botox in a wide range of non-cosmetic conditions pertaining to the head and neck (mainly level 1 evidence). With ongoing research, the spectrum of clinical applications and number of people receiving Botox will no doubt increase. Botox appears to justify its title as ‘the poison that heals’.

Exposure to sea turtles may be increasing with expanding tourism, although reports of problems arising from interaction with free-living animals appear of negligible human health and safety concern. Exposure both to wild-caught and captive-housed sea turtles, including consumption of turtle products, raises several health concerns for the public, including: microbiological (bacteria, viruses, parasites and fungi), macrobiological (macroparasites), and organic and inorganic toxic contaminants (biotoxins, organochlorines and heavy metals). We conducted a review of sea turtle associated human disease and its causative agents as well as a case study of the commercial sea turtle facility known as the Cayman Turtle Farm (which receives approximately 240,000 visitors annually) including the use of water sampling and laboratory microbial analysis which identified Pseudomonas aeruginosa, Aeromonas spp., Vibrio spp. and Salmonella spp. Our assessment is that pathogens and toxic contaminants may be loosely categorized to represent the following levels of potential risk: viruses and fungi = very low; protozoan parasites = very low to low; metazoan parasites, bacteria and environmental toxic contaminants = low or moderate to high; and biotoxin contaminant = moderate to very high. Farmed turtles and their consumable products may constitute a significant reservoir of potential human pathogen and toxin contamination. Greater awareness among health-care professionals regarding both potential pathogens and toxic contaminants from sea turtles, as well as key signs and symptoms of sea turtle-related human disease, is important for the prevention and control of salient disease.

Objectives

To assess if cohort segregation policies are effective in preventing cross-infection in cystic fibrosis (CF) clinics.

Design

A prospective cohort study.

Setting

A large adult CF centre in Northwest England.

Participants

All CF patients cared for at the Liverpool adult CF centre 2003–2009.

Methods

Regular sputum sampling with genotyping of pseudomonas aeruginosa (Psa) isolates led to a policy of inpatient and outpatient segregation by microbiological group.

Main outcome measures

Prevalence and cross-infection/super-infection rates of a transmissible Psa strain, i.e. the Liverpool epidemic strain (LES) in adult CF patients at the Liverpool adult CF centre from 2003 to 2009.

Results

There was a decline in the proportion of patients with LES (71–53%) and an increase in those with unique strains (23–31%) and without Psa infection (6–17%) from 2003 to 2009. There were two cases of LES super-infection and one case of new chronic Psa infection (with a unique strain). There were no cases of transmissible strain infection in patients previously uninfected by Psa.

Conclusions

Our segregation policy has halted the spread of the commonest highly transmissible strain in the UK (LES) in our clinic, without endangering patients who were not previously infected with Psa. It confirms that if genotypic surveillance is used, it is unnecessary to segregate patients infected with unique strains from those without Psa infection.

Objectives

Advances in oncological care have led to improved short and long-term outcomes of female patients with breast and gynecological cancer but little is known about their prognosis when admitted to the intensive care unit (ICU). Our aim was to describe the epidemiology of patients with women's cancer in ICU.

Design

Retrospective analysis of data of patients with breast and gynecological cancer in ICU between February 2004 and July 2008.

Setting

ICU in a tertiary referral centre in London.

Participants

Nineteen critically ill women with breast or gynaecological cancer.

Main outcome measures

ICU and six-month outcome.

Results

Eleven women had breast cancer and eight patients had gynaecological cancer. Twelve patients were known to have metastatic disease. The main reasons for admission to ICU were sepsis (94.7%), respiratory failure (36.8%) and need for vasoactive support (26.3%). ICU mortality was 31.6%. There was no difference in age and Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) score on admission to ICU between ICU survivors and non-survivors. During their stay in ICU, non-survivors had significantly more organ failure. Six-month mortality was 68.4%. Four patients had >1 admission to ICU.

Conclusions

ICU outcome of critically ill women with breast or gynaecological cancer was similar to that of other non-cancer patient cohorts but six-month mortality was significantly higher. The decision to admit patients with women's cancer to the ICU should depend on the severity of the acute illness rather than factors related to the underlying malignancy. More research is needed to explore the outcome of patients with women's cancer after discharge from ICU.

Objectives

To ascertain clinicians' knowledge of their patients when requesting radiological investigations, as required legally by UK government legislation ‘Ionising Radiation (Medical Exposure) Regulations 2000’ (IRMER 2000), following the implementation of European Working Time Directive.

Design

Cross sectional survey.

Participants

All doctors requesting radiological requests every Monday, following the weekend on-call, over an 8-week period. There were no exclusion criteria.

Main outcome measures

Baseline data analysis, including grade and specialty of requesting doctor, types of modality requested, knowledge of their patient, addressograph signature confirming identity and appropriateness of investigation.

Results

164 requests were received, the majority (61%) were made by Foundation Programme 1 (FP1) doctors and general medical specialties accounted for the highest proportion of requests (45%). Ultrasound scanning was the most frequently requested investigation (47%), closely followed by computed tomography (CT) scans (42%). Almost a third (30%) of requests were made by doctors who had not seen the patient to be investigated, predominantly by FP1 doctors (p=0.003) and more frequently by general medical specialties (p=0.001). Signatures were absent on 20% of the addressographs and overall, 10% of requests were deemed inappropriate.

Conclusions

In almost a third of radiological requests, doctors have not seen patients to be investigated, most likely as a result of shift working patterns. This does not fulfil the IRMER 2000 criteria and potentially exposes patients to unnecessary and inappropriate radiation.

Objectives

Chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis (ME), has provoked much controversy and led to arguments between the medical profession and patient organizations. A particular focus for debate is the categorization of the condition as physical or psychological in its nature. The aim of this study was to compare how the written media, patient organizations and medical authorities regard the illness.

Design

Content analysis of newspaper articles, ME patient organization websites, and medical websites and textbooks were assessed by two independent assessors.

Setting

Three national UK newspapers, UK ME websites, and UK medical websites and textbooks, were accessed during 2010.

Participants

146 source files were scored from 36 patients' organizations, 72 media articles and 38 medical authorities.

Main outcome measured

The overall opinion of an article or website was rated using a five point Likert scale, from ‘extremely psychological’ (scored as 1), ‘moderately psychological’ (2), ‘both psychological and physical’ (3), ‘moderately physical’ (4) or ‘extremely physical’ (5).

Results

Eighty-nine percent (32 of 36) of ME patient organizations considered the illness to be physical, compared with 58% (42/72) of newspaper articles, and 24% (9/38) of medical authorities. Sixty-three percent (24/38) of medical authorities regarded the illness as both physical and psychological. The inter-group differences of the Likert scores were statistically significant (χ2 = 27.37, 2 df, P < 0.001).

Conclusion

The considerable disagreement, particularly between ME patient organizations and medical authorities, may help to explain the gulf in understanding between doctors and patients and the consequent reluctance of some patients to engage in behavioural treatments.

Interpreting information on diagnostic accuracy is an area that health professionals struggle with. In this paper, we use the example of Mr Samways, a 45-year-old man with joint symptoms, to illustrate how to apply the results of a diagnostic accuracy study in clinical practice. We consider the various measures used to quantify diagnostic accuracy and discuss their clinical utility. We provide an overview of potential biases to consider when evaluating a diagnostic accuracy study and consider how to determine whether the results can be applied to a particular patient.

Objectives

We set out to evaluate the impact of Foundation Year (FY) training on the doctors who had been through this training system.

Design

Doctors in training were surveyed using a structured web-based questionnaire.

Setting

Postgraduate training in the UK has been the subject of much upheaval in recent years.

Participants

A total of 1065 doctors in training were surveyed in late 2011 and early 2012, of which 638 were current FY doctors.

Main outcome measures

The survey was both quantitative and qualitative, focusing on selection, working hours, training quality, training assessments and the regulation of training.

Results

A majority of current FY trainees worked extra weekly hours with the breakdown being: 5–10 hrs (54%), 10–15 hrs (17%), >15 hrs (9%) and no extra weekly hours (20%). All current FY trainees wanted to work for more than 40 h a week with the following breakdown of desired hours: per week 40–48 (22%), 48–60 (50%) and 60–70 h (19%). The average hours per week spent clerking emergency admissions by current FY trainees were as follows: zero hours (11%), 0–5 h (37%), 5–10 h (30%), 10–15 h (11%) and greater (11%).

A large majority (90%) felt that it was possible for incompetent trainees to obtain satisfactory results from assessments and that the FY training program was poor at identifying failing trainees. There were high levels of dissatisfaction with the selection process.

Conclusions

FY training appears to be failing in several key areas with the lack of emergency exposure a particular area of concern. It is essential that any future reforms of training address these problem areas.

Objectives

Chronic diseases are fast becoming the largest health burden in India. Despite this, their management in India has not been well studied. We aimed to systematically review the nature and efficacy of current management strategies for chronic obstructive pulmonary disease (COPD) in India.

Methods

We used database searches (MEDLINE, EMBASE, IndMED, CENTRAL and CINAHL), journal hand-searches, scanning of reference lists and contact with experts to identify studies for systematic review. We did not review management strategies aimed at chronic diseases more generally, nor management of acute exacerbations. Due to the heterogeneity of reviewed studies, meta-analysis was not appropriate. Thus, narrative methods were used.

Setting

India

Participants

All adult populations resident in India

Main outcome measures

1. Trialled interventions and outcomes 2. Extent and efficacy of current management strategies 3. Above outcomes by subgroup

Results

We found information regarding current management – particularly regarding the implementation of national guidelines and primary prevention – to be minimal. This led to difficulty in interpreting studies of management strategies, which were varied and generally of positive effect. Data regarding current management outcomes were very few.

Conclusions

The current understanding of management strategies for COPD in India is limited due to a lack of published data. Determination of the extent of current use of management guidelines, availability and use of treatment, and current primary prevention strategies would be useful. This would also provide evidence on which to interpret existing and future studies of management outcomes and novel interventions.

Clinical case reporting in the form of case reports and case series reports has always been an integral part of medical literature. From the late 1970s the genre appeared to fall from grace and was marginalized in many medical journals. There was controversy as to its value as a research method. From the late 1990s and onwards, there has been an increased demand for and publication of case reports and case series. The various causes for its decline and subsequent return are discussed with an emphasis on the recent historical context.

Objectives

To study the effect of an educational intervention on paediatricians' knowledge, attitudes and practices regarding children's environmental health and to identify the sources of information and common environmental history taking constrains.

Design

Before and after study.

Setting

Zagazig University Paediatric Hospital.

Participants

Practising paediatricians from all specialty units.

Main outcome measures

The outcome of a specifically designed educational programme about paediatric environmental health was assessed using structured pre- and post-test questionnaires.

Results

Nearly half the participants were aware about most of the paediatric environmental health-related topics. Textbooks/guidelines (85.7%) and the Internet (64.3%) were the main sources of information. The participants demonstrated relatively strong positive attitudes towards the importance of children's environmental health. However, less than half of them (44.6%) reported environmental history taking as a routine practice; where lack of time (94.6%), wide range of hazardous exposures (91.1%) and lack of expertise and training (91.1%) were the main constrains. Significant improvement in participants' knowledge, attitudes and practices was revealed after the educational programme.

Conclusions

There is a demand for continuous medical education about environmental health in paediatric practice, particularly environmental and occupational history taking.

Objectives

To assess sickle cell disease (SCD) patient and carer perspectives on the primary care services related to SCD that they receive from their general practitioner (GP).

Design

A focus group discussion was used to elicit the views of patients about the quality of care they receive from their primary health-care providers and what they thought was the role of primary care in SCD management. The focus group discussion was video recorded. The recording was then examined by the project team and recurring themes were identified. A comparison was made with notes made by two scribes also present at the discussion.

Setting

Sickle Cell Society in Brent, UK.

Participants

Ten participants with SCD or caring for someone with SCD from Northwest London, UK.

Main outcome measures

Patients' perceptions about the primary care services they received, and a list of key themes and suggestions.

Results

Patients and carers often bypassed GPs for acute problems but felt that GPs had an important role to play around repeat prescriptions and general health care. These service users believed SCD is often ignored and deemed unimportant by GPs.

Conclusion

Participants wanted the health service to support primary health-care providers to improve their knowledge and understanding of SCD. Key themes and suggestions from this focus group have been used to help develop an educational intervention for general practice services that will be used to improve SCD management in primary care.

Objectives

To determine if current validated psychometric evaluations could determine a difference in basic behavioural characteristics between surgical and medical specialties.

Design

Cross-sectional study.

Setting

Two district general hospitals and one University teaching hospital in England, UK.

Participants

Internal medicine (16) and trauma and orthopaedic (20) consultants.

Main outcome measures

Aggression levels as assessed by the Buss and Warren questionnaire. The self-administered questionnaire assesses aggression in terms of physical, verbal, anger, hostility, indirect hostility and an overall assessment of aggression.

Results

All participants had aggression scores below the population average. We found a significant difference (P < 0.01) in total level of aggression, with orthopaedic consultants scoring a mean of 61.1 (standard deviation [SD] 9.2) and physicians 51.3 (SD 9.5). When analysis of the five different subtypes of aggression was carried out, orthopaedic surgeons scored significantly higher in terms of verbal aggression (P = 0.005), hostility (P = 0.002) and indirect hostility (P = 0.03).

Conclusion

This study joins a growing evidence base for aspects of behaviour indicative of a given specialty. Aggression is a relatively stable behavioural characteristic from adolescence, and as such this is the first study of its type to suggest that the differences in behavioural characteristics seen between specialties are inherent, rather than learned. It is unclear if the differences observed represent an attraction of that specialty to the personality type or is required for success within the given specialty. Whether this can be used in terms of selection into higher specialty training, or influence training within specialties, requires further work.

Objectives

To introduce atraumatic (Sprotte) lumbar puncture needles and compare complication rates with traumatic (Quincke) needles.

Design

Complication rates associated with traumatic needle use were retrospectively analysed over a four-week period. Atraumatic needles were then implemented and a prospective analysis of the complication rates was undertaken for a further six weeks.

Setting

A single-centre acute neurology unit in a London teaching hospital

Participants

Traumatic needles (n = 24 patients); atraumatic needles (n = 36 patients)

Main outcome measures

Headache rates, use of over-the-counter medications, further medical assistance, time off work, nausea and vomiting, traumatic taps (as per the count of red blood cells per millilitre in the first sample of cerebrospinal fluid [CSF]) and back pain.

Results

A comparison of traumatic and atraumatic needles revealed a significant reduction in the incidence of post-lumbar puncture headaches (*P < 0.01), headaches requiring over-the-counter medication (*P < 0.00001), need for further medical assistance (*P < 0.006), time off work (*P < 0.003), nausea and vomiting (*P < 0.01) and traumatic taps as per the count of red blood cells per millilitre in the first sample of CSF (*P < 0.02). There was no significant difference in the incidence of back pain (P > 0.05).

Conclusions

Most complication outcomes are significantly lower with the use of atraumatic lumbar puncture needles. We present for the first time in the literature that the rate of ‘traumatic taps’ are significantly lower with atraumatic needles. The implementation of atraumatic needles in an acute neurology service is safe and produces reliable, reproducible results in keeping with previously published randomized controlled trials.

Objectives

To determine how patients with sickle cell disease (SCD) perceive the quality of care that they receive from their primary healthcare providers.

Design

A questionnaire-based pilot study was used to elicit the views of patients about the quality of care they have been receiving from their primary healthcare providers and what they thought was the role of primary care in SCD management.

Setting

Sickle Cell Society and Sickle Cell and Thalassaemia Centre, in the London Borough of Brent.

Participants

One hundred questionnaires were distributed to potential participants with SCD between November 2010 and July 2011 of which 40 participants responded.

Main outcome measures

Analysis of 40 patient questionnaires collected over a nine-month period.

Results

Most patients are generally not satisfied with the quality of care that they are receiving from their primary healthcare providers for SCD. Most do not make use of general practitioner (GP) services for management of their SCD. Collecting prescriptions was the reason most cited for visiting the GP.

Conclusion

GPs could help improve the day-to-day management of patients with SCD. This could be facilitated by local quality improvement schemes in areas with high disease prevalence. The results of the survey have been used to help develop a GP education intervention and a local enhanced service to support primary healthcare clinicians with SCD's ongoing management.

Objectives

To define the causes of hypokalaemia in an unselected adult population.

Design

Retrospective survey of biochemistry database.

Setting

District general hospital in southwest Scotland.

Participants and main outcome measures

There were 187,704 measurements of urea and electrolytes in 2010. Sixty-one patients had serum potassium <2.5 mmol/L on at least one occasion.

Results

Average age of the patients was 71 (range 33–99) years. The most common causes were diarrhoea and/or vomiting (51% of cases), diuretic therapy (47%), nutritional causes including poor dietary intake, re-feeding syndrome and inadequate potassium supplementation when patients were nil by mouth (37%). In 25% of patients a transient and profound fall in serum potassium appeared to coincide with their acute illness. Acute alcohol intoxication and/or alcohol withdrawal were prominent features in 11% of patients. More than one cause was commonly present. There were no cases of Bartter's, Gitelman's or Liddle's syndromes or of hypokalaemic periodic paralysis in this study.

Conclusions

Severe hypokalaemia <2.5 mmol/L occurs at least once a week in a district general hospital with a catchment population of around 150,000, suggesting there may be around 300 cases a week in the UK (population around 50,000,000). Diuretics, vomiting and diarrhoea are commonly implicated as are nutritional causes, acute illness and alcohol. Bartter's, Gitelman's, Liddle's syndrome and hypokalaemic period paralysis are all extremely uncommon.