• Drug errors, qualitative research and some reflections on ethics.

      Armitage, Gerry R. (2005)
      Observational methods as part of a qualitative approach have been specifically employed in the study of drug error and have undeniable strengths. This position paper will examine some recent research raising a number of ethical, and tangentially, methodological issues concerning the qualitative study of drug errors within United Kingdom National Health Service hospitals. Reflections on the views and ethical conduct of other qualitative researchers are provided to contextualize the discussion. Background.¿ The impact of a drug error, and any resultant adverse event can be significant. The human and financial costs are considerable. Establishing an accurate estimation of the frequency of adverse event and reporting rates has been difficult; additionally, methodological weaknesses in medical error research have sometimes caused further difficulties. Unsurprisingly, observational studies and for that matter, a whole range of other methods are now being considered in the quest to establish both understanding and predictability in relation to medical error. Relevance to clinical practice.¿ It is argued here that any participants in medical error research should be treated in a way that takes account of the prevailing culture of health care and, in the United Kingdom, the current ethos of government policy on medical error. This requires gaining informed consent, promoting transparency in method, and providing the opportunity for participants to learn. Effective error researchers can clearly increase the available knowledge in this critical area but ethical considerations and their chosen methods should show an appropriate level of respect for their participants. Carefully implemented qualitative approaches can help realize such respect.
    • Dualities of dementia illness narratives and their role in a narrative economy

      Hillman, A.; Jones, I.R.; Quinn, Catherine; Nelis, S.M.; Clare, L. (2018-06)
      The concept of 'narrative economies' has recently been proposed as a set of exchange relationships that, through biography and story-telling, facilitate access to resources and act as a source of value. We utilise this concept to inform our analysis of 18 qualitative interviews with five people with dementia and four informal carers. Our participants are members of a pre-existing group of dementia advocates, representing the voices of those living with the condition. There are a growing number of people in the early stages of dementia - like our participants - being called upon to account for their experience, as a means of developing a politicised 'collective illness identity'. These interviews present an opportunity to study a group of people who are actively involved in speaking as, and for, people with dementia. Four themes emerged from the data: becoming a voice of or for people with dementia; biographical reinforcement; responsibilisation; and resistance. These themes illustrate the ways in which people with dementia participate in their own identity construction and, as representatives of those living with dementia, they also illustrate the ways in which illness narratives produce material and symbolic value.
    • Dying to Talk? Co-producing resources with young people to get them talking about bereavement, death and dying

      Booth, J.; Croucher, Karina T.; Bryant, Eleanor J. (2021-11)
      The Dying to Talk project in Bradford, UK aimed to build resilience in young people around the topic of death, dying and bereavement. Starting conversations early in life could buttress people’s future wellbeing when faced with bereavement and indeed their own mortality. Research indicates that a key feature in young people’s experience of bereavement is ‘powerlessness’ (Ribbens McCarthy, 2007). Drawing on the principles of co-production, young people led the development of the project aimed at encouraging young people to talk about death, using archaeology as a facilitator to those conversations. The partnership between the University of Bradford, the voluntary sector and the young people proved to be a positive and empowering one. It laid the foundations for future collaboration and developed a framework for engaging young people in talking about death, building their resilience for dealing with death and dying in the future – a step towards building a ‘compassionate city’ for young people (Kellehear, 2012)
    • E-health for stroke survivors and their carers

      Lavin, Nicole; Hellawell, Michael; O'Brien, Caroline (2017-10)
      Stroke is the leading cause of adult disability in the UK. Many stroke patients report a feeling of ‘abandonment’ when they are discharged from therapy services. This in turn, leads to readmissions and re-referrals to both hospital and community services. This paper discusses the components of E-health and how E-health could be used to supplement conventional interventions to improve patient engagement, empowerment and decreased reliance on therapy services. In doing so it will consider how such interventions could better involve carers. An integrated E-health approach has the potential to improve outcomes for stroke survivors. A person centred approach needs to be employed through partnerships between stroke survivor, carer and healthcare professional. Remote monitoring could provide specific targeted interventions, preventing unnecessary hospital admissions or re-referrals and reducing cost of care. While the issues are well defined more work is required on what these integrated, patient centred E-health solutions may look like in order to be successful in supporting stroke survivors.
    • Early detection of isolated memory deficits in the elderly: the need for more sensitive neuropsychological tests.

      De Jager, C.; Anderson, Elizabeth J. (formerly Milwain); Budge, M. (2002)
      Background. Early detection of cognitive decline in the elderly is important because this may precede progression to Alzheimer's disease. The aim of this study was to see whether sensitive neuropsychological tests could identify pre-clinical cognitive deficits and to characterize the cognitive profile of a subgroup with poor memory. Methods. A neuropsychological test battery was administered to a community-dwelling sample of 155 elderly volunteers who were screened with CAMCOG at enrolment (mean age 74·7 years). The battery included tests of episodic memory, semantic and working memory, language and processing speed. Results. Episodic memory test z scores below 1 S.D. from the cohort mean identified 25 subjects with `non-robust¿ memory performance. This group was compared to the remaining `robust memory¿ group with a General Linear Model controlling for age, IQ, education and gender. Test performance was significantly different in all tests for episodic and semantic memory, but not in tests for working memory, processing speed and language. CANTAB paired associates learning and spatial recognition tests identified the highest percentages of those in the `non-robust memory¿ group. Processing speed partialled out the age effect on memory performance for the whole cohort, but the `non-robust memory¿ group's performance was not associated with age or processing speed. Conclusions. Sensitive neuropsychological tests can detect performance below the norm in elderly people whose performance on MMSE and CAMCOG tests is well within the normal range. Age-related decline in memory performance in a cohort of the elderly may be largely due to inclusion within the cohort of individuals with undetected pre-clinical Alzheimer's disease or isolated memory impairment.
    • Early experience with the vaginoscopic approach to outpatient microhysteroscopy.

      Okeahialam, Magella G.; Jones, Sian.E.; O'Donovan, Peter J. (2001)
      Objective To assess the outcome of the vaginoscopic approach to outpatient microhysteroscopy using a 2.5-mm semi-rigid hysteroscope without using a speculum, tenaculum or analgesia. Design A prospective observational study. Setting Outpatient hysteroscopy unit of a large district general hospital. Subjects 24 women referred to the outpatient hysteroscopy unit with abnormal uterine bleeding. Results A total of 24 women had vaginoscopic outpatient microhysteroscopy. Of the procedures, 20 (83.4%) were successful using the technique and four (16.6%) failed procedures occurred. Pain was not encountered during the procedure. Conclusion Outpatient hysteroscopy with a semi-rigid 2.5-mm microhysteroscope using the vaginoscopic approach is a well-tolerated and successful technique for the evaluation of abnormal genital tract bleeding.
    • Early implementation of the Mental Capacity Act 2005 in health and social care

      Boyle, Geraldine (2012)
      This paper discusses the early implementation of the Mental Capacity Act 2005 in health and social care in England. The author examines the research evidence to date, particularly monitoring data from the Department of Health, in order to review the progress made in implementation. The extent to which the Act is achieving its overall aim of facilitating decision-making by people lacking capacity is discussed, focusing on people with dementia. The author concludes that the initial implementation of the Act (and the related Deprivation of Liberty Safeguards) has had only limited effectiveness in facilitating decision-making by people lacking capacity, promoting their best interests and protecting their liberty. Future implementation needs to ensure that the rights of people lacking capacity, particularly people with dementia, are taken more seriously in health and social care and are better protected.
    • EBP and PBL: A natural alliance?

      MacVane Phipps, Fiona E. (2010)
    • An ecological framework for improving child and adolescent health

      Bem, C.; Small, Neil A. (2019-01)
      The rise in non-communicable disease as a principal cause of premature mortality and a continuing failure to address health inequalities requires a critical examination of prevailing paradigms in health. In this paper, we offer ecology as an alternative way to view health need and as a guide to action to enhance human health and model a healthy economy. After describing the shortcomings of the prevailing biophysical approach to health, we describe an ecological approach to health that brings to the forefront social and environmental determinants and empowers health workers together with their communities to achieve a health-affirming society and economy.
    • Economic Growth and the Harmful Effects of Student Loan Debt on Biomedical Research

      Ferretti, F.; McIntosh, Bryan; Jones, S. (2015-05-30)
      Modern theories of economic growth emphasize the role of research and development (R&D) activities in determining a society's standard of living. In some advanced economies, however, higher education costs and the level of indebtedness among graduates have increased dramatically during recent years. Student loans are evident throughout the Western world, particularly in the United States, and within the bio-medical sciences. In this paper the authors develop a basic model of economic growth in order to investi-gate the effects of biomedical graduates indebtedness on the allocation of human re-source in the R&D activities, and thus on the process of economic growth. Using this modified model to understand the consequences of the rising cost in biomedical educa-tion, we derive a 'science-growth curve' (a relation between the share of pure researcher and the economy rate of growth), and we find two possible effects of biomedical stu-dent indebtedness on economic growth: specifically, a composition effect and a productivity effect. First, we outline the Romer's classical growth model, and we apply it to a 'biomedical' knowledge-based economy, and second, the model is developed by factoring the difference between pure and applied biomedical research. The 'biomedical science sector' is one of the key pillars of modern knowledge-based economy. The costs of higher education in biomedical sciences and the graduates level of indebtedness represent, not only a great problem of equality of opportunity, but also a serious threat to future prosperity of the advanced economies.
    • The economic impact of hard-to-heal wounds: promoting practice change to address passivity in wound management

      Vowden, Peter; Vowden, Kath (2016)
      As the prevalence and incidence of wounds are predicted to increase due to an ageing population with increasing comorbidities, reducing the burden of wounds by optimising healing is seen as a key factor in lowering wound care costs. Inappropriate or delayed treatment adversely affects the time to wound healing, impacting quality of life, and increasing the burden on patients, their families and carers, society and the health economy. Identifying non-healing wounds is vital to cost reduction. Failure to recognise wounds not progressing towards healing increases the subsequent risk of non-healing and places the patient at unnecessary increased risk of wound complications.
    • Economic Structural Change and Cancer Incidence - An International Examination

      Ferretti, F.; McIntosh, Bryan (2014)
      After heart disease, cancer is the most common cause of death in many developed countries. In this paper, we discuss the relationship between economic growth and cancer incidence. The purposes of the paper are to describe and measure the influence of an increasing real per capita income on the overall incidence of cancer. Using cross-sectional data for 162 countries, regression results with crude and age-standardised rates allow us to measure the elasticity of cancer incidence with respect to per capita income, and to decompose the elasticity coefficient into two components: age-effect and lifestyle-effect.
    • Editorial

      Breen, Liz; McIntosh, Bryan (2016)
    • Effect of a patient blood management programme on preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthroplasty: a quality improvement cycle

      Kotze, A.; Carter, L. A.; Scally, Andy J. (2012)
      BACKGROUND: There are few data on the associations between anaemia, allogeneic blood transfusion (ABT), patient blood management, and outcome after arthroplasty in the UK. National agencies nevertheless instruct NHS Trusts to implement blood conservation measures including preoperative anaemia management. Internationally, blood management programmes show encouraging results. METHODS: We retrospectively audited 717 primary hip or knee arthroplasties in a UK general hospital and conducted regression analyses to identify outcome predictors. We used these data to modify previously published algorithms for UK practice and audited its introduction prospectively. The retrospective audit group served as a control. RESULTS: Preoperative haemoglobin (Hb) concentration predicted ABT (odds ratio 0.25 per 1 g dl(-1), P<0.001). It also predicted the length of stay (LOS, effect size -0.7 days per 1 g dl(-1), P=0.004) independently of ABT, including in non-anaemic patients. Patient blood management implementation was associated with lower ABT rates for hip (23-7%, P<0.001) and knee (7-0%, P=0.001) arthroplasty. LOS for total hip replacement and total knee replacement decreased from 6 (5-8) days to 5 (3-7) and 4 (3-6) days, respectively, after algorithm implementation (P<0.001). The all-cause re-admission rate within 90 days decreased from 13.5% (97/717) before to 8.2% (23/281) after algorithm implementation (P=0.02). CONCLUSIONS: We conclude that preoperative Hb predicts markers of arthroplasty outcome in UK practice. A systematic approach to optimize Hb mass before arthroplasty and limit Hb loss perioperatively was associated with improved outcome up to 90 days after discharge.
    • The effect of aging on crowded letter recognition in the peripheral visual field

      Astle, A.T.; Blighe, Alan J.; Webb, B.S.; McGraw, Paul V. (2014-08)
      Purpose.: Crowding describes the increased difficulty in identifying a target object when it is surrounded by nearby objects (flankers). A recent study investigated the effect of age on visual crowding and found equivocal results: Although crowded visual acuity was worse in older participants, crowding expressed as a ratio did not change with age. However, the spatial extent of crowding is a better index of crowding effects and remains unknown. In the present study, we used established psychophysical methods to characterize the effect of age on visual crowding (magnitude and extent) in a letter recognition task. Methods.: Letter recognition thresholds were determined for three different flanker separations in 54 adults (aged 18–76 years) with normal vision. Additionally, the spatial extent of crowding was established by measuring spacing thresholds: the flanker-to-target separation required to produce a given reduction in performance. Uncrowded visual acuity, crowded visual acuity, and spacing thresholds were expressed as a function of age, avoiding arbitrary categorization of young and old participants. Results.: Our results showed that uncrowded and crowded visual acuities do not change significantly as a function of age. Furthermore, spacing thresholds did not change with age and approximated Bouma's law (half eccentricity). Conclusions.: These data show that crowding in adults is unaffected by senescence and provide additional evidence for distinct neural mechanisms mediating surround suppression and visual crowding, since the former shows a significant age effect. Finally, our data suggest that the well-documented age-related decline in peripheral reading ability is not due to age-related changes in visual crowding.
    • The effect of maternal position at birth on perineal trauma: A systematic review.

      Lodge, Fay; Haith-Cooper, Melanie (2016-03)
      Perineal trauma is associated with short- and long-term maternal morbidity. Research has found that maternal position at birth can influence perineal trauma. However, there is a dearth of evidence examining specific maternal positions, including waterbirth, and how these can influence incidence and degree of perineal trauma. Such evidence is important to help reduce trauma rates and improve information for women and midwives. To address this gap in reliable evidence, a systematic review was conducted. Seven studies met the inclusion criteria. Compared to land birth, waterbirth was found to cause an increase in perineal trauma. Kneeling and all-fours positions were most protective of an intact perineum. Allowing for different variables, sitting, squatting and using a birth-stool caused the greatest incidence of trauma. The findings of this review demonstrate that further research is required around perineal guarding in alternative birth positions and how parity affects trauma rates with waterbirth, so that women may be advised appropriately. It also suggests findings that midwives can use when discussing alternative birth positions with women.
    • The effect of normal aging and age-related macular degeneration on perceptual learning

      Astle, A.T.; Blighe, Alan J.; Webb, B.S.; McGraw, Paul V. (2015-11-25)
      We investigated whether perceptual learning could be used to improve peripheral word identification speed. The relationship between the magnitude of learning and age was established in normal participants to determine whether perceptual learning effects are age invariant. We then investigated whether training could lead to improvements in patients with age-related macular degeneration (AMD). Twenty-eight participants with normal vision and five participants with AMD trained on a word identification task. They were required to identify three-letter words, presented 10° from fixation. To standardize crowding across each of the letters that made up the word, words were flanked laterally by randomly chosen letters. Word identification performance was measured psychophysically using a staircase procedure. Significant improvements in peripheral word identification speed were demonstrated following training (71% ± 18%). Initial task performance was correlated with age, with older participants having poorer performance. However, older adults learned more rapidly such that, following training, they reached the same level of performance as their younger counterparts. As a function of number of trials completed, patients with AMD learned at an equivalent rate as age-matched participants with normal vision. Improvements in word identification speed were maintained at least 6 months after training. We have demonstrated that temporal aspects of word recognition can be improved in peripheral vision with training across a range of ages and these learned improvements are relatively enduring. However, training targeted at other bottlenecks to peripheral reading ability, such as visual crowding, may need to be incorporated to optimize this approach.
    • Effect of pay-for-outcomes and encouraging new providers on national health service smoking cessation services in England: a cluster controlled study

      McLeod, H.; Blissett, D.; Wyatt, S.; Mohammed, Mohammed A. (2015-04-15)
      Payment incentives are known to influence healthcare but little is known about the impact of paying directly for achieved outcomes. In England, novel purchasing (commissioning) of National Health Service (NHS) stop smoking services, which paid providers for quits achieved whilst encouraging new market entrants, was implemented in eight localities (primary care trusts (PCTs)) in April 2010. This study examines the impact of the novel commissioning on these services. Accredited providers were paid standard tariffs for each smoker who was supported to quit for four and 12 weeks. A cluster-controlled study design was used with the eight intervention PCTs (representing 2,138,947 adult population) matched with a control group of all other (n=64) PCTs with similar demographics which did not implement the novel commissioning arrangements. The primary outcome measure was changes in quits at four weeks between April 2009 and March 2013. A secondary outcome measure was the number of new market entrants within the group of the largest two providers at PCT-level. The number of four-week quits per 1,000 adult population increased per year on average by 9.6% in the intervention PCTs compared to a decrease of 1.1% in the control PCTs (incident rate ratio 1108, p<0001, 95% CI 1059 to 1160). Eighty-five providers held 'any qualified provider' contracts for stop smoking services across the eight intervention PCTs in 2011/12, and 84% of the four-week quits were accounted for by the largest two providers at PCT-level. Three of these 10 providers were new market entrants. To the extent that the intervention incentivized providers to overstate quits in order to increase income, caution is appropriate when considering the findings. Novel commissioning to incentivize achievement of specific clinical outcomes and attract new service providers can increase the effectiveness and supply of NHS stop smoking services.
    • The effect of refractive blur on postural stability.

      Anand, Vijay; Buckley, John G.; Scally, Andy J.; Elliott, David B. (2002)
      The effect of refractive blur upon postural stability was investigated under three conditions: normal standing, standing with input from the somatosensory system disrupted and standing with input from the somatosensory and vestibular systems disrupted. Standing stability was assessed using the centre of pressure (COP) signal from force plate data in four young subjects (mean 23.9 ± 3.1 years) and five repeated sets of measurements were taken. The subjects looked straight ahead at a horizontal and vertical square wave pattern of 2.5 cycles (degree)¿1. Under each of the three test conditions, standing stability was measured with the optimal refractive correction and under binocular blur levels of 0, + 1, + 2, + 4, and + 8 D and with eyes closed. In the normal standing condition, dioptric blur had only a mild effect on postural stability. However refractive blur produced large increases in postural instability when input from one or both of the other two sensory systems were disrupted. We hypothesized that dioptric blur would have an even great effect on postural stability if the visual target used was of higher spatial frequency. This was confirmed by repeated measurements on one subject using a target of 8 cycles (degree)¿1. The study highlights the possible importance of an optimal correction to postural stability, particular in situations (or people) where input from the somatosensory and/or vestibular systems are disrupted, and where the visual surrounds are of high spatial frequency.