Darlington College

Renin-angiotensin-aldosterone system inhibitor (RAASi) therapies are a cornerstone of guideline-directed medical therapy in the management of cardiorenal disease, including chronic kidney disease and heart failure. Management guidelines state that these therapies should be prescribed at the maximum licensed or tolerated dose in order to prevent disease progression and adverse events. However, both cardiorenal disease and RAASi therapies increase the risk of hyperkalaemia. When hyperkalaemia occurs, clinicians often down-titrate or discontinue these important RAASi therapies, leaving patients at risk of adverse cardiorenal outcomes. Eleven cardiorenal experts considered how hyperkalaemia can act as a barrier to optimised RAASi therapy in patients with cardiorenal disease and how these issues could be mitigated. Four key areas of suboptimal and variable clinical practice were identified: optimisation of RAASi therapy; definition and management of acute hyperkalaemia; secondary to primary care communications; and patient education. In this podcast article, two of the experts discuss the clinical challenges and principles of optimal care for each of the four areas identified. The experts agreed that hyperkalaemia should be considered a predictable and manageable condition, requiring a pre-emptive and long-term approach. When hyperkalaemia occurs, down-titrating or discontinuing RAASi therapy should be a last resort, after all other management approaches have been employed. Healthcare professionals in secondary and primary care must communicate and collaborate to ensure effective, consistent management of patients with cardiorenal disease. Finally, patients should be educated to understand their cardiorenal disease and its management and the importance of optimal RAASi therapy. Supplementary file1 (MP4 173853 KB).

IntroductionPeople with dementia are more likely than people without dementia to be hospitalized and to experience in-hospital preventable adverse events, such as falls, skin injury, and infection, compared to other hospitalized groups. Negative attitudes towards people with dementia are common among acute healthcare workers and have been linked to a cascade of negative adverse events in this population. However, no qualitative systematic review has ever been conducted to synthesize the existing evidence in this area, which hampers the development of preventative measures.AimThis is a protocol for a qualitative systematic review aimed at exploring and synthesizing existing qualitative evidence regarding the attitudes of nursing staff towards the prevention of adverse events among hospitalized people with dementia.MethodsLiterature searches will be performed in PubMed, CINAHL, PsycINFO, Web of Science, Biblioteca Virtual de Salud, Scopus, The Cochrane Library, and Google Scholar. The references of eligible studies will be checked for eligibility. All primary qualitative or mixed-methods studies with a qualitative component published in peer-reviewed academic journals in English, Portuguese, or Spanish will be eligible. There will be no limitations to the date of publication. The selection process will be conducted independently by two researchers using the software Rayyan and then compared and discussed. Any disagreements regarding eligibility will be discussed among the entire research team and resolved via consensus. Methodological quality will be assessed using Cochrane’s guidance. A meta-aggregative approach will be employed to extract and synthesize the evidence using the software package QARI from the JBI. The confidence in the findings will be graded using ConQual.ImplicationsThis review will help identify and better understand specific attitudinal and psychosocial aspects that influence nursing care delivery for people with dementia in hospital settings. Such data can be used to generate novel explanatory models of nursing behaviors in dementia care, as well as capacity building and training to enhance hospital care for people with dementia globally.

Background:Atrial fibrillation (AF) management represents a significant burden on the UK NHS. Understanding this burden will be important in informing future health care planning and policy development.Aim:To describe the non-anticoagulation costs associated with AF management in routine UK clinical practice.Materials, patients and methods:A retrospective observational study of 825 patients with AF undertaken in eight UK primary care practices. Data collected from routine clinical and prescribing records of all eligible, consenting patients, for a period of up to 3 years. The first 12 weeks following diagnosis was defined as the ‘initiation phase’; the period after week 12 was defined as the ‘maintenance phase’.Results:Mean (SD) total cost of AF management was £941 (£1094) per patient in the initiation phase and £426 (£597) per patient-year in the maintenance phase. AF-related inpatient admissions contributed most to total costs; the mean (SD) total cost per patient in the initiation phase was £2285 (£900) for admitted and £278 (£252) for non-admitted patients. Mean maintenance phase costs per year were £1323 (£755) and £168 (£234), respectively, for admitted and non-admitted patients. Significant patient variables contributing to high cost in the initiation phase were hypertension and younger patient age, although only accounting for 6% of cost variability. Significant variables in the maintenance phase (18% of cost variability) were the presence of congestive heart failure, structural heart disease or diabetes and the frequency of day case admissions, ECGs and hospitalisations in the initiation phase.Conclusions:Inpatient admissions contributed most to total AF management costs. Given the burden of hospital care, future work should focus on evaluating the appropriateness and reasons for hospitalisation in patients with AF and the factors affecting length of stay, with the aim of identifying opportunities to safely reduce inpatient costs.A number of significant patient characteristics and initiation phase variables were identified, which accounted for 18% of the variability in total maintenance phase costs. However, none of these could adequately predict high maintenance phase costs.

As his ‘theological autobiography’ makes clear, James Robinson (1924–) has been at the forefront not only of ‘Q’ and Historical Jesus research but also of Nag Hammadi publication and controversy (NH). As recently as 2006 he has written on NH, especially the Gospel of Judas. To this huge advance in our knowledge of Christian-Coptic ‘Gnosticism’ he has now added the story of his involvement with the puzzles posed by the Greek and Coptic Bodmer Papyri (BP) and their contribution to other parts of early Christian literature and history, including the New Testament, and, linguistically, the differentiation of Coptic dialects. No one is better qualified to unravel them. Robinson has written a very readable and detailed account, in parts a highly technical one, telling the story of the discovery in Upper Egypt, as it happens near to the NH finds and the monastery of Pachomius, from the first days in the 1950s until the mid-1980s. At that point he finished his manuscript but did not publish it. It has now been edited and published by K. C. Hanson, editor-in-chief at Cascade Books. Five chapters clarify (1) the very confusing enumeration of BP’s constituent papyri and their ‘provenience’; (2–3) those BP which are now in the Chester Beatty Library in Dublin and in collections in Mississippi, Cologne, and Barcelona; (4–5) the connection of BP with ‘the Dishnā papers’ and the Pachomian Library. Two appendices follow. The first is an extract, first published in Manuscripts of the Middle East 5 (1990–1), pp. 26–40, tackling ‘the Pachomian Monastic Library at the Chester Beatty Library and the Bibliothèque Bodmer’. This with chapter 5 means that a third of the book is devoted to Pachomius; it involves some repetition. The second appendix is a valuable ‘List of Papyrus Bodmer Publications’. Hanson has contributed a list of ‘Collectors, Dealers, Scholars and Institutes’, a ‘Glossary of Technical Terms’, a good bibliography and ‘Index of Names’.

Early intervention (EI) for children with physical disabilities is advocated as a means of enhancing child outcomes and family functioning. The issues confronted by service providers in delivering this support have received relatively little attention. The purpose of this study was to gain an understanding of the experiences of frontline EI staff delivering services to children with physical disabilities and their families. Researchers sought views about the ways in which EI programs provide services, how programs build and maintain relationships with families and team members, the prevalence of changing and unmet family needs, the presence of barriers to optimal service delivery, and recommendations for service improvement. Qualitative interviews with 10 staff members highlighted both positive aspects of service quality and issues encountered in the provision of services. Staff commented favorably on family-centered practice; aspects of service structure/delivery, including offering a wide range of supports, flexible service provision, and the focus on intervening early; and provider-related aspects including teamwork and interagency coordination and appropriate personal qualities and skills. Despite the strong endorsement of EI, participants also identified several challenges: meeting the high demand for services, under and unmet needs, and inadequate funding and staffing.

Linnie Price, Judy Ravenscroft and Sandra Nutley report on the perceived effectiveness of a set of materials (the Fostering Voices pack) aimed at disseminating the messages emerging from research in the field of fostering services. Having commissioned a review of the body of research on fostering, the DfES funded production of materials — a combination of video CDs and targeted leaflets — to ensure that the research messages were taken up in practice. Two questionnaire surveys of a range of stakeholders (including social care practitioners, foster carers, young people in foster care, education advisers and managers) and researchers were used to gauge the effectiveness of the pack, including its actual and intended use. The multifaceted Fostering Voices pack was perceived to be a successful and effective mechanism for communicating relevant information and messages, with both the content and format highlighted as particular strengths. An overwhelming majority of stakeholders indicated that access to the pack would change their practice.

Musculoskeletal disorders are common in people who undertake adventure travel to the Antarctic, and in those who support them, because of the hard physical demands and lack of rest. This paper describes the successful use of acupuncture as first line treatment for ten patients in these circumstances, and comments on its advantages, particularly in its capacity to reduce the use of non-steroidal anti-inflammatory drugs.

EDITOR - In response to the article “Learning respect” and the response of Ashley Williams who considers the words “uncorrupted by medical training” insulting, there are perhaps some useful learning issues. Firstly, the person “uncorrupted by medical training” may actually be a medical student, not a lay person. Whether it was by jest, or not many a true word is spoken in jest and often people get upset precisely for that reason. The person concerned may have chosen to disassociate herself from her training. Secondly, is it an issue of learning respect? The whole practice of “using” other people without consideration stemmed from an old fashioned patronising attitude that used to prevail, that “doctors were gods” who could do what they liked. Their castle (the hospital) was where their “study material” came to receive their “benificence.” Since they were “gods,” with a social status elevated way above others, who knew everything, and since people who were …

"Using Cues to Teach Trainable Mentally Handicapped Students." Journal of Physical Education, Recreation & Dance, 64(9), pp. 11–12