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Background: Outcome measurement plays an increasing role in improving the quality, effectiveness, efficiency and availability of palliative care. Aim: To provide expert recommendations on outcome measurement in palliative care in clinical practice and research. Methods: Developed by a European Association for Palliative Care Task Force, based on literature searches, international expert workshop, development of outcome measurement guidance and international online survey. A subgroup drafted a first version and circulated it twice to the task force. The preliminary final version was circulated to wider expert panel and 28 international experts across 20 European Association for Palliative Care member associations and the European Association for Palliative Care Board of Directors and revised according to their feedback. The final version was approved by the European Association for Palliative Care Board for adoption as an official European Association for Palliative Care position paper. Results: In all, 12 recommendations are proposed covering key parameters of measures, adequate measures for the task, introduction of outcome measurement into practice, and national and international outcome comparisons and benchmarking. Compared to other recommendations, the White Paper covers similar aspects but focuses more on outcome measurement in clinical care and the wider policy impact of implementing outcome measurement in clinical palliative care. Patient-reported outcome measure feedback improves awareness of unmet need and allows professionals to act to address patients’ needs. However, barriers and facilitators have been identified when implementing outcome measurement in clinical care that should be addressed. Conclusion: The White Paper recommends the introduction of outcome measurement into practice and outcomes that allow for national and international comparisons. Outcome measurement is key to understanding different models of care across countries and, ultimately, patient outcome having controlled for differing patients characteristics. [ABSTRACT FROM AUTHOR]

The introduction of an electronic medical record (EMR) has been rapidly accelerating in South Korea. The EMR was expected to improve quality of care, readability, availability, and the quality of data. However, the reluctance of healthcare providers to use the EMR may have caused a reduction of information recorded in EMRs. The purpose of this study was to identify whether there was any loss of information following the introduction of a narrative text-based EMR in the recording of chief complaint and present illness in inpatient medical records. Inpatient medical records of a university hospital were retrospectively evaluated for one month before and one month after the introduction of the EMR in June 2006. The volume of information for chief complaint and present illness was measured by number of words in Korean and normalised bytes. Change in volume of information was measured by two-way ANOVA and multiple regression analyses, controlling for doctors' gender, age, and grade/year of residents, patients' readmission status, reasons for admission and service department to assess any effect of the introduction of an EMR. Total numbers of paper-based medical records (PMRs) and EMRs for analysis were 1,159 and 1,122, respectively. Forty-three doctors participated in the study. Thirty-one (72%) doctors were less than 30 years of age. Number of words proved a better outcome measure (R2=.22 for CC, R2=.36 for PI) than normalised bytes (R2=.18 for CC, R2=.35 for PI) for measuring volume of information. Results showed that the volume of information in the chief complaint and present illness was not decreased after the introduction of the EMR, except when the dependent variable was measured by number of words in the present illness. The study showed that the introduction of the EMR did not reduce the volume of information documented for chief complaint and present illness in inpatient medical records. However, further studies are needed to identify how to control the probable loss of information as showed in present illness measured by number of words. [ABSTRACT FROM AUTHOR]

Introduction: A National Cancer Information System is planned for phased implementation in Irish cancer centres to enable electronic prescribing (ePrescribing) of systemic anti-cancer therapy. This study aimed to capture the opinions of healthcare professionals in a hospital setting relating to the current paper-based workflow for systemic anti-cancer therapy prescribing and their attitudes and expectations of the new ePrescribing system to develop recommendations, which assist in the planning and implementation of future ePrescribing systems. Methods: A mixed methods study of concurrent design was conducted. Interviews with healthcare professionals primarily aimed to evaluate processes and identify areas requiring improvement within the current paper-based workflow for systemic anti-cancer therapy prescribing. An online questionnaire adapted from the Information Systems Expectations and Experiences tool primarily aimed to capture expectations of the new ePrescribing system and attitudes towards the transition. Results: Twelve healthcare professionals were interviewed, and 50 healthcare professionals responded to the online questionnaire (response rate: 33.3%). Eight major themes emerged from interview transcripts relating to opinions on the paper-based workflow. Questionnaire respondents reported positive attitudes towards ePrescribing implementation and had high expectations for workflow improvements and functionalities of the new system. Seven recommendations for ePrescribing implementation were developed: (1) prioritise specific processes; (2) plan for changes in communication; (3) repeat research in the post-implementation setting; (4) ensure good information technology infrastructure and system support; (5) ensure optimum training; (6) outline limitations of clinical decision support; (7) provide clear instructions on local configurability. Conclusion: This study identifies potential challenges in transitioning to ePrescribing and provides recommendations, which assist stakeholders in ensuring safe and effective transitions, thus informing future ePrescribing systems' implementation in haematology/oncology settings. [ABSTRACT FROM AUTHOR]

Objective: Lacan is often deemed an obscure theorist with little clinical application. However, in film studies his psychoanalytic theory has been highly influential. This paper is part of a series of articles published in this journal accompanying a psychiatry registrar teaching programme on film and psychodynamic concepts. It introduces the Lacanian ideas of the Symbolic, Imaginary and Real as they appear in Jane Campion's The Power of the Dog, and discusses their societal and clinical significance. Conclusions: A Lacanian reading of Power of the Dog offers insights into 'toxic masculinity'. Furthermore, it demonstrates how clinical symptoms can represent an escape from socially mediated toxicities. [ABSTRACT FROM AUTHOR]

Clinician-scientists play a valuable role in bridging the gap between patient care and clinical research. However, there are no clear guidelines that describe how to handle the day-to-day ethical and methodological questions that arise when navigating the competing responsibilities of practitioner and researcher—a situation that can easily leave the clinician-scientist confused and frustrated. This article outlines common ethical and methodological concerns for the clinician-scientist when developing, implementing, and analyzing research in practice, and offers practical suggestions to address these issues. This paper will outline the role that reflexivity can play throughout the research process to assist the clinician-scientist in maintaining ethical and methodological rigor, as well as upholding the moral obligations of both practitioner and researcher. [ABSTRACT FROM AUTHOR]

Comments on the increase in the number of submitted papers accepted for publication in "Palliative Medicine." Description of the editorial processes of the journal; Total number of manuscripts for external peer review; Factors contributing to the increase in the acceptance rate of manuscripts for publication.

Objectives: The field of early psychosis has undergone considerable expansion over the last few decades and has a strong evidence base of effectiveness. Like all areas of healthcare, however, early psychosis services need to more consistently deliver higher quality care to achieve better outcomes for patients and families. A national clinical research infrastructure is urgently required to enable the sector to deliver the highest quality care and expand and translate evidence more quickly and efficiently. This paper describes the establishment of the Australian Early Psychosis Collaborative Consortium (AEPCC) that aims to achieve this. Conclusion: AEPCC is the first of its kind in Australia (and internationally). It will deliver the required clinical research infrastructure through the implementation of a clinical quality registry, clinical trials and translation network, and lived experience network. AEPCC will provide a critical resource to better understand the state of early psychosis care, and trial new interventions on a scale that has not previously been possible in Australia. [ABSTRACT FROM AUTHOR]

Transgender patients are at elevated risk of intimate partner violence (IPV), but national guidelines do not recommend routine screening for this population. This paper explores the feasibility and effectiveness of routine IPV screening of transgender patients in a primary care setting by describing an existing screening program and identifying factors associated with referral and engagement in IPV-related care for transgender patients. An IPV "referral cascade" was created for 1,947 transgender primary care patients at an urban community health center who were screened for IPV between January 1, 2014 to May 31, 2016: (a) Of those screening positive, how many were referred? (b) Of those referred, how many engaged in IPV-specific care within 3 months? Logistic regression identified demographic correlates of referral and engagement. Of the 1,947 transgender patients screened for IPV, 227 screened positive. 110/227 (48.5%) were referred to either internal or external IPV-related services. Of those referred to on-site services, 65/103 (63.1%) had an IPV-related appointment within 3 months of a positive screen. IPV referral was associated with being assigned male at birth (AMAB) versus assigned female at birth (AFAB) (AOR = 2.69, 95% CI 1.52, 4.75) and with nonbinary, rather than binary, gender identity (AOR = 2.07, 95%CI 1.09, 3.73). Engagement in IPV-related services was not associated with any measured demographic characteristics. Similar to published rates for cisgender women, half of transgender patients with positive IPV screens received referrals and two-thirds of those referred engaged in IPV-specific care. These findings support routine IPV screening and referral for transgender patients in primary care settings. Provider training should focus on how to ensure referrals are made for all transgender patients who screen positive for IPV, regardless of gender identity, to ensure the benefits of screening accrue equally for all patients. [ABSTRACT FROM AUTHOR]

Narrative theory is a dynamic and evolving field of inquiry that has made tremendous inroads in the medical humanities over the past 40 years. Numerous authors have popularized the idea that "thinking narratively" can produce important insights about the illness experience for physician and patient alike. This paper draws on aspects of narrative theory to emphasize the moral responsibilities that arise when we step into another person's life narrative, becoming a character in her or his story. This has especially significant ethical implications for the physician–patient encounter in that each character in this shared story experiences time somewhat differently. This gives rise to the notion of "slow motion ethics" and a somewhat unique perspective on the moral responsibilities clinicians bear toward their patients. [ABSTRACT FROM AUTHOR]

This paper addresses a fundamentally important issue in health care, namely how to make informed decisions on product selection when two products, from different manufacturers, appear to be similar and have medical claims that sound comparable. In such cases, manufacturers of competing products often use each other's evidence. They argue that the published evidence is generally applicable even if the original bioengineering tests and clinical trials were performed on a specific product, and no equivalence was obtained for their product that has similar medical claims. In this work, we use prophylactic dressings for pressure injury prevention as a good demonstrative example on how patient safety may be compromised if study conclusions are generally projected to such unstudied products. The medical device industry is regulated differently than the pharmaceutical industry, and consequently, voids in current medical device regulation are sometimes used to promote commercial interests. This paper analyzes gaps and potential pitfalls that occur where guiding documentations (e.g. guidelines, standards) do not cope well with medical technology. We explain how that can eventually lead to potential compromises to the well-being of patients, primarily if nurses are unaware of the aforementioned pitfalls. We conclude that currently, there is no alternative to rigorousness: Clinicians and decision-makers need to scrutinize up-to-date literature, decide which products have the best portfolio of bioengineering and clinical research to support the claims made, and which products have the best cost–benefit models. This is fundamentally different from simply buying the least expensive product because of appealing sale arguments. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this paper is to describe the development and technical specifications of a framework and national key performance indicators (KPIs) for Australian mental health Court Liaison Services (CLSs) by the National Mental Health Court Liaison Performance Working Group (Working Group).Methods: Representatives from each Australian State and Territory were invited to form a Working Group. Through a series of national workshops and meetings, a framework and set of performance indicators were developed using a review of literature and expert opinion.Results: A total of six KPIs for CLSs have been identified and a set of technical specifications have been formed.Conclusions: This paper describes the process and outcomes of a national collaboration to develop a framework and KPIs. The measures have been developed to support future benchmarking activities and to assist services to identify best practice in this area of mental health service delivery. [ABSTRACT FROM AUTHOR]

The aim of this is paper is to propose Benner's "Novice to Expert" Framework to underpin learning for students as they progress through the clinical components of an undergraduate nursing educational program. Steinaker and Bell's "Experiential Taxonomy" is presented as a practical medium for itemizing the nursing activities novices are exposed to at the initiation of clinical experience and to the clinical competencies expected of nurses on completion of their educational program. The authors also propose a range of theories of learning applicable to the clinical education of undergraduate nursing students, which can be maximized to enhance clinical learning. [ABSTRACT FROM AUTHOR]

Objective: Distinguished authors in the field have repeatedly alerted psychiatrists of the alarming trends in the treatment of bipolar disorders: decline of lithium use, paralleled by the increase of prescribing anticonvulsants and secondgeneration antipsychotic drugs. Research has been conducted in order to explore the factors that led to this development and to provide arguments for the need to reverse this trend. Method: This paper represents a narrative review of the literature containing retrieved research articles focusing on the efficacy of lithium. The papers included in this overview were published prior to June 2016; additional papers were identified by searching the reference lists of reviewed articles. Taking into account the amount of literature available, no search can be exhaustive; on the other hand, the studies consulted, all of which explore the effectiveness of various compounds, may have their own limitations as well. Results: The evidence of the effectiveness of lithium in the treatment of acute mania, acute bipolar depression and the prevention of manic and depressive episodes is compelling. Lithium is the most effective augmentation agent in treatment-resistant depression. Its anti-suicidal effects are well established. The neuroprotective effects of lithium have been demonstrated in case-control studies and in population-based research. It has been established that starting lithium early in the course of the disorder reduces the rates of treatment non-response. Conclusions: Despite abundant evidence regarding the efficacy of lithium and its effectiveness in the treatment of bipolar disorders, its use is declining at the beginning of the 21st century. It is of paramount importance to keep reminding psychiatrists and educating physicians about the unique properties of lithium and about monitoring patients treated with lithium, since it has been suggested that lithium should once again become the first-line treatment for bipolar disorders. [ABSTRACT FROM AUTHOR]

Background: Nursing Ethics has featured several discussions on what good care comprises and how to achieve good care practices. We should "nurse" ethics by continuously reflecting on the way we "do" ethics, which is what care ethicists have been doing over the past few decades and continue to do so. Ethics is not limited to nursing but extends to all caring professions. In 2011, Elin Martinsen argued in this journal that care should be included as a core concept in medical ethical terminology because of "the harm to which patients may be exposed owing to a lack of care in the clinical encounter," specifically between doctors and patients. However, Martinsen leaves the didactical challenges arising from such a venture open for further enquiry. Objectives: In this article, we explore the challenges arising from implementing care-ethical insights into medical education. Research design: Medical education in the Netherlands is investigated through a "care-ethical lens". This means exploring the possibility of enriching medical education with care-ethical insights, while at the same time discovering possible challenges emerging from such an undertaking. Participants and research context: This paper has been written from the academic context of a master in care ethics and policy. Ethical considerations: We have tried to be fair and respectful to the authors discussed and take a neutral stance towards the findings portrayed. Findings: Several challenges are identified, which we narrow down to two types: didactical and non-didactical. Discussion and conclusion: In order to overcome these challenges, we must not underestimate the possible resistance to a paradigm shift. Our efforts should mainly target the learning that takes place in the clinical phases of medical training and should be accompanied by the creation of awareness in healthcare practice. [ABSTRACT FROM AUTHOR]

BACKGROUND: Epigenetics is an important mRNA expression regulator. However, how distinct epigenetic factors, such as microRNAs (miRNAs) and promoter methylation, cooperatively regulate mRNA expression is rarely discussed. Recently, apparent miRNA regulation of promoter methylation was identified by bioinformatic analysis; however, it has not yet been experimentally confirmed. If miRNA regulation of other epigenetic factors were identified, it would reveal another layer of epigenetic regulation. In this paper, histone modifications (H3K4me1, H3K4me3, H3K27me3, H3K27ac, H3K9ac, and H2AZ) during mammalian spermatogenesis were studied and the apparent miRNA-target-specific histone modification was investigated by bioinformatic analyses of publicly available datasets. RESULTS: We identified several miRNAs' target genes that are significantly associated with histone modification during mammalian spermatogenesis. MiRNAs that target genes associated with the most significant histone modifications are expressed before or during spermatogenesis; thus the results were convincing. CONCLUSIONS: In this paper, we identified apparent miRNA regulation of histone modifications using a bioinformatics approach. The biological mechanisms of this effect should be further experimentally investigated. [ABSTRACT FROM AUTHOR]

Interprofessional collaborative education and practice is essential in the current complex healthcare climate. Barriers to interprofessional education include difficulty scheduling joint activities amid the silos of discipline-specific curricula and the lack of urgency by faculty to find innovative ways to commit to interprofessional training. Barriers in practice include poor understanding of the roles of different professionals and lack of awareness of the concept because the people in the workforce were mostly educated before interprofessional practice and education were prioritized by national bodies representing academic professions. The author of this paper describes opportunities for interprofessional education and practice and describes a way to create an educational-practice partnership to drive quality in healthcare settings. [ABSTRACT FROM AUTHOR]

Tailored messages are those that specifically target individuals following an assessment of their unique characteristics. This systematic review assesses the evidence regarding the effectiveness of tailoring within eHealth interventions aimed at chronic disease management. OVID Medline/Embase databases were searched for randomised control trials, controlled clinical, trials, before -after studies, and time series analyses from inception - May 2014. Objectively measured clinical processes/outcomes were considered. Twenty-two papers were eligible for inclusion: 6/22 used fully tailored messaging and 16/22 used partially tailored messages. Two studies isolated tailoring as the active component. The remainder compared intervention with standard care. In all, 12/16 studies measuring clinical processes and 2/6 studies reporting clinical outcomes showed improvements, regardless of target group. Study quality was low and design did not allow for identification of interventions’ active component. Heterogeneity precluded meta-analysis. This review has demonstrated that there is a lack of evidence to suggest that tailoring within an eHealth context confers benefit over non-tailored eHealth interventions. [ABSTRACT FROM AUTHOR]

Background: There is growing global interest into the attitudes and clinical management of persons who deliberately self-harm. People who self-harm experience many problems and typically have many needs related to management of their psychological wellbeing. A positive attitude amongst general hospital staff should prevail with people who self-harm. The principal purpose was to determine student staff attitudes towards patients who self-harmed from a professional and cultural perspective, which might influence patient treatment following hospital admission. The focus concentrated upon staff knowledge, attitudes and beliefs regarding self-harm. Methods: A cross sectional survey of the hospital staff using a validated questionnaire was carried out. This paper reports on interdisciplinary staff from two large general hospitals in Mysuru, South India (n=773). Results: Findings suggest that within a general hospital setting there is wide variation in staff attitudes and knowledge levels related to self-harm. Whilst there is attitudinal evidence for staff attitudes, this study investigates interprofessional differences in an attempt to progress treatment approaches to a vulnerable societal group. Very few staff had any training in assessment of self harm survivors. Conclusion: There is an urgent need for training general hospital staff in self harm assessment and prevention in south India. The results allow a series of recommendations for educational and skills initiatives before progressing to patient assessment and treatment projects and opens potential for cross cultural comparison studies. In addition, interventions must focus on current resources and contexts to move the evidence base and approaches to patient care forward. [ABSTRACT FROM AUTHOR]

Little evidence is available about nurses’ use of electronic tools during handoffs. This qualitative study explored information management and use of electronic tools during nursing handoffs. The sample included 93 handoffs by 26 nurses on 5 medical/surgical units in 2 western hospitals with a robust electronic health record (EHR). Data collection included audiotaping handoffs, semi-structured interviews, observations, and fieldnotes. The dataset was inductively coded into 33 categories and 5 themes: good nurse expectations for handoffs, paper forms are best, information at a glance, only pertinent information please, and information tools that work. Two-thirds of the nurses abandoned use of the leadership-endorsed electronic handoff form, preferring personal paper forms. The findings suggest effective electronic solutions will require extensive contextually-based information, information integrated across EHR modules and portable, electronic support throughout shifts. This is a call to action for leaders and informaticists as they select and design future electronic tools. [ABSTRACT FROM PUBLISHER]

Health-related quality of life (HRQoL) is an important outcome measure in patients with systemic lupus erythematosus (SLE). A review was undertaken of the literature relating to HRQoL in SLE. MEDLINE, EMBASE, CINAHL, Allied and Complimentary Medicine were searched to locate full papers in the English language reporting on HRQoL in adult SLE patients published between 1990 and 2005. In total 53 papers were included and the review was subdivided into: 1) description of HRQoL in SLE patients; 2) HRQoL and disease activity and/or damage; 3) the impact of other variables on HRQoL; and 4) HRQoL measures used in clinical trials in SLE patients. The findings were as follows: HRQoL is reduced in SLE patients; HRQoL is not correlated to disease activity or damage; age appears to have a negative impact on HRQoL especially physical health but the effect of disease duration is unclear; other potentially modifiable variables such as fatigue and psychosocial factors impact on HRQoL in a complex manner; and HRQoL measures which are sensitive to change should be an essential outcome measure in all clinical trials on SLE patients. [ABSTRACT FROM AUTHOR]

Speciality journals have several roles. Until recently, the main role of Clinical Rehabilitation has been to publish a record of scientific research into aspects of rehabilitation and, for convenience, three types of paper have been recognized: evaluative studies; studies concerning data collection tools; and other exploratory studies. Another role of speciality medical journals is to improve practice through education, debate and discussion. This concerns the practice of rehabilitation. The journal is looking for and will welcome papers that concern the improvement of clinical practice based on the available evidence. The section will be entitled 'Rehabilitation in practice'. [ABSTRACT FROM AUTHOR]

Background: Brain metastases are the most common intracranial tumour in adults, estimated to occur in up to 40% of patients with cancer. Despite being used in clinical practice for 50 years, the effectiveness of whole brain radiotherapy for the treatment of brain metastases remains uncertain. Objectives: To assess the effectiveness of whole brain radiotherapy (WBRT) on survival and quality of life. To identify whether patient performance status, number of brain metastases, extent of extracranial disease and primary site of cancer are important effect modifiers. Design: Systematic literature review. Methods: Electronic searches of four databases, augmented by hand searches of the most frequently encountered journal and assessment of the reference lists of consensus statements and all retrieved papers. Included papers underwent structured data extraction, assessment and qualitative synthesis. Results: Thirty-two primary studies were included, with a range of study designs, methodological quality, pre-treatment variables, interventions and outcome measures. From the limited evidence available, survival appeared to increase when patients were selected by performance status (survival increasing from approximately three to seven months in high performance status groups, as defined by Karnofsky performance status or Recursive Partitioning Analysis classification). The evidence suggests no survival benefit when patients with poor performance status were treated with whole brain radiotherapy. No studies undertook direct measurement of patients' quality of life. Surrogate measures of patients' quality of life, such as improvement in neurological function or improvement/maintenance of KPS ≥ 70, produced response rates ranging from 7 to 90%. Conclusion: The heterogeneity of study designs, quality and outcomes necessitates caution in interpreting the review findings. WBRT appears to be of benefit in higher performance status patients but not in low performance status patients. This suggests a basis for current practice, however further robust trial evidence is required. [ABSTRACT FROM AUTHOR]

Objective To review the evidence on commissioning schemes involving clinicians in the United Kingdom National Health Service, between 1991 and 2010; report on the extent and impact of clinical engagement; and distil lessons for the development of such schemes both in the UK and elsewhere. Methods A review of published evidence. Five hundred and fourteen abstracts were obtained from structured searches and screened. Full-text papers were retrieved for UK empirical studies exploring the relationship between commissioners and providers with clinician involvement. Two hundred and eighteen published materials were reviewed. Results The extent of clinical engagement varied between the various schemes. Schemes allowing clinicians to act autonomously were more likely to generate significant engagement, with ‘virtuous cycles’ (experience of being able to make changes feeding back to encourage greater engagement) and ‘vicious cycles’ (failure to influence services generating disengagement) observed. Engagement of the wider general practitioner (GP) membership was an important determinant of success. Most impact was seen in GP prescribing and the establishment of services in general practices. There was little evidence of GPs engaging more widely with public health issues. Conclusion Evidence for a significant impact of clinical engagement on commissioning outcomes is limited. Initial changes are likely to be small scale and to focus on services in primary care. Engagement of GP members of primary care commissioning organizations is an important determinant of progress, but generates significant transaction costs. [ABSTRACT FROM AUTHOR]

Objective: This paper is based on a case report, describing a protocol to help practitioners communicate mental-health diagnosis to patients from culturally and linguistically diverse (CALD) backgrounds. The protocol was presented by integrating the DSM-5 Cultural Formulation Interview (CFI) and the SPIKES protocol for communicating the diagnosis of cancer, yielding a modified CFI-SPIKES protocol (i.e. S, Support; P, Perception using CFI; I, Invitation; K, Knowledge; E, Emotions). The protocol was demonstrated using a case report with a patient of a Middle-Eastern background experiencing generalised anxiety disorder.Conclusions: The CFI-SPIKES protocol for communicating mental-health diagnosis allows for a collaborative process, whereby the CALD patient and practitioner can address the stigma associated with communicating a mental-health diagnosis, ensuring patient engagement and informed shared decision making. [ABSTRACT FROM AUTHOR]

Background: Surgical site infections (SSI) account for 16% of healthcare associated infections, and are associated with considerable morbidity, mortality and increased costs of care. Ensuring evidence-based practice to prevent SSI is incorporated across the patient�s surgical journey is complex. OneTogether is a quality improvement collaborative of infection prevention and operating department specialists, formed to support the spread and adoption of best practice to prevent SSI. This paper describes the findings of an expert workshop on infection prevention in operating departments. Methods: A total of 84 delegates from 75 hospitals attended the workshop, comprising 46 (55%) theatre nurses operating department practitioners; 16 (19%) infection control practitioners and 22 (26%) other healthcare practitioners.Discussion focused on evidence, policy implementation and barriers to best practice. Responses were synthesised into a narrative review. Results: Delegates reported significant problems in translating evidence-based guidance into everyday practice, lack of local polices and poor compliance. Major barriers were lack of leadership, poorly defined responsibilities, and lack of knowledge/training. Conclusions: This workshop has provided important insights into major challenges in assuring compliance with best practice in relation to the prevention of SSI. The OneTogether partnership aims to support healthcare practitioners to improve the outcomes of patients undergoing surgery by reducing the risk of SSI. [ABSTRACT FROM AUTHOR]

Background: It is known that when crude Pinelliae rhizome and Pinelliae rhizoma preparatum are combined with Aconiti Radix Cocta respectively, the toxicity of the combination varies. However, the component's transformation between different compatibility have remained unclear. Objective: In this paper, a novel approach using rapid resolution liquid chromatography-quadrupole time-of-flight mass spectrometry (RRLC-Q-TOF-MS) coupled with multivariate statistical analysis was established for exploring the influence of processing adjuvants (PAs) on the compatibility of Aconiti Radix Cocta and Pinelliae rhizome. Materials and Methods: In order to obtain information about the representative markers between different groups, an exhaustive study of different protocols based on adding or removing different PAs step by step was carried out and the influence of PAs on compatibility was investigated. Results: It was found that lime can facilitate diester diterpenoid alkaloids with high toxicity in Aconiti Radix Cocta to be converted into low-toxic or non-toxic derivatives. Glycyrrhizae Radix et Rhizoma had no remarkable effect on the process. Conclusion: The established method in this study will be of great significance to process research mechanism and study on traditional Chinese Medicine compatibility and clinical application. [ABSTRACT FROM AUTHOR]

This article describes the technological trajectory of the Institute of Technology in Immunobiologicals (Bio-Manguinhos) of a public institution (Fiocruz) linked to the Brazilian Ministry of Health, showing how it affected the learning process and the technological capabilities accumulation. It also tackled the government policies to stimulate the local production of similar biotherapeutics through the productive development partnerships, and the regulatory framework involved in this process. Bio-Manguinhos was created in the second half of 1976 aiming to supply the Brazilian National Program of Immunizatio (NPI) created in 1973, by organizing an incipient vaccine production done in several different research laboratories of Fiocruz. Since then, through different types of technology agreements and maintaining the investments on intrinsic technological development, the Institute had an extraordinary growth. Today it is responsible for more than 60% of the vaccines distributed to the Brazilian population, supplies diagnostic kits for several public programs and became an innovative organization launching high-tech kits intrinsically developed. In 2006, Bio-Manguinhos entered the biopharmaceutical field and is becoming the vanguard production in the country for different types of treatment covered by the government. This paper also shows the public health policies that focus to induce the local biological production by stimulating partnerships between public and private companies, the impact of the local production and the changes in the regulatory environment to follow the new scenario. Through different types of technology agreements, Bio-Manguinhos today produces more than 100 million doses of vaccines, including technologically complex ones as streptococcus pneumonia 10 valent. The technological trajectory of the in vitro diagnosis tests was similar to the vaccines, whereas the institute began supplying to the ministry of health programs tests produced in old technological platforms and then became an innovative organization launching high-tech products. Through this case it is possible to realize the learning process as well as the technological capabilities accumulation of Bio-Manguinhos. [ABSTRACT FROM AUTHOR]

Aim: Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy. Methods: This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7th–10th May 2012 in Mainz. The conference was organized by the German Society of Phlebology. Results: This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, Polidocanol (POL) and Sodium tetradecyl sulphate (STS). Other sclerosants are not discussed in detail. In this paper the results from recent RCTs in sclerotherapy are reviewed. [ABSTRACT FROM AUTHOR]

Major advances are taking place in the development of therapeutics for multiple sclerosis (MS), with a move past traditional immunomodulatory/immunosuppressive therapies toward medications aimed at promoting remyelination or neuroprotection. With an increase in diversity of MS therapies comes the need to assess the effectiveness of such therapies. Magnetic resonance imaging (MRI) is one of the main tools used to evaluate the effectiveness of MS therapeutics in clinical trials. As all new therapeutics for MS are tested in animal models first, it is logical that MRI be incorporated into preclinical studies assessing therapeutics. Here, we review key papers showing how MR imaging has been combined with a range of animal models to evaluate potential therapeutics for MS. We also advise on how to maximize the potential for incorporating MRI into preclinical studies evaluating possible therapeutics for MS, which should improve the likelihood of discovering new medications for the condition. [ABSTRACT FROM PUBLISHER]

The article presents a response to commentators Cynthia Rogers and Amélie Noack for their commentaries on the author's paper. The author is very moved by the commentators' engagement with his positions and questions, in a sense he feels seen and related to. This is a memorable event insofar as, in his experience, the academic contexts he is located in are delimited by the attempt to account intellectually for the terms and motivations of our engagement, so that they often become seriously impersonal and abstract. Secondly and significantly he finds the commentators' reading of his paper and their associations to issues relevant to therapeutic practice very valuable and inspiring. In his background, therapeutic practice and training were meant, among other things, to establish rather than question the therapist's authority. Even where the power of therapist was destabilized, this more often than not was constructed as a tactical, strategic or therapeutic move, thereby conserving unchallenged the position of the therapist as the one who knows and determines the client's progress.

Although there are a number of quality frameworks available for evaluating palliative services, it is necessary to adapt these frameworks to models of care designed for the rural context. The purpose of this paper was to describe the development of a program assessment framework for evaluating a rural palliative supportive service as part of a community-based research project designed to enhance the quality of care for patients and families living with life-limiting chronic illness. A review of key documents from electronic databases and grey literature resulted in the identification of general principles for high-quality palliative care in rural contexts. These principles were then adapted to provide an assessment framework for the evaluation of the rural palliative supportive service. This framework was evaluated and refined using a community-based advisory committee guiding the development of the service. The resulting program assessment framework includes 48 criteria organized under seven themes: embedded within community; palliative care is timely, comprehensive, and continuous; access to palliative care education and experts; effective teamwork and communication; family partnerships; policies and services that support rural capacity and values; and systematic approach for measuring and improving outcomes of care. It is important to identify essential elements for assessing the quality of services designed to improve rural palliative care, taking into account the strengths of rural communities and addressing common challenges. The program assessment framework has potential to increase the likelihood of desired outcomes in palliative care provisions in rural settings and requires further validation. [ABSTRACT FROM AUTHOR]

This paper examines the future sustainability of the Fijian Ministry of Health's (MoH) information and communication technology (ITC) system for patient management (PATIS). PATIS was developed with AusAID funding and, as the owner of the system, AusAID has no commercial competence or interest in further development of the system. Thus, the question that arises is: should Fiji adopt a commercially available patient administration system or retain the existing PATIS? In-depth consultations with senior executives and line managers of units that were major users of PATIS were undertaken. Semi-structured interviews and focus group discussion approaches were utilised. The consensus or majority views of the users were that the existing PATIS performed more than adequately. The future sustainability of the system is threatened by the lack of investment in resources (e.g. hardware maintenance and human resources) required to keep the system operating at its optimum. It was found that PATIS provides Fiji with a satisfactory patient administration system. The identified problems with the system are not related to the application per se but rather to an under-investment in resources for its utilisation. [ABSTRACT FROM AUTHOR]

Despite significant progress in the development of therapies for relapsing MS, progressive MS remains comparatively disappointing. Our objective, in this paper, is to review the current challenges in developing therapies for progressive MS and identify key priority areas for research. A collaborative was convened by volunteer and staff leaders from several MS societies with the mission to expedite the development of effective disease-modifying and symptom management therapies for progressive forms of multiple sclerosis. Through a series of scientific and strategic planning meetings, the collaborative identified and developed new perspectives on five key priority areas for research: experimental models, identification and validation of targets and repurposing opportunities, proof-of-concept clinical trial strategies, clinical outcome measures, and symptom management and rehabilitation. Our conclusions, tackling the impediments in developing therapies for progressive MS will require an integrated, multi-disciplinary approach to enable effective translation of research into therapies for progressive MS. Engagement of the MS research community through an international effort is needed to address and fund these research priorities with the ultimate goal of expediting the development of disease-modifying and symptom-relief treatments for progressive MS. [ABSTRACT FROM AUTHOR]

This paper details the development of the Infection Prevention Society strategic plan 2011–2016 from its inception in 2009 to its launch in September 2011 at the Infection Prevention Society’s annual conference. It aims to provide a transparent account of how the vision, mission and strategic aims of the strategy were shaped and crafted through a number of iterations that involved members at key stages. [ABSTRACT FROM PUBLISHER]

The article looks at the role of disease classification in clinical and hospital work. It references the concept of Ways of Knowing (WoK) in the fields of science, technology and medicine (STM) developed by science historian John Pickstone. According to the author, a variety of factors including notions of specificity in diseases, new developments in paper technologies and administrative practices, and the use of statistics to determine medical norms came together in the 19th century to form disease classification systems (DCS). It is suggested that these systems can be seen as mediating work styles bring together different technologies and processes into new and efficient configurations. Topics discussed include the Paris Clinical School, medical labour, and cancer.

Objective:Measuring quality of care through performance indicators and subsequently using these to compare, learn, and improve (benchmarking) has become a central component of health care policy. This paper aims to identify the main themes of health services research in this area and focuses on opportunities for improving the evidence underpinning performance indicators. Methods: A literature survey was carried out to identify research activities and main research themes in Europe in the years 2000-09. Identified literature was categorized into sub-topics and for each topic the main methodological issues were identified and discussed. Experts validated the findings and explored the potential for related further European research. Results: The distribution of research on performance and benchmarking across EU member states varies in time, scope and settings with a large amount of studies focusing on hospitals. Eight specific fields of research were identified (research on concepts and performance frameworks; performance indicators and benchmarking using mortality data; performance indicators and benchmarking related to cancer care; performance indicators and benchmarking on care delivered in hospitals; patient safety indicators; performance indicators in primary care; patient experience; research on the practice of benchmarking and performance improvement). Expert discussions confirmed that research on performance indicators and benchmarking should focus on the development of indicators, as well as their use. The research should involve the potential users and incorporate scientific approaches from biomedicine and epidemiology as well as the social sciences. Further progress is hampered by data availability. Issues which need to be addressed include the use of unique patient identifiers (UPIs) to facilitate linkages between separate databases; standardized measurement of the experiences of patients and others; and deepening collaboration between Eurostat, the World Health Organization (WHO), and the Organization for Economic Co-operation and Development (OECD) to facilitate the availability of internationally comparable performance information. Conclusions: This study suggests a number of themes for future research. These include testing and improving: the validity and reliability of performance indicators, especially related to avoidable mortality and other outcome indicators; the effectiveness and efficiency of embedding performance indicators in the various governance, monitoring and management models, and their effect on health systems, services and professionals; and the effectiveness and efficiency of linking performance indicators to other national and international strategies and policies such as accreditation and certification, practice guidelines, audits, quality systems, patient safety strategies, national standards on volume and/or quality, public reporting, pay-for-performance and patient/consumer involvement. The field would benefit from strengthening the clearinghouse function for research findings, training of researchers and appropriate scientific publication media. Results should be systematically shared with policy-makers and managers, and networking stimulated between the growing number of regional and national institutes involved in quality measurement and reporting. [ABSTRACT FROM AUTHOR]

Aim: Clinical practice improvement carried out in a quality assurance framework relies on routinely collected data using clinical indicators. Herein we describe the development, minimum training requirements, and inter-rater agreement of indicators that were used in an Australian multi-site evaluation of the effectiveness of early psychosis (EP) teams. Methods: Surveys of clinician opinion and face-to-face consensus-building meetings were used to select and conceptually define indicators. Operationalization of definitions was achieved by iterative refinement until clinicians could be quickly trained to code indicators reliably. Calculation of percentage agreement with expert consensus coding was based on ratings of paper-based clinical vignettes embedded in a 2-h clinician training package. Results: Consensually agreed upon conceptual definitions for seven clinical indicators judged most relevant to evaluating EP teams were operationalized for ease-of-training. Brief training enabled typical clinicians to code indicators with acceptable percentage agreement (60% to 86%). For indicators of suicide risk, psychosocial function, and family functioning this level of agreement was only possible with less precise 'broad range' expert consensus scores. Estimated kappa values indicated fair to good inter-rater reliability (kappa > 0.65). Inspection of contingency tables (coding category by health service) and modal scores across services suggested consistent, unbiased coding across services. Conclusions: Clinicians are able to agree upon what information is essential to routinely evaluate clinical practice. Simple indicators of this information can be designed and coding rules can be reliably applied to written vignettes after brief training. The real world feasibility of the indicators remains to be tested in field trials. [ABSTRACT FROM AUTHOR]

Objective: There has been a recent dissemination of the term 'excellence' in psychiatric services without a full appreciation of the origins of its contemporary usage. In recent years, we have also been witness to an increasing emphasis on the language and notions of goals and outcomes in clinical practice, particularly in the public sector. This paper examines the origin and prevalence of the term excellence in both commercial and clinical services and the corresponding preoccupation with strategies and outcomes. Conclusions: It is argued that the contemporary talk of 'excellence' has been directly imported from the commercial sector. A closer examination of the ascendency of the use of this term has not been borne out by the results of the companies purported to be 'excellent'. In a similar vein, the political and corporate talk of strategies and outcomes has been transferred onto the clinical field. Such a movement has occurred primarily through political and financial motivations. A model of outcome-driven treatment is examined as an end result of such a preoccupation with outcomes. [ABSTRACT FROM AUTHOR]

Objective: Language has always been a means of imposing political and economic dominance. The ascendancy of the discourse of economics is examined in the context of economic rationalism. Some of the effects of this discourse, both upon our services, as well as upon different modes of conceptualizing the therapeutic relationship, will be examined in this paper. Conclusions: The intensification of the use of terms from economics and management can be dated from the introduction of neo-liberal policies in our Western democracies, but the economic discourse circulates with a life of its own. The use of the language of economics and management has spread generally through our society. Thus, if the economic discourse is the language utilized by some clinicians, it is also to some degree the language adopted by our patients. It is proposed that the extension of the economic discourse into the clinical field is re-shaping the therapeutic relationship with our patients. [ABSTRACT FROM AUTHOR]

Objective: This paper describes the development of a collaborative group of mental health clinicians who have come together to improve practice in adult acute mental health settings for the inpatient management of schizophrenia. Method: Sixteen acute adult mental health inpatient services across Queensland worked together to develop clinical indicators related to the inpatient treatment of schizophrenia. Data collection was conducted by using information available on existing databases and through statewide chart audits using scannable form technology. Through a secure intranet site, and statewide forums, clinicians were able to access information on clinical indicators enabling them to compare their site data to peer and state data. Results: Available data from 15 of the 16 sites provided information on clinical indicators including average length of stay, 28-day readmission rates, antipsychotic prescribing, medication dose and the use of multiple antipsychotic medications at discharge. Conclusions: The formation of the Mental Health Clinical Collaborative has brought together clinicians across the State to develop clinical indicators and openly discuss ideas to inform and improve clinical practice. This process has been effective in improving the quality of routinely collected information across the State and in engaging clinicians in using health information to drive clinical practice. [ABSTRACT FROM AUTHOR]

Objective: This paper aims to describe some of the challenges in psychiatric classification, using generalized anxiety disorder (GAD) as an example. A range of different conceptualizations of GAD are presented. Some are based on theoretical formulations, while others draw on epidemiological data. Each has merit, but also deficiencies. The evolution of diagnostic criteria is not simply a theoretical exercise, but reflects assumptions about the nature of the underlying pathology and the relationships between different disorders. Furthermore, these criteria determine which subjects are included in research and in clinical trials, so they shape the further development of psychiatric classification systems. Conclusion: The controversies about the classification of GAD illustrate the complexities and challenges of developing a valid classification system for psychiatric disorders. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper was to review the large US National Institute of Mental Health-sponsored depression intervention effectiveness study, STAR*D, in order to evaluate critically its relevance for Australasian clinicians. Conclusions: STAR*D is a landmark study which tried to address issues of effectiveness rather than efficacy, of a number of interventions for depression. However, methodological shortcomings limit the utility of the study in informing Australasian clinical practice. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper is to outline and review some of the qualitative approaches - specifically interviewing and case studies - that can contribute to psychiatric research, and to highlight the existing skills that psychiatrists can bring to such approaches. Conclusions: Qualitative research methods are currently under-utilized in psychiatric research. Psychiatrists are well placed to utilize qualitative methodologies by applying the skills that they acquire through training and clinical practice. Psychiatrists wishing to conduct research might wish to consider and adopt qualitative methods where appropriate. [ABSTRACT FROM AUTHOR]

Clinical ethics has developed significantly in Europe over the past 15 years and remains an evolving process. While sharing our experiences in different European settings, we were surprised to discover marked differences in our practice, especially regarding the position and role of patients. In this paper, we describe these differences, such as patient access to and participation or representation in ethics consults. We propose reasons to explain these differences, hypothesizing that they relate to the historic and sociocultural context of implementation of clinical ethics consultation services (Cecs), as well as the initial aims for which each structure was established. Then, we analyse those differences with common ethical arguments arising in patient involvement. We conclude that there is no unique model of best practice for patient involvement in clinical ethics, as far as Cecs reflect on how to deal with the challenging ethical issues raised by patient role and position. [ABSTRACT FROM AUTHOR]

Sternal fractures are relatively common and range from simple unicortical cracks to displaced fractures associated with life threatening injuries. This paper describes the relevant anatomy, biomechanics, mechanism of injury, clinical presentation, investigation, treatment and complications and also includes associated and concomitant injuries. A management flow chart including criteria for discharge from the emergency department is presented. [ABSTRACT FROM AUTHOR]

Objective: A meta-analysis of 42 studies on tobacco smoking among schizophrenia subjects found an average smoking prevalence of 62% (range=14-88%). Statements are common, however, in the research literature and the media that between 80% and 90% of people with schizophrenia smoke. The purpose of the present paper was therefore to determine if citation bias exists in the over-citation and reportage of studies finding high rates of smoking prevalence in schizophrenia subjects. Methods: Two hypotheses were tested: (i) that studies on the prevalence of smoking in people with schizophrenia reporting high smoking rates would be cited more often than studies reporting lower rates; and (ii) that statements about smoking rates among schizophrenic people on the Internet would report very high rates more often than more realistic, less dramatic rates. Results: A 10% increase in reported prevalence of smoking was associated with a 61% (95% confidence interval (CI)=30-98%) increase in citation rate. Journal impact factor (IF) was significantly associated with citation rate (p=0.001) but the country in which a study was carried out did not have an effect (p=0.90). After adjusting for IF, a 10% increase in prevalence of smoking was associated with a 28% increase (95%CI=1-62%) in citation rate. This bias is mirrored on the Internet, where statements abound about uncommonly highly rates of smoking by people with schizophrenia. Conclusions: Studies reporting very high prevalence of smoking among people with schizophrenia are cited more often than those studies reporting a low prevalence, a result consistent with citation bias. This citation bias probably contributes to the misinformation available on the Internet, and may have adverse policy and clinical implications. [ABSTRACT FROM AUTHOR]

Objective: There is an emerging consensus that the assessment and management of adverse outcomes in mental health, such as violence and self harm, is best achieved by approaches which incorporate validated tools using “structured professional judgement”. Although several useful tools have emerged from the literature, there is no clear consensus on the best way to integrate these with clinical practice. This paper describes a framework, the Forensicare Risk Assessment and Management Exercise (F.R.A.M.E.), employed by a statewide community forensic mental health service, which incorporates two structured professional judgement tools, and explicitly integrates these into case management and psychiatric treatment. The potential benefits of the framework are discussed in the context of contemporary trends in risk assessment and management. Conclusions: The F.R.A.M.E. appears to assist with the task of integrating risk assessment with clinical management. Formal evaluative research is indicated before it can be recommended for use by other services. [ABSTRACT FROM AUTHOR]

Objective: This paper describes and reflects upon the experience of a small, integrated aged care psychiatry service that has utilized the National Outcomes Casemix Collection (NOCC) routine outcome measurements within clinical practice, service management and evaluation. The goals of the NOCC initiative are reviewed in light of this experience. Conclusion: Routine outcome measurement has the potential to significantly improve aged care psychiatric service delivery. The service described has developed a model that the authors believe demonstrates the potential for routine outcome measures to improve the monitoring of patient progress, care planning, team communication, management and the understanding of service effectiveness - goals that are consistent with NOCC philosophy. However, this requires both ongoing development of infrastructure support and the willingness of clinicians to explore their utility. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper is to describe the use of the Health of the Nation Outcome Scale (HoNOS) in an outreach-based rehabilitation program in regional Victoria, Australia. Method: Routine outcome measures (ROM), including the HoNOS, were introduced in the Stepping Stones Recovery Program (SSRP) in 2002. HoNOS data routinely collected for 122 patients between 2003 and 2006 was examined for sensitivity in capturing clinical changes by using paired t-tests. Results: There was a statistically significant decrease in total HoNOS scores as well as scores on subsets of 'impairment' and 'symptomatic problems'. HoNOS scores reflected positive changes in patients and were useful as a global overview, but did not tap into process issues that are more clinically meaningful. Conclusions: The SSRP provided a wide range of interventions and promoted a structured collaborative approach which could be the main reason for the uptake of ROM in this service. There are significant hurdles in integrating ROM in routine clinical practice, such as feasibility issues and clinician attitudes, along with larger systemic issues that need to be addressed. The introduction of ROM in Australia has resulted in strongly polarized viewpoints. Suggestions for facilitating the administration and use of ROM in routine clinical practice are discussed. [ABSTRACT FROM AUTHOR]

Objective: Venlafaxine and mirtazapine in combination are increasingly used in clinical practice to treat treatment-refractory depression. Putative efficacy for this combination of antidepressants, beyond that of monotherapy, stems from their synergistic actions. This paper describes a prospective case series that examined the efficacy of the venlafaxine-mirtazapine combination in the treatment of depressed patients who had failed at least one antidepressant trial. Method: Twenty-two depressed patients with major depression were treated with venlafaxine and mirtazapine in combination for an average of just under 8weeks. Baseline ratings on the 17-item Hamilton Depression Rating Scale (HAM-D17), Montgomery-Åsberg Depression Rating Scale (MADRS) and the Clinical Global Impression-Severity Scale (CGI-S) were repeated at end-point, determined by the naturalistic termination of the depressive treatment episode or the discontinuation of the combination treatment due to adverse effects. The length of treatment until end-point was documented for each patient. Descriptive statistics were used on the collated data. Results: At baseline, mean scores were 28.8 (SD=3.8) for HAM-D17, 30.1 (SD=5.8) for MADRS, and 4.5 (SD=0.5) for CGI-S, reflecting a cohort at the moderate to severe end of the spectrum. At end-point, mean absolute scores were 10.2 (SD=4.7) for HAM-D17, 10.8 (SD=4.6) for MADRS, and 2.3 (SD=0.6) for CGI-S. Mean change from baseline was 18.6 (SD=6.4) for HAM-D17, 19.3 (SD=6.8) for MADRS, and 2.3 (SD=0.6) for CGI-S. Mean duration of treatment was approximately 8weeks, producing a response rate of 81.8% and a remission rate of 27.3%. Only one patient was unable to tolerate the combination although nearly half (10) had significant side-effects during treatment. Conclusion: This study demonstrates relatively high response and remission rates that are encouraging and contribute to the efficacy database for this antidepressant combination. Further studies using randomized controlled designs are needed. [ABSTRACT FROM AUTHOR]