Sam A Harding

The performance of junior doctors in applying clinical pharmacology knowledge and prescribing skills to standardized clinical cases

AIMS Recent studies suggest a worryingly high proportion of final year medical students and new doctors feel unprepared for effective and safe prescribing. Little research has been undertaken on UK junior doctors to see if these perceptions translate into unsafe prescribing practice. We aimed to measure the performance of foundation year 1 (FY1) doctors in applying clinical pharmacology and therapeutics (CPT) knowledge and prescribing skills using standardized clinical cases. METHODS A subject matter expert (SME) panel constructed a blueprint, and from these, twelve assessments focusing on areas posing high risk to patient safety and deemed as essential for FY1 doctors to know were chosen. Assessments comprised six extended matching questions (EMQs) and six written unobserved structured clinical examinations (WUSCEs) covering seven CPT domains. Two of each assessment types were administered over three time points to 128 FY1 doctors. RESULTS The twelve assessments were valid and statistically reliable. Across seven CPT areas tested 51-75% of FY1 doctors failed EMQs and 27-70% failed WUSCEs. The WUSCEs showed three performance trends; 30% of FY1 doctors consistently performing poorly, 50% performing around the passing score, and 20% performing consistently well. Categorical rating of the WUSCEs revealed 5% (8/161) of scripts contained errors deemed as potentially lethal. CONCLUSIONS This study showed that a large proportion of FY1 doctors failed to demonstrate the level of CPT knowledge and prescribing ability required at this stage of their careers. We identified areas of performance weakness that posed high risk to patient safety and suggested ways to improve the prescribing by FY1 doctors.

A complication of Le Fort I osteotomy

Le Fort I osteotomy is a routine procedure for oral and maxillofacial surgeons. Following advances in instrumentation and anaesthesia, it is usually carried out safely as an elective procedure in hospitals with no adverse complications. Life-threatening complications are rare although the operation is performed in an area with an extensive vascular supply. The authors report a case of Le Fort I osteotomy that resulted in an unusual complication of cerebrospinal fluid leak.

Existence of benefit finding and posttraumatic growth in people treated for head and neck cancer: a systematic review

Background. The impact of head and neck cancer (HNC) in long-term survivors differs widely among individuals, and a significant number of them suffer from the negative effects of disease, whereas others report significant positive effect. This systematic review investigated the evidence the implications of treatment for HNC and subsequent development of Benefit Finding (BF) or Posttraumatic Growth (PTG). Purpose. To understand how differing medical, psychological and social characteristics of HNC may lead to BF/PTG and subsequently inform post-treatment interventions to encourage positive outcomes. Method. In February 2012, five databases including Pubmed, and Psych Info, were searched, for peer-reviewed English-language publications. Search strings included key words pertaining to HNC, BF, and PTG. One thousand three hundred and sixty three publications were identified, reviewed, and reduced following Cochrane guidelines and inclusion/exclusion criteria specified by a group of maxillofacial consultants and psychologists. Publications were then quality assessed using the CASP Cohort Critical Appraisal tool. Findings. Five manuscripts met the search and selection criteria, and were sourced for review. All studies were identified as being level IIb evidence which is a medium level of quality. The majority of studies investigated benefit finding (80%) and were split between recruiting participant via cancer clinics and postal survey. They focused on the medical, psychological and social characteristics of the patient following completion of treatment for HNC. Conclusion. Demographic factors across the papers showed similar patterns of relationships across BF and PTG; that higher education/qualification and cohabitation/marriage are associated with increased BF/PTG. Similarly, overlap with disease characteristics and psychosocial factors where hope and optimism were both positively correlated with increased reported BF/PTG.

The prevalence of posttraumatic stress disorder in patients undergoing pulmonary rehabilitation and changes in PTSD symptoms following rehabilitation.

PURPOSE Posttraumatic stress disorder (PTSD) is a common serious condition, which, although treatable, is often undetected. We investigated the prevalence of PTSD in patients with chronic obstructive pulmonary disease (COPD) referred to pulmonary rehabilitation and the impact of rehabilitation on PTSD symptoms. METHODS Patients with COPD attending pulmonary rehabilitation programs in South West England completed cross-sectional and longitudinal surveys. Outcome measures included the Posttraumatic Diagnostic Scale, Impact of Events scale, Incremental Shuttle Walking Test, Medical Outcomes Short Form 12, Hospital Anxiety and Depression scale (HADS), and Chronic Respiratory Questionnaire. Questionnaires were completed at face-to-face interviews with participants 1 week before commencing pulmonary rehabilitation and at the end of the program. RESULTS Patients (N = 100), mean age 68 years, 65% men, served as subjects. Seventy-four participants reported traumatic experiences (37 related to lung disease) and 70 completed the pulmonary rehabilitation program. Eight of 100 participants met diagnostic criteria for PTSD. Participants with PTSD reported worse health status than those without PTSD. After pulmonary rehabilitation, exercise capacity and quality of life scores improved significantly, but PTSD symptom severity did not change. CONCLUSIONS PTSD was present in 8% of COPD patients referred for pulmonary rehabilitation. After rehabilitation, participants with PTSD improved more in respect to anxiety and disease-specific health status than those without PTSD. PTSD symptoms did not improve following rehabilitation, despite its positive effects on HADS scores, exercise, and health status in this cohort.

Characteristics of Parent-Child Interactions: A Systematic Review of Studies Comparing Children with Primary Language Impairment and Their Typically Developing Peers.

The importance of parent–child interaction (PCI) for language development has been well established. This has led many speech and language therapy (SLT) interventions to focus on modifying PCI as a means to improving children’s early language delay. However, the success of such programs is mixed. The current review compares PCI, observed in naturally occurring contexts, with preschool children with language delay and age- or language-matched typically developing (TD) controls. A systematic review of the literature searched 10 databases for studies using a case-control design and extracted data concerning participants, matching, selection, design, assessments, measures, findings, statistics, and bias. Quality appraisal used the Critical Appraisal Skills Programme case-control checklist. The search identified 17,824 articles, which were reviewed against exclusion criteria. The final review included 9 studies, which were diverse in terms of matching, delay criteria, and PCI measure. A narrative synthesis was conducted. The evidence for PCI differences between children with language delay and TD peers was limited and any suggestion that parents were less responsive could be attributed to limited language skills of children with language delay. The findings question the assumption that communicative environments of children with language delay are different, although the evidence is from a small sample of children from middle-class families. Children with language delay may instead be less able to learn from their environment. The review highlights the gap in understanding the relationship between parent and child language use during PCI. The need for further, longitudinal research is emphasized, including children ranging in type and severity of delay, across diverse socioeconomic backgrounds.

An unusual presentation of metastatic colon adenocarcinoma in the oral cavity.

Background. A case report of a nonhealing ulcer of the tongue histologically proven to be adenocarcinoma. Method. A 92-year-old man underwent clinical, immunochemistry, and imaging investigation. Results. Tests confirmed a distant metastasis of a primary colorectal carcinoma. Conclusion. Metastasis from colorectal carcinoma to the oral cavity is primarily to bone, but non-healing ulcers of the oral cavity should be considered in differential diagnoses.

Defining communication disability in under-served communities in response to the World Report on Disability

Abstract The World Report on Disability takes a broad emphasis on disability. In their paper on the implications of this report for speech-language pathology and for people with communication disabilities, Wylie, McAllister, Davidson, and Marshall (2013) emphasize the importance of promoting a broader view of communication disability. This commentary explores the challenges of investigating the epidemiology of communication disability, in particular, the difficulties defining the disability and then measuring it in a valid and reliable manner. The two interpretations are discussed of the concept medically under-served as it relates to speech-language pathology: service availability and service accessibility. Bourdieus forms of capital were then explored as a way of understanding an individuals perception of capital and how service provision can enhance perceived capital and minimize loss of capital. It is important services are mindful of the variations of capital and engage with communities to facilitate access and increase their perceptions of the value of speech-language pathology (SLP) services. The focus throughout is on pre-school children with communication disability in the context of a program of research in England, called Child Talk–What Works.

A systematic review and classification of interventions for speech sound disorder in preschool children

BACKGROUND Multiple interventions have been developed to address speech sound disorder (SSD) in children. Many of these have been evaluated but the evidence for these has not been considered within a model which categorizes types of intervention. The opportunity to carry out a systematic review of interventions for SSD arose as part of a larger scale study of interventions for primary speech and language impairment in preschool children. AIMS To review systematically the evidence for interventions for SSD in preschool children and to categorize them within a classification of interventions for SSD. METHODS & PROCEDURES Relevant search terms were used to identify intervention studies published up to 2012, with the following inclusion criteria: participants were aged between 2 years and 5 years, 11 months; they exhibited speech, language and communication needs; and a primary outcome measure of speech was used. Studies that met inclusion criteria were quality appraised using the single case experimental design (SCED) or PEDro-P, depending on their methodology. Those judged to be high quality were classified according to the primary focus of intervention. OUTCOMES & RESULTS The final review included 26 studies. Case series was the most common research design. Categorization to the classification system for interventions showed that cognitive-linguistic and production approaches to intervention were the most frequently reported. The highest graded evidence was for three studies within the auditory-perceptual and integrated categories. CONCLUSIONS & IMPLICATIONS The evidence for intervention for preschool children with SSD is focused on seven out of 11 subcategories of interventions. Although all the studies included in the review were good quality as defined by quality appraisal checklists, they mostly represented lower-graded evidence. Higher-graded studies are needed to understand clearly the strength of evidence for different interventions.

Positive Psychological Change in Head and Neck Cancer populations

Head and neck cancer (HNC) carry a high level of morbidity and mortality, but the impact of HNC on survivors differs widely among individuals, and a significant number of them suffer from negative psychological effects of the disease. However, some people report a significant positive effect of experiencing HNC and its treatment. This review looks at demographic, clinical and psychological factors associated with positive psychological change (PPC) in HNC populations. Eight quantitative manuscripts were identified as reporting on PPC in HNC. These studies were split between recruiting participants via cancer clinics and postal surveys, and the majority use a cross-sectional study design. Demographic factors across the papers showed similar patterns of relationships across PPC; that higher education/qualification and cohabitation/marriage are associated with increased PPC. Limited research reported longitudinal patterns of change and showed that for people with lower stage tumours and those who only had a surgical intervention greater PPC developed over time. Multivariable modeling adjusting for psychosocial variables found that PPC had a quadratic relationship with time since diagnosis, increasing initially and leveling off after 18 months. Further research would aid the identification of bio-psychosocial factors that influence the development of PPC and inform the development of rehabilitation interventions while enabling consideration of the natural development of the phenomenon.

The trajectory of positive psychological change in a head and neck cancer population

A stressful event may be sufficient to challenge a strongly held set of assumptions about the world and the self. In some people this may lead to post-traumatic stress disorder (PTSD) and in others to positive psychological change (PPC), whereby a persons reactions to the challenge are beneficial. Little research has investigated PPC in people who have had head and neck cancer (HNC). The aim of this study was to identify demographic, clinical, and psychological factors associated with PPC over time. A cross-sequential study collected data over 5 years. Participants were sent the Silver Lining Questionnaire (SLQ; a measure of PPC), the University of Washington HNC quality of life measure, and the Medical Outcomes Short-Form 12 each year. Additional data were collected from clinical records. Analysis using linear mixed-effects modelling revealed that participants with lower stage tumours and those who only had a surgical intervention reported greater PPC over time. Multivariable modelling adjusting for psychosocial variables found that PPC had a quadratic relationship with time since diagnosis, increasing initially and levelling off after 18 months. These findings build on the minimal PPC research with people following HNC. In particular it demonstrates a model of trajectories for the development of PPC longitudinally over time.