Rationale, aims, and objectives
Underuse of anticoagulants in atrial fibrillation is known to increase the risk of stroke and is an international problem. The National Institute for Health Care and ...Excellence guidance CG180 seeks to reduce atrial fibrillation related strokes through prescriptions of Non‐vitamin K antagonist Oral Anticoagulants. A quality improvement programme was established by the West of England Academic Health Science Network (West of England AHSN) to implement this guidance into General Practice.
A realist evaluation identified whether the quality improvement programme worked, determining how and in what circumstances.
Methods
Six General Practices in 1 region, became the case study sites. Quality improvement team, doctor, and pharmacist meetings within each of the General Practices were recorded at 3 stages: initial planning, review, and final. Additionally, 15 interviews conducted with the practice leads explored experiences of the quality improvement process. Observation and interview data were analysed and compared against the initial programme theory.
Results
The quality improvement resources available were used variably, with the training being valued by all. The initial programme theories were refined. In particular, local workload pressures and individual General Practitioner experiences and pre‐conceived ideas were acknowledged. Where key motivators were in place, such as prior experience, the programme achieved optimal outcomes and secured a lasting quality improvement legacy.
Conclusion
The employment of a quality improvement programme can deliver practice change and improvement legacy outcomes when particular mechanisms are employed and in contexts where there is a commitment to improve service.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Lower urinary tract symptoms (LUTS) result from conditions and diseases that affect the bladder and the urethra, and can occur in men and women of all ages. LUTS can be debilitating and affect a ...person's quality of life significantly. This article describes the definitions and classification of various LUTS, explains the aspects of an initial LUTS assessment and outlines the validated tools that can be used to support this process, including questionnaires and bladder diaries. It also provides information about the contributing factors associated with LUTS and the effects of these symptoms on patients' quality of life.
OBJECTIVES
To assess the long‐term natural history of overactive bladder (OAB) symptoms due to idiopathic detrusor overactivity (IDO) in women.
PATIENTS AND METHODS
Original urodynamic traces were ...reviewed and women who were referred with OAB symptoms and found to have IDO on investigation in our urodynamic unit ≥10 years previously were invited for a repeat urodynamic and symptomatic assessment.
RESULTS
In all, 174 women were identified and invited to participate; 53 had repeat urodynamics, another 32 attended the unit for symptom assessment and a further 23 completed postal questionnaires. There were no significant symptomatic or urodynamic differences between these groups at baseline. Of the 53 who had repeat urodynamics, 46 (88%) had persistent symptomatic IDO.
CONCLUSIONS
OAB symptoms have a significant effect on the quality of life of those affected. OAB symptoms due to IDO in women are persistent, lasting for ≥10 years in 88% of this study population. This information might affect the treatment choices made by patients and their doctors in the management of this condition.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
OBJECTIVES
To assess the long‐term outcomes of untreated bladder outlet obstruction (BOO), assuming that, if there is little or no deterioration, a conservative approach to management is justified, ...as there is little information on the natural history of untreated BOO and lower urinary tract symptoms (LUTS) in men, and studies to date suggest that neither BOO nor LUTS inevitably progress to a stage at which prostatectomy is required.
PATIENTS AND METHODS
Men aged >45 years who were investigated in our department between 1972 and 1986, diagnosed with BOO, and who initially opted for no specific treatment were invited for repeat symptomatic and urodynamic evaluation. Identical methods of assessment were used, allowing results to be compared directly.
RESULTS
In all, 1068 men were initially diagnosed with BOO; 428 (40%) of these died. Of the 170 men who initially opted for a conservative approach and attended for repeat assessment, 141 (83%) remained untreated, with a mean follow‐up of 13.9 years. The only significant urodynamic changes were a reduction in detrusor contractility and an increased prevalence of detrusor overactivity. Most patients reported no change in their symptoms but a significant minority experienced a gradual deterioration. Of the 29 men in whom the conservative approach failed, 22 proceeded to surgery for LUTS, and seven for acute urinary retention.
CONCLUSIONS
Patients with untreated BOO do not significantly deteriorate urodynamically in the long term, with only a minority deteriorating symptomatically. These findings justify a conservative approach to men with LUTS associated with BOO.
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Despite long-term symptomatic and uroflowmetry studies following transurethral prostate resection (TURP) there are sparse pressure flow data. Consequently there is minimal information to account for ...the long-term symptomatic failure and flow rate decrease seen with time following early improvements after surgery.
Men older than 45 years who were investigated at our department between 1972 and 1986, diagnosed with bladder outlet obstruction and elected surgical intervention were invited for repeat symptomatic and urodynamic assessment. Identical methods were used, allowing direct comparison of results.
A total of 1,068 men were initially diagnosed with bladder outlet obstruction, of whom 428 (40%) died in the interim. Of the men who were followed 217 underwent TURP with a mean followup since surgery of 13.0 years. A significant, sustained decrease in the majority of symptoms and improvements of urodynamic parameters was seen. Long-term symptomatic failure and decreased flow rate were principally associated with detrusor under activity (DUA) rather than obstruction. Presentation predictive factors for the future development of DUA were decreased detrusor contractility and a lesser degree of obstruction.
This unique long-term study provides valuable information on surgically treated bladder outlet obstruction. The association of long-term failure following surgery with DUA emphasizes the importance of pressure flow studies before repeat surgery. However, our faith in the long-term efficacy of TURP is justified.
There are two papers from Bristol on the natural history of lower urinary tract dysfunction in men, in both cases with a minimum 10‐year follow‐up. The first of these is a urodynamic study of ...neurologically untreated men with untreated detrusor underactivity, most of whom remained untreated with a mean follow‐up of 13.6 years. The results provide important information on the natural history of this condition, and show that there are minimal symptomatic and urodynamic changes with time.
In the second of these papers the natural history of untreated BOO in men is described. The authors showed that patients with untreated BOO show no significant urodynamic deterioration in the long‐term, with only a minority having worsening of their symptoms.
OBJECTIVES
To assess the long‐term symptomatic and urodynamic outcomes of men with untreated detrusor underactivity (DUA) as there has been little long‐term follow‐up information on men with DUA, a cause of lower urinary tract symptoms (LUTS) in a significant minority of men.
PATIENTS AND METHODS
Neurologically intact men aged > 18 years who were investigated in our department between 1972 and 1986, diagnosed with DUA, and who initially opted for no specific treatment were invited for a repeat symptomatic and urodynamic evaluation. Identical methods of assessment were used, allowing results to be compared directly.
RESULTS
In all, 224 men were initially diagnosed with DUA; 87 (39%) of these died. Of the 69 men who initially opted for a conservative approach and attended for repeat assessment, 58 (84%) remained untreated, with a mean follow‐up of 13.6 years. There were no significant changes in symptoms over the follow‐up. The only significant urodynamic finding was an increase in the proportion of patients with detrusor overactivity, but with no apparent worsening of chronic retention. Of the 11 men in who failed the conservative approach , eight proceeded to surgery for LUTS, and three for acute urinary retention.
CONCLUSIONS
These results provide important information on the natural history of DUA. In men with DUA presenting with LUTS there are few symptomatic and urodynamic changes with time.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
ABSTRACT
The translation of clinical guidelines into practice is a complex process, primarily because it is a ‘top down’ approach to disseminating information. The aim of this study was to determine ...whether current guidelines and standards have been applied to everyday urodynamic practice, and establish how health care professionals have interpreted the terminology. It was also an ideal opportunity to explore the systems in place that support personal and professional development, and identify factors that can contribute to, or obstruct, ‘good’ urodynamic practice. A descriptive exploratory research design was adopted using a mixed methodological approach. A purposive sample (n = 60) of doctors, nurses and technicians who currently undertake urodynamic investigations within one NHS region were identified. Most of the participants were familiar with the International Continence Society guidelines; with over half routinely using them in their current practice. Although there was a comprehensive uptake of formal urodynamic training courses, there was limited evidence of formal assessment either before or after training/education. This was also reflected in some of the themes that emerged during the semi‐structured interviews; access to supervision, multidisciplinary team meetings, team working, networking, isolation, attitudes and time, were all identified as factors that could have either a positive or negative effect on urodynamic practice. These findings confirm that guidelines, in one NHS region, are reaching their target population. However, the translation of training and assessment into practice is a complex issue to address, as it requires skills in reflective practice, self‐assessment and critical analysis. Although guidelines/recommendations exist, a more robust framework may be required; incorporating structured mentoring and clinical assessment with experienced practitioners, in order to address the barriers that clearly exist.
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The purpose of this doctoral submission, through a collection of published work, is to present a personal journey of academic enquiry and engagement in developing and conducting high quality ...research. The collection includes ten published papers, which predominantly involve quantitative and mixed methods, and one book chapter. These research outputs will demonstrate how I have advanced urodynamic practice, as well as my critical understanding of current knowledge in this highly specialist field.
Deaf learners Moores, Donald F; Martin, David S
2006, 20090930, 2009, 2006-03-23
eBook, Book
This in-depth collection by 17 renowned international scholars that details a developmental framework to maximize academic success for deaf students from kindergarten through grade 12. Part One: The ...Context commences with an overview of the state of general education and that of deaf learners, followed by a state-of-the art philosophical position on the selection of curriculum. Part Two: The Content considers critical subjects for deaf learners and how to deliver them, including mathematics, print literacy, science, social studies, and physical education. This section also addresses the role of itinerant services, as well as how to teach Deaf culture, provide for students with multiple disabilities, and facilitate school-to-work transitions. Part Three: Instructional Considerations Across the Curriculum provides suggestions and guidelines for assessing and planning programs for deaf students using meaningful contexts; optimizing the academic performance of deaf students with emphasis on access and opportunities; implementing a cognitive strategy that encourages teaching for and about thinking as an overriding principle; establishing instructional and practical communication in the classroom, especially in relation to ASL and English-based signing; and solving old problems with new strategies, including Web-based technologies, resources, and applications. The lessons of these assembled scholars coalesce in the Part Four: Summary as a general recommendation for ongoing adaptability, a fitting capstone to this extraordinary volume of work.
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