The potential of ecological theory for building an integrated framework to develop the public health contribution of health visiting

In line with recent UK and Scottish policy imperatives, there is increasing pressure for the health visiting service to assume an enhanced role in improving public health. Although health visiting has so far maintained its unique position as a primarily preventive service within the UK health service, its distinctive contribution now appears under threat. The continuing absence of a comprehensive and integrated conceptual basis for practice has a negative impact on the profession’s ability to respond to current challenges. Establishing an integrative framework to conceptualise health visiting practice would enable more sensitive, focused and appropriate research, education and evaluation in relation to practice. Work in this area could thus usefully contribute to the future development of the service at a difficult time. Our paper aims to make such a contribution. In support of our conceptual aims, we draw on a study of health visiting practice undertaken within a large conurbation in central Scotland. The study used a mixed method, collaborative approach involving 12 audio‐recorded and observed health visitor–client interactions, semi‐structured interviews with the 12 HVs and 12 clients, examination of related documentation and workshops with the HV participants. We critically consider prevalent models of health visiting practice and describe the more integrative conceptual approach provided by Bronfenbrenner’s ecological, ‘person‐in‐context’ framework. The paper subsequently explores relationships between this framework and understandings of need demonstrated by health visitors who participated in our study. Current policy emphasises the need to focus on public health and social inclusion in order to improve health. However, if this policy is to be translated into practice, we must develop a more adequate understanding of how practitioners work effectively with families and individuals in a sensitive and context‐specific manner. Bronfenbrenner’s framework appears to offer a promising means of building on the current strengths of the health visiting service to further develop a ‘person‐in‐context’ approach to health improvement that is mindful of and responsive to multiple, inter‐related influences on health. We therefore recommend further research to directly test the utility of this framework.     

Evaluation of pain experienced during breast ductal endoscopy

PURPOSE: Ductal endoscopy is valuable for the differential diagnosis of bloody nipple discharge; however, the pain associated with this procedure has not been evaluated. This study aims to assess the pain experienced by patients during ductal endoscopy. METHODS: We studied a consecutive series of women who underwent ductal endoscopy, to investigate the cause of bloody nipple discharge. The procedure was performed using standard local anesthesia (lidocaine 1% 10 ml without epinephrine, involving nipple block and periaureolar administration). Patients were asked to score the level of pain with a visual analog scale, 1, 4, 7, 12, 17, 22, 27, and 32 min after the procedure, and describe their overall and maximum pain. RESULTS: This series comprised 20 women aged from 27 to 68 years old. The overall pain (mean +/- SE) score was equal to 5.8 +/-0.3, and the maximum pain score was 8.3 +/- 0.2. The peak of pain corresponded with when the dilator was inserted through the sphincter. The group in which the dilator was inserted after 4 min experienced more intense maximum and overall pain after 7, 12, 17 and 22 min. CONCLUSIONS: Pain is an important factor in ductal endoscopy, and peaks relatively early. A standard, baseline local lidocaine dose of greater than 10 ml may be necessary at the beginning of the procedure. Late insertion of the dilator seems to be an indicator of the force of the procedure.     

Moving on time: brain network for auditory-motor synchronization is modulated by rhythm complexity and musical training

Much is known about the motor system and its role in simple movement execution. However, little is understood about the neural systems underlying auditory-motor integration in the context of musical rhythm, or the enhanced ability of musicians to execute precisely timed sequences. Using functional magnetic resonance imaging, we investigated how performance and neural activity were modulated as musicians and nonmusicians tapped in synchrony with progressively more complex and less metrically structured auditory rhythms. A functionally connected network was implicated in extracting higher-order features of a rhythm's temporal structure, with the dorsal premotor cortex mediating these auditory-motor interactions. In contrast to past studies, musicians recruited the prefrontal cortex to a greater degree than nonmusicians, whereas secondary motor regions were recruited to the same extent. We argue that the superior ability of musicians to deconstruct and organize a rhythm's temporal structure relates to the greater involvement of the prefrontal cortex mediating working memory.     

A review of natural orifice translumenal endoscopic surgery (NOTES) for intra-abdominal surgery: experimental models, techniques, and applicability to the clinical setting

OBJECTIVE: Evaluation of models, techniques, outcomes, pitfalls, and applicability to the clinical setting of natural orifice translumenal endoscopic surgery (NOTES) for performing intra-abdominal surgery through a systematic review of the literature. SUMMARY BACKGROUND DATA: NOTES has attracted much recent attention for its potential to allow traditional surgical procedures to be performed entirely through a natural orifice. Amid the excitement for potentially scar-free surgery and abolishment of dermal incision-related complications, the safety and efficacy of this new surgical technology must be evaluated. METHODS: Studies were identified by searching MEDLINE, EMBASE, CINAHL, Current Contents, Cochrane Library, Entrez PubMed, Clinical Trials Database, National Health Services Centre for Reviews and Dissemination (NHS CRD) databases, and National Research Register from 2000 to June 2007. Studies identified in September 2007 were included if they were performed in live human subjects. RESULTS: Of the 34 studies included for review, 30 were experimental studies conducted in animals, thus the evidence base was very limited. Although intra-abdominal access could be achieved reliably via oral, anal, or urethral orifices, the optimal access route and method could not be established. Viscerotomy closure could not be achieved reliably in all cases and risk of peritoneal infection has not been adequately minimized. Although the majority of interventions could be performed in animals using NOTES, a number of technical problems were encountered that need to be resolved. CONCLUSIONS: NOTES is still in early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-managed human studies need to be conducted to determine the safety and efficacy of NOTES in a clinical setting.     

Are We Improving the Long-Term Burden of Hodgkin's Lymphoma Patients with Modern Treatment?

The cure rate of patients who have Hodgkin's lymphoma (HL) amounts to 80% or more because of risk-adapted treatment using modern chemotherapy and radiotherapy schedules. In this article we describe important late effects after treatment of HL and how we expect the long-term burden of patients who have HL to change applying modern treatments. Because treatment always has side effects to some extent, awareness of possible late effects after treatment remains important for patients and treating physicians.