Regional Specialist Research Articles

Application of OCT-angiography to characterise the evolution of chorioretinal lesions in acute posterior multifocal placoid pigment epitheliopathy.

PurposeThe aim of this study was to determine a sequence of structural changes in acute posterior multifocal placoid pigment epitheliopathy (APMPPE) using optical coherence tomography-angiography (OCT-A) and comparing with other imaging modalities.Patients and methodsPatients with a new diagnosis of acute-onset APMPPE referred to a regional specialist centre from October 2015 to October 2016 were included. Multimodal imaging employed on all patients from diagnosis included the following: fundus fluorescein angiography, indocyanine green angiography, fundus autofluorescence, spectral domain-OCT (SD-OCT), and OCT-A. All non-invasive imaging processes were repeated during follow-up.ResultsTen eyes of five patients were included in the study, three males and two females, with a mean age of 26.2 years (range: 21-32) and a mean follow-up of 6.4 months (range: 2.6-13.3). All patients presented with bilateral disease and macular involving lesions. OCT-A imaging of the choriocapillaris was supportive of hypoperfusion at the site of APMPPE lesions during the acute phase of this condition with normalisation of choroidal vasculature during follow-up. Multimodal imaging consistently highlighted four sequential phases from presentation to resolution of active disease.ConclusionsMultimodal imaging in patients with APMPPE in acute and long-term follow-up demonstrates a reversible choroidal hypoperfusion supporting the primary inciting pathology as a choriocapillaritis. The evolution shows resolution of the ischaemia through a defined sequence that results in persistent changes at the level of the retinal pigment epithelium and outer retina. OCT-A was able to detect preclinical changes and chart resolution at the level of the choriocapillaris.

1133P - Non-elective admissions in cancer care - A review of acute oncology services (AOS) implementation in a north-west region of England

Background: Parallel to advances in cancer therapeutics in the clinics, high quality and patient-centred management of cancer or treatment-related complications during non-elective attendance especially to a non-specialist hospital is crucial in achieving excellent patient outcome. AOS was innovated in the UK to meet this need and has rapidly expanded in recent years. Here, we describe findings of an on-going audit of this expanding networked service within Greater Manchester and Cheshire East County consisting of 10 district general hospitals in collaboration with a regional specialist cancer centre (The Christie NHS Foundation Trust). Methods: Information related to any hospital episodes warranting AOS input was collated from all participating hospitals using standardised proforma and analysed. Results: Between Jan 2015 - Sep 2016, 7638 non-elective hospital attendances were recorded of which 58% occurred within working hours. Common cancer sites were lung 16%, breast 15%, lower GI 12%, urology 12%, upper GI and HPB 9%, haematology 7%, gynaecology 6%, cancer of unknown primary(CUP) 6%, and others 7%. Majority were related to cancer complication 40% (Type III), treatment - related 32% (Type II), new cancer diagnosis 10% (Type I) and others 17%. 94% of AOS involvement occured within 24hr of attendance. Level of intervention by AOS was considered major in 60% while 30% and <10% was intermediate or minor respectively. Median length of stay (LOS) is 4 days, 20% of episodes lasted <24hr (11.2% admission avoidance), 50% 1-7 days, and 30% 2-6 weeks (predominantly type I and III). Conclusions: This large multi-sites audit documented the service delivery pattern of a growing oncology subspecialty at the same time provided a glimpse into the healthcare implication of unplanned admission in the current era of advancing oncology lanscape. Excellent median LOS in this region compared to national average likely a reflection of pertinent AOS team involvement in a timely manner. AOS is now an integral component to the cancer care in the UK and its role in the non-elective setting serves to ensure excellent patient experience as well as providing far-reaching potential in healthcare efficiciency. Legal entity responsible for the study: not applicable Funding: None Disclosure: All authors have declared no conflicts of interest.

Tracing Ingombe Ilede's trade connections

McIntosh and Fagan (above) write that “For 45 years, Ingombe Ilede has been viewed as a key nexus linking the Copperbelt and Great Zimbabwe”. Some regional specialists have not believed this since the publication of Swan's (2007) important review of the sizes and shapes of prehistoric copper ingots found in modern Zimbabwe. Swan noted that both of the ingot moulds found at Great Zimbabwe (which have a clear stylistic connection to the Copperbelt) are of the earlier HIH style (ninth to fourteenth centuries AD; de Maret 1995; Nikis &amp; Livingstone Smith in press). But neither the later HXR-style copper ingots (fourteenth to seventeenth centuries)—some of which were excavated at Ingombe Ilede—nor the moulds to make them have been found on a Zimbabwe tradition site. The distribution of HXR ingots within the modern nation of Zimbabwe is almost exclusively in the north, within the former territory of the Mutapa state (Swan 2007: fig. 2). The clear implication is that the HXR ingot style—and thus the elite burials at Ingombe Ilede—post-date the breakup of the state ruled from Great Zimbabwe, which gave birth to the Mutapa (northern) and Torwa (southern) states. The new radiocarbon dates by McIntosh and Fagan provide welcome confirmation of this inference.

Exploring the digital technology preferences of teenagers and young adults (TYA) with cancer and survivors: a cross-sectional service evaluation questionnaire

PurposeDigital technology has the potential to support teenagers and young adults (TYAs) with cancer from the onset of their disease into survivorship. We aimed to establish (1) the current pattern of use of TYA digital technologies within our service-user population, and (2) their preferences regarding digital information and support within the service.MethodsA cross-sectional survey was administered as a paper and online self-completed questionnaire to TYAs aged 13–24 accessing outpatient, inpatient, and day care cancer services at a regional specialist centre over a 4-week period.ResultsOne hundred two TYAs completed the survey (55.7% male; 39.8% female; 83.3% paper; 16.7% online; mean age 18.5 years [SD = 3.51]). Of the TYAs, 41.6% rated the importance of digital communication as “essential” to their lives. Half (51.0%) kept in contact with other patients they had met during treatment, and 12.0% contacted patients they had not met in person. Respondents wanted to receive clinical information online (66.3%) and use online chat rooms (54.3%). Future online services desired included virtual online groups (54.3%), online counselling or psychological support (43.5%), and receiving (66.3%) and sharing (48.9%) clinical information online.ConclusionsYoung people with cancer are digital natives. A significant subgroup expressed a desire for digital resources from oncology services, though existing resources are also highly valued. Digital resources have potential to improve patient experience and engagement.Implications for cancer survivorsThere is considerable scope to develop digital resources with which TYAs can receive information and connect with both professionals and fellow patients, following diagnosis, through treatment and survivorship.

Sexuality's Learning Area 1967–2017 in Germany

SEXUALITY LEARNING AREA 1967–2017 accompanied by DGG Germany NGO as a critical accompaniment and helpful advocate for the implementation of the sexual pedagogic goals. 1977 we began to work for school sex-ed. 2017 Our professional job is help to update sex-ed. What we want: Courageous Engagement for better sex-education. According to the current heated discussions about sexual abuse, neglect of the media by uncontrolled internet and also social stressful homophobia, this requirement is more than necessary. We cure for a scientifically teacher training. Better sex-ed profession needs training: 1. Phase: education at University, 2. Phase: training at Referendariat and 3. Phase initiative of regular further education in professional life; Guidelines need to be revised according the area of the diversities; A regional specialist counselling to coordinate the necessary tasks is to be installed; Society at all have to get involved in the work against sexual abuse; At each school of every type a contact point for an information about sex-ed-asks and against abuse should be known by announcement; Standards for Sexuality Education as a framework.

Conjunctival provocation test in diagnosis of peanut allergy in children.

Peanut allergy frequently causes severe allergic reactions. Diagnosis includes detection of IgE to peanuts in serum or by skin prick tests. While children may have allergic sensitization without having clinical peanut allergy, oral peanut challenge is often required for accurate diagnosis. The conjunctival provocation test is used for diagnosis and evaluation of treatment effect in inhalant allergies, but it has not been evaluated as a tool for diagnosing peanut allergy. To investigate whether the conjunctival provocation tests may be feasible, accurate and safe in diagnosing clinically relevant peanut allergy in patients with suspected peanut allergy. This cross-sectional case-control study in children with clinical or laboratory suspected peanut allergy included 102 children recruited from the regional paediatric departments and specialist practices during one year from April 2011. A peanut-tolerant control group of 28 children of similar age was recruited locally. A double-blind placebo-controlled conjunctival provocation test with peanut extract was performed in all children, while oral peanut provocation was performed as double-blind placebo-controlled challenge in children with suspected peanut allergy and as an open challenge in the control children. All 81 children with a positive double-blind placebo-controlled oral food challenge (OFC) also had a positive conjunctival provocation test. None of the children with negative conjunctival provocation test had a positive OFC. The sensitivity and the specificity of the conjunctival provocation test were 0.96 and 0.83, respectively. No children had severe adverse reaction caused by the conjunctival provocation test, whereas 23 children suffered an anaphylactic reaction to the OFC. Conjunctival allergen challenge appears to be feasible, accurate and safe in diagnosing children referred for suspected peanut allergy.

Networking with regional specialists

Networking with regional specialists

Working time structure of pediatric nurses in hospital wards representing different referential levels

Working time is a non-renewable and important element in the management of an organization. The implementation of changes in the structure of working time may be facilitated by the insight into activities undertaken by employees during work. Such an approach plays an important role since the effective use of time improves the quality of care, prevents timewasting and optimizes the use of the full potential of employees, including nurses. The objective of the study was to determine the structure of working time of pediatric nurses in hospital wards of 2 referential levels. The study was conducted in 2 wards (2nd and 3rd levels of reference) in the Regional Specialist Children's Hospital in Olsztyn. The research method involved the measurement of working time, as well as continuous and snap-shot observation techniques. Standardized research instruments were used in the study; 8 continuous observations and 2333 snap-shot observations were carried out. In the structure of working time of pediatric nurses indirect nursing-related activities predominated (52.2%). Direct nursing made 28.7% of the working time. The nurses devoted the smallest amount of time to coordination and organization - 8%. The percentage of time associated with non-duty activities and breaks at work was 11.1%. In direct nursing activities associated with diagnosing (9%) and treatment (11.7%) prevailed. In indirect nursing activities pertaining to documentation of activities related to direct nursing made 24.6%. Pediatric nurses devote insufficient amount of time to direct nursing. Activities associated with documentation of activities related to direct nursing, preparation for direct nursing, as well as treatment and diagnosing predominate in the working time structure of nurses. Med Pr 2017;68(1):95-103.

Brazilian Specialists' Perspectives on the Patient Referral Process.

Since 1988, healthcare has been considered a citizen’s right in Brazil. The Sistema Único de Saúde (SUS), has undergone development and expansion to ensure universal health coverage for the Brazilian public, the world’s fifth largest population. The coordination of effective communications between primary care physicians, specialists and patients is a significant challenge, particularly the referral process. Our study objective was to understand the facilitators and barriers associated with referral process communications between primary care physicians and regional university hospital specialists in the State of Sao Paulo. This paper reports specialists’ perspectives of the referral process. This was a phenomenological study that employed a qualitative research method with three components (description, reduction and comprehension). We conducted focus groups with 54 hospital residents from different specialties (surgery, medicine, obstetrics/gynecology, pediatrics) from July to October 2014. The main results showed lack of an adequate referral-return referral process resulting in treatment delays and inappropriate use of emergency services. Communications were impeded by lack of integrated, computerized booking and standardized referral-return referral processes; underlying lack of trust in primary care physicians; and patients’ inappropriate use of healthcare services. Although computerized systems will facilitate communications between primary and specialty care, other strategies are needed to promote collaboration between services, and ensure appropriate utilization of them.

Sex-based differences in pain distribution in a cohort of patients with persistent post-traumatic neck pain

Objectives: To analyze a cohort of 745 consecutive patients referred to a regional specialist clinic for evaluation of post-traumatic neck pain during a five-year period.Methods: A cross-sectional observational study of baseline assessments performed by multi-professional rehabilitation teams according to a standardized checklist.Results: The cohort contained nearly twice as many females as males (64% versus 36%). The type of injury did not differ between sexes. Of the entire cohort, 38% were diagnosed with widespread pain, 50% with regional pain, and 12% with local pain. The pain distribution among the females was 43% widespread, 48% regional, and 9% local, and corresponding figures among males were 29%, 53%, and 18%. Longer time between trauma and assessment did not affect pain distribution among the men, but a tendency towards more widespread pain was observed among the women.Discussion: The importance of "female sex" as risk factor for the development of persistent pain after neck trauma needs to be discussed further. The high frequency of regional and widespread pain among patients with persistent neck pain after trauma calls for both multidisciplinary assessments and treatment strategies. The relationships between different pain distribution patterns, disability, activity, and psychological factors need to be studied further.Implications for rehabilitationPatients suffering from pain and disability after neck trauma constitute a significant proportion of patients with persistent pain.The importance of the risk factor “female sex" should be further discussed in the development of persistent pain after neck trauma.The high frequency of regional and widespread pain among patients with persistent neck pain after trauma calls both for multidisciplinary assessments and treatment strategies.The relationships between different pain distribution patterns, disability, activity, and psychological factors need to be studied further.

Focused Cardiac Ultrasound for the Regional Anesthesiologist and Pain Specialist.

This article in our point-of-care ultrasound (PoCUS) series discusses the benefits of focused cardiac ultrasound (FoCUS) for the regional anesthesiologist and pain specialist. Focused cardiac US is an important tool for all anesthesiologists assessing patients with critical conditions such as shock and cardiac arrest. However, given that ultrasound-guided regional anesthesia is emerging as the new standard of care, there is an expanding role for ultrasound in the perioperative setting for regional anesthesiologists to help improve patient assessment and management. In addition to providing valuable insight into cardiac physiology (preload, afterload, and myocardial contractility), FoCUS can also be used either to assess patients at risk of complications related to regional anesthetic technique or to improve management of patients undergoing regional anesthesia care. Preoperatively, FoCUS can be used to assess patients for significant valvular disease, such as severe aortic stenosis or derangements in volume status before induction of neuraxial anesthesia. Intraoperatively, FoCUS can help differentiate among complications related to regional anesthesia, including high spinal or local anesthetic toxicity resulting in hemodynamic instability or cardiac arrest. Postoperatively, FoCUS can help diagnose and manage common yet life-threatening complications such as pulmonary embolism or derangements in volume status. In this article, we introduce to the regional anesthesiologist interested in learning FoCUS the basic views (subcostal 4-chamber, subcostal inferior vena cava, parasternal short axis, parasternal long axis, and apical 4-chamber), as well as the relevant sonoanatomy. We will also use the I-AIM (Indication, Acquisition, Interpretation, and Medical decision making) framework to describe the clinical circumstances where FoCUS can help identify and manage obvious pathology relevant to the regional anesthesiologist and pain specialist, specifically severe aortic stenosis, hypovolemia, local anesthetic systemic toxicity, and massive pulmonary embolism.

By Air or by Sea?

An OEM motor manufacturer is deciding where to locate a new manufacturing line for one of its customers. The options are China, Eastern Europe, Mexico and the U.S. Information is given to begin an initial location analysis. The decision focus of the case concerns transferring the line (after a 6-month to 2 year start-up phase) by either airfreight or sea freight. Students must calculate the freight cost, the inventory build-up and its associated cost and the overtime labor necessary to transfer the line. Excerpt UVA-OM-1314 By Air or By Sea? Like clockwork, a passing late-afternoon thunderstorm pounded the roof of Montalto's Poplar facility, preventing the first shift from reaching the parking lot and, ultimately, their families and homes. With only two weeks remaining until he needed to submit his summer-internship report, Bill Small was in his office finalizing the critical pieces of the data analysis for his final manufacturing-strategy recommendation. Small's main project required him to assess the merits of producing a new motor program for Cosway, a Western European global industrial OEM (original equipment manufacturer), at one or more Poplar manufacturing facilities in China, Eastern Europe, Mexico, and the southeastern United States, where he was spending the summer. Management had already determined that the manufacturing line would be designed and started in the U.S. facility in order to leverage its engineering talent to establish an efficient process and a high-quality product as quickly as possible. Once stabilized, the production location would be optimized and most likely relocated to a low-cost region (LCR) or, possibly, multiple LCR sites. Montalto relied on data analysis to drive most decisions, particularly major ones, and the manufacturing recommendation for the Cosway program was no exception. The assessment involved a rigorous analysis of the cost and investment at each factory stemming from the new program's required labor, overhead, inventory (both upstream from suppliers and downstream to customers), equipment and tooling, supply-chain and customer-delivery logistics, and import taxes. Throughout the summer, Small had met with associates from various functional groups to ensure that he was capturing all the financial implications of establishing production at the various sites. The latest component, however, had him puzzled. Should his analysis assume that the manufacturing line would be relocated by airfreight or by sea freight? Montalto's regional logistics specialist assured him that airfreight was not worth wasting time on, especially for 75,000 kg of equipment and tooling. Could the economics be more complex than comparing the obviously low-cost ocean transport with a high-priced air shipment? If so, what aspects was he missing and how should he quantify them? Montalto's History . . .

Lung Ultrasound for the Regional Anesthesiologist and Acute Pain Specialist

In this article, we discuss the emerging role of lung point-of-care ultrasonography for regional anesthesiologists and pain management specialists. Lung ultrasonography is a well-established clinical tool that is used on a routine basis in emergency rooms and critical care units internationally to evaluate patients with respiratory distress; however, its benefits to the regional anesthesiologist and pain specialist are not as well known and are practiced less frequently. This review article covers the clinical evidence in support of lung point-of-care ultrasonography as a rapid and superior tool to traditional imaging modalities such as chest radiography and fluoroscopy. As anesthesiologists routinely perform nerve blocks that put patients at potential risk of complications such as pneumothorax or diaphragmatic paresis, it is important to understand how to use lung ultrasonography to evaluate for these conditions, as well as to differentiate between other potential causes of respiratory distress, such as interstitial syndrome and pleural effusions. This article describes the normal and pathological findings that can be used to quickly and confidently evaluate a patient for these conditions.

Changes in the Occurrence of Abdominal Complaints in Surgically Treated Patients due to Cholecystolithiasis

Introduction: The post cholecystectomy syndrome is defined as the maintenance or the occurrence of digestive tract symptoms after cholecystectomy due to extra hepatic biliary duct disorders. The introduction of a laparoscopic approach has revolutionized the procedure in the treatment of cholecystolithiasis. Laparoscopic cholecystectomy is less invasive for patients as compared to the classic surgical procedure. Aim: Determination of the frequency and the intensity of abdominal symptoms occurring after laparoscopic surgery and classic cholecystectomy related to the post cholecystectomy syndrome. Material and methods: The study group consisted of 105 patients of the Clinical Department of Surgery of the Regional Specialist Hospital in Tychy, Poland. Patients were divided into two groups: patients who underwent laparoscopic (n=83) or classic (n=22) cholecystectomy. The assessments were performed preoperatively, 1 month and 6 months postoperatively, using the “Gastric Symptom Questionnaire”. Results: The results were compared using statistical methods. Results: The symptoms of the syndrome were observed in 32 (30.5%) patients from the study group. Symptoms related to the post cholecystectomy syndrome included abdominal pain, flatulence, nausea, vomiting, movement difficulties, loss of appetite or diarrhea. These symptoms occurred more frequently after classic cholecystectomy as compared to the laparoscopic approach, 1 month and 6 months after cholecystectomy. Conclusions: The post cholecystectomy syndrome may occur in 1/3 of patients after cholecystectomy. The symptoms occur less frequently in laparoscopically treated patients. In a large number of patients the syndrome may be related to the treatment method.

Injury to Urinary Organs during Natural Deliveries, Caesarean Sections and Peripartum Hysterectomies

Objective: The purpose of the study is to analyze the causes and types of injuries to the urinary organs related to past deliveries. Material and methods: There were 34,866 deliveries at the Obstetric-Gynecological Ward, Regional Specialist Hospital in Radom between 1998 and 2016. Medical records of 11 patients with injuries to the urinary organs related to past delivery were retrospectively studied. Results: The following injuries were found: - Ligation of the left ureter: 1 case, - Injury to the urinary bladder: 10 cases - Vesicovaginal fistula (VVF): 1 case (following injury to the urinary bladder at hysterectomy in the postpartum¬ period). In 9 patients, the detected injuries were managed during hospitalization for labor, in 3 cases the injuries were diagnosed during the postpartum period; one patient was treated in the General Surgery Ward on 5th day following natural delivery. Another patient suffered injury to the urinary bladder during hysterectomy in the postpartum period. It was sutured up. VVF was diagnosed on 10th day after the surgery, and was successfully managed at the Urology Department. The injuries to the urinary organs were most frequently related to hysterectomies in the peripartum and postpartum period (54.5%) Conclusions: 1. Both peripartum and postpartum hysterectomy pose a high risk of urological complications, 15.8% in the group of discussed patients. 2. Patients at high risk of complications necessitating peripartum hysterectomy should be duly transferred to reference wards to provide multi-specialist medical care.

It’s more than money: policy options to secure medical specialist workforce for regional centres

Objectives Regional centres and their rural hinterlands support significant populations of non-metropolitan Australians. Despite their importance in the settlement hierarchy and the key medical services provided from these centres, little research has focused on their issues of workforce supply and long-term service requirements. In addition, they are a critical component of the recent growth of 'regional' hub-and-spoke specialist models of service delivery. Methods The present study interviewed 62 resident specialists in four regional centres, seeking to explore recruitment and retention factors important to their location decision making. The findings were used to develop a framework of possible evidence-informed policies. Results This article identifies key professional, social and locational factors, several of which are modifiable and amenable to policy redesign, including work variety, workplace culture, sense of community and spousal employment; these factors that can be targeted through initiatives in selection, training and incentives. Conclusions Commonwealth, state and local governments in collaboration with communities and specialist colleges can work synergistically, with a multiplicity of interdigitating strategies, to ensure a positive approach to the maintenance of a critical mass of long-term rural specialists. What is known about the topic? Rural origin increases likelihood of long-term retention to rural locations, with rural clinical school training associated with increased rural intent. Recruitment and retention policy has been directed at general practitioners in rural communities, with little focus on regional centres or medical specialists. What does this study add? Rural origin is associated with regional centre recruitment. Professional, social and locational factors are all moderately important in both recruitment and retention. Specialist medical training for regional centres ideally requires both generalist and subspecialist skills sets. Workforce policy needs to address modifiable factors with four groups, namely commonwealth and state governments, specialist medical colleges and local communities, all needing to align their activities for achievement of long-term medical workforce outcomes. What are the implications for practitioners? Modifiable factors affecting recruitment and retention must be addressed to support specialist models of care in regional centres. Modifiable factors relate to maintenance of a critical mass of practitioners, training a fit-for-purpose workforce and coordinated effort between stakeholders. Although remuneration is important, the decision to stay relates primarily to non-financial factors.

ЕКСПЕРТНА ОЦІНКА ЛІКАРСЬКИХ ЗАСОБІВ ГРУПИ S01E «ПРОТИГЛАУКОМНІ ПРЕПАРАТИ ТА МІОТИКИ»

Проведено анкетування 280 лікарів-спеціалістів (офтальмологів та лікарів загальної практики - сімейної медицини) з метою експертної оцінки препаратів групи S01E «Протиглаукомні препарати та міотики». Розраховано сумарні та середні оцінкові характеристики кожного з досліджуваних препаратів за показниками ефективності, наявності побічної дії, фактичної вірогідності призначення препарату на сьогодні, перспективності застосування препарату, наявності в аптечній мережі. Згідно з отриманими даними здійснено ранжування протиглаукомних препаратів на групи високої, середньої та низької доцільності включення у формулярні та страхові переліки

Needs forecast and fund allocation of medical specialty positions in Emilia-Romagna (Italy) by system dynamics and integer programming

Each year Emilia-Romagna health managers have to negotiate the number of medical specialization grants to be financed by the National government and define the number of additional grants to be funded by the regional budget. The final goal of this study is to provide a Decision Support System for grant allocation to medical specializations within Emilia-Romagna over a 20-year planning horizon. We have developed a System Dynamics (SD) model that represents regional medical specialist human resources and forecasts population needs over the planning horizon. The SD model provides a requirement indicator for each medical specialization. On the basis of these indicators, an Integer Programming model computes optimal assignments of medical specialization grants. We then define three demand scenarios and show how regional and national funded grants can be managed in order to reduce future gaps by comparing our results with current policies.

Needs Assessment of Coastal Land Managers for Drought Onset Indicators in the Southeastern United States

ABSTRACT Nolan, C.B.; Tufford, D.L., and Chalcraft, D.R., 2016. Needs assessment of coastal land managers for drought onset indicators in the southeastern United States. The ability to detect the onset of drought is important to coastal resource managers because the knowledge enhances preparedness and mitigation. Existing drought indicators, however, were generally designed with agricultural, hydrological, meteorological, socio-economic, or wildfire management in mind and generally quantify deficits in freshwater availability. It is unclear whether coastal resource managers find existing indicators adequate for managing coastal resources and, if not, what information would be most useful to manage resources under threat of drought. A needs assessment was conducted with 30 land managers and natural resource specialists of the coastal Carolinas region to enhance the understanding of drought indicators and to comprehend the indicators' utility for managing coastal natural resources. Eighty-three percent of p...

How to manage a minor burn.

Rationale and key points This article outlines the technique for dressing a minor burn. The nurse should be aware of national burn care referral guidance, and have the knowledge and skills to establish the severity and extent of a burn. The nurse should also be able to determine whether referral to a regional specialist centre is required. » The extent and severity of a burn determines its ongoing management. » The burn wound requires regular evaluation, since its appearance and management needs can change over time. » Competence in general wound care is essential for nurses undertaking this procedure. Reflective activity 'How to' articles can help update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: » The classification of burn depth and guidelines for specialist referral. » How you think this article will change your practice. Subscribers can update their reflective accounts at rcni.com/portfolio.