Does a balance deficit persist in Australian football players with previous lower limb ligament injury?

A history of lower limb ligament injury is a commonly-cited risk factor for another similar injury. During the acute phase of injury, there is a balancing skill deficit in the injured limb. It has been unclear as to whether this deficit persists in the medium-to-long term for previously injured Australian footballers, contributing to the risk of re-injury. This study compared the balance ability of footballers with and without previous lower limb ligament injury and, for previously injured players, the balance ability of the previously injured limb to the opposite uninjured limb. A total of 216 players from 6 teams from the Australian Football League were tested. The balance task comprised stepping on to a foam mat on top of a force plate and maintaining one-legged balance. The subjects were divided into 4 groups based on their injury history: all ankle injuries to only one limb, recent ankle injuries to only one limb (within the last 12 months), knee ligament injury only to one limb, and no previous ankle or knee ligament injury. Statistical analysis revealed that there was no significant difference between the balance scores of any of the previously injured players and those with no previous lower limb ligament injury. There was no significant difference between the balance score of the previously injured limb with the opposite uninjured limb. It appears that a balance deficit does not persist in Australian Football players with previous lower limb ligament injury.

Energy system contribution to 100-m and 200-m track running events

While sprint track running events, lasting 10-25 secs, are characterised by an anaerobic metabolic dominance, no actual track running data exist which have quantified the relative energy system contributions. Using previous methods employed by our laboratory, including 'in race' measures of VO2, accumulated oxygen deficit (AOD), blood lactate concentration and estimated phosphocreatine degradation (La/PCr), the aerobic-anaerobic energy system contributions to 100-m and 200-m events were calculated. For the 100-m event, results indicated a relative aerobic-anaerobic energy system contribution (based on AOD measures) of 21%-79% and 25-75% for males and females respectively (9%-91% and 11%-89% based on La/PCr measures; p<0.05 for both genders for 100-m from AOD estimates). For the 200-m, a 28%-72% and 33%-67% contribution for male and female athletes was estimated (21%-79% and 22%-78% based on La/PCr measures; NS from AOD estimates). A range of energy system contribution estimates for events of these durations have previously been proposed using a variety of techniques. The data from the current study also show different results depending on the measurement technique utilised. While AOD measures are often used to estimate anaerobic energy contribution, at such high exercise intensities (and brief exercise durations) as used in the present study, AOD measures showed larger aerobic energy estimates than expected.

Widespread increased expression of the DNA repair enzyme PARP in brain in ALS

Expression of the DNA repair enzyme poly(ADP-ribose) polymerase (PARP) is a known response to oxidative damage of DNA. In ALS brain, PARP expression by western analyses was increased in the motor cortex, parietal cortex, and cerebellum. PARP immunostaining in the motor cortex was increased in ALS neurons and subcortical glia and macrophages. Importantly, there was widespread increased PARP expression in neurons in the parietal cortex and cerebellum, regions that are typically clinically unaffected in ALS, suggesting widespread oxidative stress.

A threshold analysis of the cost-effectiveness of artemisinin-based combination therapies in sub-saharan Africa

Artemisinin-based combination therapies (ACTs) are generally regarded as vital in addressing the growing problem posed by the development of antimalarial resistance across sub-Saharan Africa. However, the costs of the new ACTs are likely to be significantly higher than current therapies. Therefore, it is important to examine formally the cost-effectiveness of the more effective yet more expensive ACTs before advocating a switch in policy. Importantly, any such economic evaluation must consider the temporal dynamics of drug resistance, and not just focus on the static question of whether switching today would be cost-effective at current levels of resistance, particularly since the development of new antimalarials in the future is so uncertain. However, predicting the future changes in drug resistance is a major difficulty in accurately quantifying the relative costs and health outcomes associated with different drug therapies over time. Here, we use a simple decision tree model to estimate the incremental cost-effectiveness of using ACTs, compared with persisting with current therapies, over 5-, 10-, and 15-year periods. We describe the dynamics of drug resistance using a general logistic growth function, in which the starting frequency of resistance and maximum growth may be altered. However, rather than make assumptions about the absolute rate at which resistance to ACTs will progress, we allow the ratio of the growth rate of resistance to ACTs relative to that of current therapies to vary. Defining the growth rate of ACT resistance in this manner allows us to calculate the threshold ratio at which ACTs would no longer appear cost-effective, for any starting conditions of resistance to current therapies and ACTs, and over any time period. The influence of uncertainty in other decision tree parameters on the threshold ratio values is also quantified, using Monte Carlo simulation techniques. This analysis shows that ACTs are more than 95% likely to be cost-effective under most conditions, other than very low levels of initial resistance to sulfadoxine/pyrimethamine and a five-year time frame. These predictions are conservative in that 95% certainty is a stringent decision rule favoring the rejection of new policies. The importance of other variables not included in the analysis for the robustness of the findings are discussed (e.g., consideration of the entire population at risk for malaria, the affordability of ACTs in specific settings, and the growth of resistance modeled according to population genetic parameters).

Retail supply of malaria-related drugs in rural Tanzania: risks and opportunities

OBJECTIVES

To characterize availability of fever and malaria medicines within the retail sector in rural Tanzania, assess the likely public health implications, and identify opportunities for policy interventions to increase the coverage of effective treatment.

METHODS

A census of retailers selling drugs was undertaken in the areas under demographic surveillance in four Tanzanian districts, using a structured questionnaire.

RESULTS

Drugs were stocked by two types of retailer: a large number of general retailers (n = 675) and a relatively small number of drug shops (n = 43). Almost all outlets stocked antipyretics/painkillers. One-third of general retailers stocking drugs had antimalarials, usually chloroquine alone. Almost all drug shops stocked antimalarials (98%): nearly all had chloroquine, 42% stocked quinine, 37% sulphadoxine-pyrimethamine and 30% amodiaquine. A large number of antimalarial brands were available. Population ratios indicate the relative accessibility of retail drug providers compared with health facilities. Drug shop staff generally travelled long distances to buy from drugs wholesalers or pharmacies. General retailers bought mainly from local general wholesalers, with a few general wholesalers accounting for a high proportion of all sources cited.

CONCLUSIONS

Drugs were widely available from a large number of retail outlets. Potential negative implications include provision of ineffective drugs, confusion over brand names, uncontrolled use of antimalarials, and the availability of components of potential combination therapy regimens as monotherapies. On the other hand, this active and highly accessible retail market provides opportunities for improving the coverage of effective antimalarial treatment. Interventions targeted at all drug retailers are likely to be costly to deliver and difficult to sustain, but two promising points for targeted intervention are drug shops and selected general wholesalers. Retail quality may also be improved through consumer education, and modification of the chemical quality, packaging and price of products entering the retail distribution chain.

Test-retest reliability of the aerobic power index component of the tri-level fitness profile in a sedentary population

Use of maximal aerobic power (VO2(max)) testing, which requires subjects to exercise to physiological limits, may deter eligible candidates from volunteering for trials and may also be contraindicated in patients suffering from various medical illnesses. An alternative to maximal testing is submaximal testing. The Aerobic Power Index, which represents the aerobic component of the Tri-level Fitness Profile, is a submaximal test that has been shown to be reliable in trained athletes. The purpose of this study was to establish reliability of the Aerobic Power Index, as well as associated variables of VO2 (ml x kg(-1) x min(-1) and rate of perceived exertion (RPE), in a group of sedentary subjects. Results for the 20 subjects who participated in a test-retest trial indicated high reliability (ICC r = 0.98, %TEM 3.87 W x kg(-1); SEM 0.04 W x kg(-1) for the main measurement outcome of Watts per kilogram (W x kg(-1)). Oxygen uptake (ml x kg(-1)min(-1)) also demonstrated high reliability (ICC r = 0.92; %TEM 4.63 ml x kg(-1) x min(-1); SEM 0.58 ml x kg(-1) min (-1), as did RPE (ICC r = 0.97,%TEM 7.78; SEM 0.63). Limits of agreement were -0.02+/-0.16 W x kg(-1). -0.41+/-2.31 ml x kg(-1) x min(-1) for VO2 and -0.05 < or = 2.10 for RPE. These results indicate that the Aerobic Power Index is a reliable submaximal exercise test for use in sedentary subjects.

The effect of glucosamine supplementation on people experiencing regular knee pain

OBJECTIVE

The purpose of this study was to examine the effects of oral glucosamine supplementation on the functional ability and degree of pain felt by individuals who had regular knee pain, most likely due to previous articular cartilage damage, and possibly osteoarthritis.

METHODS

Subjects were randomly supplemented with either glucosamine (G) (n=24) or placebo (P) (lactose) (n=22) for 12 weeks at a dose of 2,000 mg per day. Over this period, four testing sessions were conducted, with changes in knee pain and function assessed by clinical and functional tests, (joint line palpation, a 3 metre "duck walk" and a repeated, walking stair climb), two questionnaires (the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Knee Pain Scale (KPS)) and participant subjective evaluations.

RESULTS

The clinical and functional test scores improved with time (main effects: p<0.05, p<0.01) but there were no significant differences between the two groups. The questionnaire results also recorded a significant main effect for time (p<0.05), but the glucosamine group was found to have significantly better KOOS quality of life scores at week eight and 12 (p<0.05), and lower KPS scores (p<0.05) at week eight than the placebo group. On self report evaluations of changes across the 12 week supplementation period, 88% (n=21) of the glucosamine group reported some degree of improvement in their knee pain versus only 17% (n=3) in the placebo group.

CONCLUSIONS

These results suggest that glucosamine supplementation can provide some degree of pain relief and improved function in persons who experience regular knee pain, which may be caused by prior cartilage injury and/or osteoarthritis. The trends in the results also suggest that, at a dosage of 2,000 mg per day, the majority of improvements are present after eight weeks.

Grandmothers raising grandchildren: family structure and well-being in culturally diverse families

PURPOSE

This study addressed well-being of grandmothers raising grandchildren in coparenting and custodial households in a sample of African American, Latino, and White grandmothers.

DESIGN AND METHODS

A sample of 1,058 grandmothers was recruited through the schools and media. Grandmothers raising or helping to raise school-aged grandchildren in Los Angeles were interviewed, and analyses were conducted within ethnic groups.

RESULTS

African American grandmothers experienced equal well-being in coparenting and custodial families; however, if the stresses related to the parents' problems were removed by statistical control, they favored the custodial arrangement. Latino grandmothers had greater well-being in coparenting families, reflecting a tradition of intergenerational living. White custodial grandmothers experienced somewhat higher levels of affect (positive and negative) but showed no difference in other types of well-being.

IMPLICATIONS

The cultural lens through which grandparenthood is viewed has a marked impact on the adaptation to custodial or coparenting family structures.

A new technique for the analysis of background and evoked EEG activity: time and amplitude distributions of the EEG deflections

OBJECTIVES

The EEG during background activity and that evoked in response to sensory stimuli (evoked potential, EP) has traditionally been studied by averaging and by frequency analysis. These obscure trial to trial variability. A new analysis technique is presented here which leads to single trial analysis and to insight into the mechanisms of EP generation.

METHODS

This technique is based on the identification of the EEG deflections recorded on the scalp before (background) and immediately after visual stimuli. A statistical description of the time and amplitude distributions of these deflections is defined and leads to the differentiation between background and evoked activity.

RESULTS

In response to stimuli, the time and amplitude of ongoing deflections (background) are re-organized (time locking) and amplified, generating the EP. Not all stimulus trials are accompanied by an appropriate response. Separate analysis of those single trials that do contain a response deflection provides information on the exact timing, variability, amplitude, etc., of those EEG deflections which contribute to the EP.

CONCLUSIONS

New EEG analysis techniques are described which provide single trial EP analysis and insight into mechanisms of EP generation.

Pre-exercise oral creatine ingestion does not improve prolonged intermittent sprint exercise in humans

BACKGROUND

This investigation determined whether pre-exercise oral Cr ingestion could enhance prolonged intermittent sprint exercise performance.

METHODS

EXPERIMENTAL DESIGN

a randomised, double-blind crossover design was employed.

SETTING

testing was performed at the Western Australian Institute of Sport and participants were monitored and treated by both scientific and medical personnel.

PARTICIPANTS

eight active, but not well-trained males with a background in multiple-sprint based sports acted as subjects for this investigation.

INTERVENTIONS

subjects ingested either 15 g Cr.H2O or placebo 120 min and 60 min prior to the start of an 80-min maximal sprint cycling task (10 sets of multiple 6-sec sprints with varying active recoveries). Subjects were retested 14 days later, being required to ingest the alternate supplement and repeat the exercise test.

MEASURES

performance variables (work done and peak power) were obtained throughout the exercise challenge. Muscle biopsies (vastus lateralis) were raised to a peak of 2348+/-223 micromol x l(-1) prior to the commencement of exercise after Cr ingestion. There were no significant changes in any cycling performance parameters following Cr ingestion, although blood La- was significantly lower (p<0.05) than placebo at all time points during were taken preexercise as well as immediately and 3 min post-exercise in order to determine concentrations of ATP, PCr, Cr, La- and glycogen. Venous blood was drawn prior to and on four occasions during the exercise test, and analysed for Cr, NH3+, La- and pH.

RESULTS

Serum Cr concentrations exercise, and plasma NH3+ accumulation was also significantly reduced (p<0.05) in the Cr condition, but only in the second half of the 80-min exercise test. Muscle ATP and TCr levels as well as postexercise PCr replenishment were unaffected following Cr administration.

CONCLUSIONS

The data suggest that although the pre-exercise ingestion of a large Cr dose was shown to have some impact on blood borne metabolites, it does not improve maximal prolonged intermittent sprint exercise performance, possibly due to an insufficient time allowed for uptake of serum Cr by skeletal muscle to occur. Therefore, this form of loading does not provide an alternative method of Cr supplementation to the traditional five-day supplementation regimes established by previous research.

Effect of Vitamin C and E supplementation on biochemical and ultrastructural indices of muscle damage after a 21 km run

This study investigated whether 4 weeks of daily supplementation with 500 or 1000 mg of Vitamin C and 500 or 1000 IU of Vitamin E could modify biochemical and ultrastructural indices of muscle damage following a 21 km run. Fifteen experienced male distance runners were divided into two groups (vitamin or placebo) and received supplementation for four weeks before completing the first 21 km run in as fast a time as possible. A four-week "washout" period followed before the subjects crossed over and received the alternate supplement for the next four weeks. They then completed a second 21 km run. Before, immediately after and 24 h after each run venous blood samples were taken and analysed for serum creatine kinase, myoglobin, malondialdehyde and vitamin C and E (before-samples only) concentrations. A subgroup of six subjects also had muscle biopsy (gastrocnemius) samples taken 24 h before and 24 h after each 21 km run, which were later analysed by electron microscopy. The two dosages of supplementation produced similar results, so a single vitamin group was formed for further analysis of results. Significant increases (p < 0.05) in creatine kinase and myoglobin, but not in malondialdehyde, were found post-run in both groups. However, no significant differences were found between the vitamin and placebo groups for creatine kinase, myoglobin and malondialdehyde concentrations recorded after the 21 km runs. A qualitative ultrastructural examination of pre-run muscle samples revealed changes consistent with endurance training, but little further change was seen after the 21 km run in either the vitamin or placebo groups. It was concluded that vitamin C and E supplementation (500 or 1000 mg or IU per day) for four weeks does not reduce either biochemical or ultrastructural indices of muscle damage in experienced runners after a half marathon.

Exercise training, vascular function, and functional capacity in middle-aged subjects

PURPOSE

The aim of this study was to investigate the effect of 8 wk of exercise training on functional capacity, muscular strength, body composition, and vascular function in sedentary but healthy subjects by using a randomized, crossover protocol.

METHODS

After familiarization sessions, 19 subjects aged 47 +/- 2 yr (mean +/- SE) undertook a randomized, crossover design study of the effect of 8 wk of supervised circuit training consisting of combined aerobic and resistance exercise. Peak oxygen uptake (.VO(2peak)), sum of 7 maximal voluntary contractions and the sum of 8 skinfolds and 5 segment girths were determined at entry, crossover, and 16 wk. Endothelium-dependent and -independent vascular function were determined by forearm strain-gauge plethysmography and intrabrachial infusions of acetylcholine (ACh) and sodium nitroprusside (SNP) in 16 subjects.

RESULTS

Training did not alter ACh or SNP responses. .VO(2peak), (28.6 +/- 1.1 to 32.6 +/- 1.3 mL.kg(-1).min(-1), P < 0.001), exercise test duration (17.4 +/- 1.1 to 22.1 +/- 1.2 min, P < 0.001), and muscular strength (465 +/- 27 to 535 +/- 27 kg, P < 0.001) significantly increased after the exercise program, whereas skinfolds decreased (144 +/- 10 vs 134 +/- 9 mm, P < 0.001).

CONCLUSION

These results suggest that moderate intensity circuit training designed to minimize the involvement of the arms improves functional capacity, body composition, and strength in healthy, middle-aged subjects without significantly influencing upper limb vascular function. This finding contrasts with previous studies in subjects with type 2 diabetes and heart failure that employed an identical training program.

Muscle glycogen supercompensation: absence of a gender-related difference

Recently it has been reported that women do not have the capacity to accumulate supranormal levels of muscle glycogen when subjected to a carbohydrate (CHO) loading regimen [Tarnopolsky et al. (1995) J Appl Physiol 78:1360-1368]. Since, in this study, CHO intake relative to body mass in the female subjects was much lower than that in males, our primary aim was to re-examine this issue using subjects fed comparable amounts of CHO. Endurance-trained female and male subjects ingested 12 g CHO x kg(-1) lean body mass day(-1) in conjunction with the cessation of their daily physical training. A 3-day exposure to this diet resulted in a marked rise in muscle glycogen levels from [mean (SD)] 108 (15) mmol x kg(-1) wet weight to 193 (14) mmol x kg(-1) wet weight and 111 (16) m mol x kg(-1) wet weight to 202 (20) mmol x kg(-1) wet weight in the female participants during the post-menstrual and pre-menstrual phases of their menstrual cycle, respectively, and from 109 (27) mmol x kg(-1) wet weight to 183 (25) mmol x kg(-1) wet weight in males. We conclude that (1) female athletes have the capacity to accumulate supranormal levels of muscle glycogen, and (2) when exercise-trained males and females are fed comparable amounts of CHO relative to lean body mass, there is no gender-related difference in their ability to accumulate supranormal levels of muscle glycogen.

The effect of combined aerobic and resistance exercise training on vascular function in type 2 diabetes

OBJECTIVES

The purpose of this study was to examine whether exercise training stimulates a generalized improvement in vascular function in patients with type 2 diabetes mellitus.

BACKGROUND

Exercise is often recommended for patients with type 2 diabetes to improve physical conditioning and glycemic control. This study examined the effect of eight weeks of exercise training on conduit and resistance vessel function in patients with type 2 diabetes, using a randomized crossover design.

METHODS

Both resistance vessel endothelium-dependent and -independent functions were determined by forearm plethysmography and intrabrachial infusions of acetylcholine (ACh) and sodium nitroprusside (SNP), respectively, in 16 patients with type 2 diabetes. Conduit vessel endothelial function was assessed in 15 of these patients using high-resolution ultrasound and flow-mediated dilation of the brachial artery; glyceryl trinitrate (GTN) was used as an endothelium-independent dilator.

RESULTS

Flow-mediated dilation increased from 1.7 +/- 0.5% to 5.0 +/- 0.4% following training (p < 0.001). The forearm blood flow ratio to ACh was significantly improved (analysis of variance, p < 0.05). Responses to SNP and GTN were unchanged. Endothelium-dependent vasodilation was enhanced in both conduit and resistance vessels.

CONCLUSIONS

If endothelial dysfunction is an integral component of the pathogenesis of vascular disease, as currently believed, this study supports the value of an exercise program in the management of type 2 diabetes.

A review of resistance exercise and posture realignment

Exercise has been promoted in an attempt to correct postural deviations, such as excessive lumbar lordosis, scoliosis, kyphosis, and abducted scapulae. One of the assumed causes of these conditions is a weak and lengthened agonist muscle group combined with a strong and tight antagonist muscle group. Strengthening and stretching exercises have been prescribed accordingly. It is implied that strengthening exercises will encourage adaptive shortening of the muscle-tendon length, reposition skeletal segments, and produce static posture realignment. A review of the literature has found a lack of reliable, valid data collected in controlled settings to support the contention that exercise will correct existing postural deviations. Likewise, objective data to indicate that exercise will lead to postural deviations are lacking. It is likely that exercise programs are of insufficient duration and frequency to induce adaptive changes in muscle-tendon length. Additionally, any adaptations from restricted range-of-movement exercise would likely be offset by daily living activities that frequently require the body segments to go through full ranges of motion.

Manifestations of tick-borne illness. Incidence and variety are increasing worldwide

The incidence and variety of diseases associated with tick bites have continued to grow worldwide. Lyme disease, the most common tick-borne disease in the United States, has received extensive media coverage because of its protean manifestations and propensity for causing chronic disease. Our ability to prevent, identify, and effectively treat Lyme disease and other tick-borne diseases has significantly improved in the last decade. Tick-borne illnesses should be one of the differential diagnostic considerations in patients with consistent clinical findings and exposure history. In addition, the prudent use of laboratory testing ensures an accurate diagnosis while avoiding the cost and risk of inappropriate diagnostic tests and antibiotic therapy.

Brief intense exercise followed by passive recovery modifies the pattern of fuel use in humans during subsequent sustained intermittent exercise

The role of work period duration as the principal factor influencing carbohydrate metabolism during intermittent exercise has been investigated. Fuel oxidation rates and muscle glycogen and free carnitine content were compared between two protocols of sustained intermittent intense exercise with identical treadmill speed and total work duration. In the first experiment subjects (n=6) completed 40 min of intermittent treadmill running involving a work : recovery cycle of 6 : 9 s or 24 : 36 s on separate days. With 24 : 36 s exercise a higher rate of carbohydrate oxidation approached significance (P=0.057), whilst fat oxidation rate was lower (P < or = 0.01) and plasma lactate concentration higher (P < or = 0.01). Muscle glycogen was lower post-exercise with 24 : 36 s (P < or = 0.05). Muscle free carnitine decreased (P < or = 0.05), but there was no difference between protocols. In the second experiment a separate group of subjects (n=5) repeated the intermittent exercise protocols with the addition of a 10-min bout of intense exercise, followed by 43 +/- 5 min passive recovery, prior to sustained (40 min) intermittent exercise. For this experiment the difference in fuel use observed previously between 6 : 9 s and 24 : 36 s was abolished. Carbohydrate and fat oxidation, plasma lactate and muscle glycogen levels were similar in 6 : 9 s and 24 : 36 s. When compared with the first experiment, this result was because of reduced carbohydrate oxidation in 24 : 36 s (P < or = 0.05). There was no difference, and no change, in muscle free carnitine between protocols. A 10-min bout of intense exercise, followed by 43 +/- 5 min of passive recovery, substantially modifies fuel use during subsequent intermittent intense exercise.

Effect of creatine loading on long-term sprint exercise performance and metabolism

PURPOSE

This study examined whether creatine (Cr) supplementation could enhance long-term repeated-sprint exercise performance of approximately 80 min in duration.

METHODS

Fourteen active, but not well-trained, male subjects initially performed 10 sets of either 5 or 6 x 6 s maximal bike sprints, with varying recoveries (24, 54, or 84 s between sprints) over a period of 80 min. Work done (kJ) and peak power (W) were recorded for each sprint, and venous blood was collected preexercise and on four occasions during the exercise challenge. Muscle biopsies (vastus lateralis) were obtained preexercise as well as 0 min and 3 min postexercise. Subjects were then administered either 20 g.d-1 Cr.H2O (N = 7) or placebo (N = 7) for 5 d. Urine samples were collected for each 24 h of the supplementation period. Subjects were then retested using the same procedures as in test 1.

RESULTS

Total work done increased significantly (P < 0.05) from 251.7 +/- 18.4 kJ presupplementation to 266.9 +/- 19.3 kJ (6% increase) after Cr ingestion. No change was observed for the placebo group (254.0 +/- 10.4 kJ to 252.3 +/- 9.3 kJ). Work done also improved significantly (P < 0.05) during 6 x 6 s sets with 54-s and 84-s recoveries and approached significance (P = 0.052) in 5 x 6 s sets with 24-s recovery in the Cr condition. Peak power was significantly increased (P < 0.05) in all types of exercise sets after Cr loading. No differences were observed for any performance variables in the placebo group. Resting muscle Cr and PCr concentrations were significantly elevated (P < 0.05) after 5 d of Cr supplementation (Cr: 48.9%; PCr: 12.5%). Phosphocreatine levels were also significantly higher (P < 0.05) immediately and 3 min after the completion of exercise in the Cr condition.

CONCLUSION

The results of this study indicate that Cr ingestion (20 g.day-1 x 5 d) improved exercise performance during 80 min of repeated-sprint exercise, possibly due to an increased TCr store and improved PCr replenishment rate.

The use of metaphor in district nursing: maintaining a balance

AIM OF THE STUDY

To explore with practitioners and others, their priorities for and definitions of district nursing.

BACKGROUND/RATIONALE

This paper discusses whether the use of metaphor in nursing literature and research can offer particular insights about the situation and experiences of nurses.

DESIGN/METHODS

A case study approach was used to examine district nursing during a time of policy change. The study was undertaken in two stages using a range of qualitative methods of enquiry. Participants of the study were district nurses, General Practitioners (GP) and Community Nursing managers.

RESULTS/FINDINGS

Qualitative data from interviews and periods of observation revealed that district nurses, and to a lesser extent General Practitioners and nurse managers used a shared group of metaphors to try and capture district nursing work. The paper suggest that this recurring group of metaphors demonstrated coherence between the language used, observed practice and accounts of how district nurses worked which provided useful insights for district nursing. The metaphoric language revealed both negative and positive dimensions of district nursing work. It illuminated the context dependent nature of district nursing work and the conflicting interests they had to accommodate. It also revealed the emotional work, skills and strategies district nurses employed in order to achieve their work.

CONCLUSIONS

The paper concludes that an examination of metaphoric language offers an opportunity to examine what otherwise would be tacit or even misunderstood in nursing work.

Managed care companies and the practice of medicine

One of the major issues pertaining to the pending legislation for Patient's Bill of Rights is the potential of liability health care plans, particularly when they decline coverage they consider not medically necessary. We call these contracts "managed health care" plans. But, realistically, when is it managing? When is it medicine? When, if at all, does management undermine medicine? And if it does, should managed care organizations--and their representatives--be held legally liable for medical decisions that go wrong? A panel of seven experts examines these questions from medical, payment, patient, legal, insurance, and governing viewpoints.