Women recovering from first-time myocardial infarction (MI): a feminist qualitative study

Although myocardial infarction (MI) is a leading cause of death and disablement for women internationally, little is known about women's recovery. This paper describes an exploratory descriptive study that was informed by feminist principles, and which aimed to explore the recovery experiences of a group of women survivors of first-time MI in the initial period following discharge from hospital. A total of 10 female survivors were interviewed using an open-ended semi-structured interview schedule administered at 7, 14 and 21 days post-hospital discharge. Findings revealed that recovery was experienced as a complex process, initially characterized by fear and uncertainty. Over the duration of the study these feelings were replaced with a more positive outlook, a return of energy, and a sense of confidence in the future. Participants identified an unmet need for reliable information which persisted over the duration of the study. The findings of this study have implications for nursing practice and research. Chief among these is the issue of effective provision of information to women following an acute MI. The importance of providing relevant information to be understood and retained by people experiencing crisis cannot be overstated. Equally important are the provision of opportunities for patients to have regular contact with health professionals to question and seek clarifying information. These findings should now be tested on larger populations.

The emergence of Streptococcus pneumoniae resistant to macrolide antimicrobial agents: a 6-year population-based assessment

From 1994 through 1999, the available isolates (4148 isolates) from active population-based surveillance of invasive pneumococcal disease in metropolitan Atlanta were serotyped and were tested for antimicrobial susceptibility. Macrolide-resistant isolates were studied for the presence of ermAM (a ribosomal methylase gene), mefE (a macrolide efflux gene), and tetM (the class M tetracycline resistance gene). Macrolide resistance increased from 16% of all invasive isolates in 1994 to 32% in 1999. Of the macrolide-resistant pneumococcal isolates studied, 99% contained genomic copies of mefE or ermAM. Isolates with ermAM were mainly serotypes 6B, 23F, 14, or 19F and contained tetM; mefE-associated isolates were predominantly serotypes 14, 6A, or 19F, and most did not contain tetM. The frequency of the ermAM-mediated phenotype in invasive Streptococcus pneumoniae remained stable over the 6-year surveillance. However, the mefE-mediated phenotype increased from 9% in 1994 to 26% of all isolates in 1999 and was noted in new serotypes. By 1999, 93% of the mefE-containing strains had minimum inhibitory concentrations >/=8 microgram/mL. Dissemination of the mefE determinant accounted for the rapid increase in the rate of macrolide resistance in our S. pneumoniae population.

The E1E4 protein of human papillomavirus type 16 associates with a putative RNA helicase through sequences in its C terminus

Human papillomavirus type 16 (HPV16) infects cervical epithelium and is associated with the majority of cervical cancers. The E1E4 protein of HPV16 but not those of HPV1 or HPV6 was found to associate with a novel member of the DEAD box protein family of RNA helicases through sequences in its C terminus. This protein, termed E4-DBP (E4-DEAD box protein), has a molecular weight of 66,000 (66K) and can shuttle between the nucleus and the cytoplasm. It binds to RNA in vitro, including the major HPV16 late transcript (E1E4. L1), and has an RNA-independent ATPase activity which can be partially inhibited by E1E4. E4-DBP was detectable in the cytoplasm of cells expressing HPV16 E1E4 (in vivo and in vitro) and could be immunoprecipitated as an E1E4 complex from cervical epithelial cell lines. In cell lines lacking cytoplasmic intermediate filaments, loss of the leucine cluster-cytoplasmic anchor region of HPV16 E1wedgeE4 resulted in both proteins colocalizing exclusively to the nucleoli. Two additional HPV16 E1E4-binding proteins, of 80K and 50K, were identified in pull-down experiments but were not recognized by antibodies to E4-DBP or the conserved DEAD box motif. Sequence analysis of E4-DBP revealed homology in its E4-binding region with three Escherichia coli DEAD box proteins involved in the regulation of mRNA stability and degradation (RhlB, SrmB, and DeaD) and with the Rrp3 protein of Saccharomyces cerevisiae, which is involved in ribosome biogenesis. The synthesis of HPV16 coat proteins occurs after E1E4 expression and genome amplification and is regulated at the level of mRNA stability and translation. Identification of E4-DBP as an HPV16 E1E4-associated protein indicates a possible role for E1E4 in virus synthesis.

Three dimensional OCT images from retina and skin

We demonstrate the functionality of an en-face optical coherence tomography (OCT) system with images from the retina and skin. En-face images collected at different depths are subsequently used to reconstruct a 3D volume of the tissue. The reconstruction allows software inferred OCT longitudinal images at any transversal position in the stack. The position in depth in the stack before creating longitudinal OCT images is also adjustable, offering a valuable guidance tool for exploring the 3D volume of the tissue. This is illustrated by Quick time movies showing either depth or lateral exploration along one of two possible different directions in the stack of transversal OCT images. Sufficient accuracy of the volume rendered is obtained in 20 seconds when the system operates at 2 frames a second. The system, equipped with the 3D rendering feature acts as a valuable diagnostic tool allowing "peeling off" of transversal and longitudinal biologic material to investigate different internal features.

The diagonal ear lobe crease (Frank's sign) is not associated with coronary artery disease or retinopathy in type 2 diabetes: the Fremantle Diabetes Study

BACKGROUND

The diagonal ear lobe crease (ELC) has been suggested as a simple marker of vascular disease in the general population but there are few data from diabetic patients despite their increased risk of angiopathy.

AIM

To determine whether the ELC is a clinically useful sign of coronary artery disease (CAD) or retinopathy in type 2 diabetes.

METHODS

One thousand and twenty-two patients from the multi-ethnic urban catchment area of Fremantle Hospital in Western Australia were studied. This sample represents 79% of the type 2 diabetic subjects recruited to the ongoing Fremantle Diabetes Study and 49% of all 2072 patients with type 2 diabetes identified through active case detection in a postcode-defined region of 120,097 people. In addition to other comprehensive data relating to diabetes and its management, the presence of an ELC and evidence of both CAD and retinopathy were ascertained for each patient.

RESULTS

The prevalence of ELC was 55%. Patients with an ELC were more likely to have CAD than those without an ELC (p=0.019), but the proportions with retinopathy were not significantly different (p=0.085). The sensitivity and specificity of ELC for detecting CAD were 60% and 48%, and for retinopathy 61% and 47% respectively. The patients with an ELC were significantly older, more likely to be male and had a higher systolic blood pressure than those without (p<0.02). After adjusting for known vascular risk factors, socioeconomic variables and ethnicity in a logistic regression model, an ELC was neither a significant independent predictor of CAD (p=0.45) nor of retinopathy (p=0.14).

CONCLUSIONS

The ELC is of little value as a sign of the presence of diabetic vascular complications.

Opening up the communication channels: recent insights into plasmodesmal function

The past year has seen significant advances in our understanding of the function and regulation of plasmodesmata. Notably, we have learned that plasmodesmata undergo dynamic changes during development and may participate in long-range communication through the transmission of RNA signals. Biochemical studies have enriched our understanding of a putative plasmodesmal receptor and of plant factors involved in viral cell-to-cell movement.

Can young severely disabled stroke patients regain the ability to walk independently more than three months post stroke?

OBJECTIVE

To investigate the acquisition of ability to walk independently in young severely disabled stroke patients unable to walk three months after onset.

SETTING

A regional rehabilitation unit providing post-acute neurorehabilitation mainly for patients aged 16-65 years.

SUBJECTS AND METHODS

A retrospective analysis of records was undertaken for 152 stroke patients admitted consecutively over a three-year period. All had a combination of physical, cognitive and language impairments; male/female 98/54; median age 54 (IQR 47-60) years.

MAIN OUTCOME MEASURES

Time taken from stroke onset to regain the ability to walk safely and independently at least 5 metres around the hospital bay.

RESULTS

Seventy-five (49%) regained the ability to walk independently between 3 and 11 months post onset. Patients with cognitive impairments and neglect took longer to walk. Time from stroke onset to admission was longer in patients who did not walk (median 16.3 weeks), than in those who regained walking (median 12.7 weeks; p = 0.009). Independent positive associations were found between the time taken to walk and time from onset to referral for rehabilitation (p = 0.55; p < 0.001), and time from acceptance to admission (p = 0.30; p = 0.008).

CONCLUSION

With intensive specialist input, significant numbers of severely disabled young stroke patients can regain independent walking many months after onset, though late walkers may follow a slower recovery course. These results argue for investment in appropriate rehabilitation for these patients. Waiting list delays may prolong rehabilitation and potentially compromise cost effectiveness.

Effects of prenatal cocaine exposure on dopamine system development: a meta-analysis

Several studies have investigated the effects of prenatal cocaine (PCOC) exposure on the nigrostriatal dopaminergic system in animal models of maternal drug abuse, yet independent examinations of striatal dopamine (DA) receptors and tissue DA levels have produced equivocal results. The current meta-analysis provides a quantitative review of the literature on these topics, and analyzes potential moderators of the effects of PCOC exposure on these variables. The results indicate that the effects of PCOC exposure on striatal DA levels, D1 and D2 receptor-binding densities, and D2 receptor-binding affinity are negligible when collapsed over age, sex, species, and several other methodological variables. However, effects of PCOC exposure on some dopaminergic measures were significantly influenced by factors such as age and sex. As expected, and as suggested by the selectivity and specificity of PCOC-induced changes reported in the published literature, the direction and magnitude of differences between genders or age groups in this study were not systematic across all dependent measures. Generally, PCOC exposure was more often linked to decreases, rather than increases, in the selected dependent measures. These findings indicate that PCOC exposure produces selective alterations in striatal dopaminergic system function which do not appear under all experimental circumstances, but which may be important factors in behavioral alterations seen in selected groups after PCOC exposure.

Magnetic resonance contrast enhancement of neovasculature with alpha(v)beta(3)-targeted nanoparticles

Site-directed contrast enhancement of angiogenic vessels in vivo was demonstrated using antibody targeting of an MRI contrast agent to the alpha(v)beta(3) integrin, a molecular marker characteristic of angiogenic endothelium. The agent was tested in a rabbit corneal micropocket model, in which neovasculature is induced in the cornea using basic fibroblast growth factor. The targeted contrast agent consists of Gd-perfluorocarbon nanoparticles linked to alpha(v)beta(3) integrin antibody DM101. The animal group receiving the targeted contrast agent displayed a 25% increase in the average MR signal intensity after 90 min. Control groups in which the nanoparticles are either used alone, linked to an isotype-matched antibody, or linked to DM101 and administered following receptor blocking did not display MR contrast enhancement at similar dose levels. These findings indicate that the antibody-targeted agent enhances MR signal intensity in the capillary bed in a corneal micropocket model of angiogenesis, and is selectively retained within the angiogenic region via specific interaction with the alpha(v)beta(3) epitope.

Radiation doses to members of the public near to Sellafield, Cumbria, from liquid discharges 1952-98

Liquid wastes containing low levels of radioactivity have been discharged to the Irish Sea from the nuclear fuel reprocessing site at Sellafield since operations began in the early 1950s, and monitoring of radioactivity in foodstuffs has been undertaken over many years. Based on the best available monitoring data, supplemented by modelled values where necessary, doses to local critical groups have been reassessed using the most recent dosimetry. Contemporary habits data have been used where available, again supplemented by assumed habits where necessary. During the 1950s and 1960s the highest doses were received by individuals consuming Cumbrian Porphyra as laverbread, and peak doses around 0.8 to 1.0 mSv year(-1) have been estimated. During the 1970s and 1980s the critical exposure group switched to consumers of local fish and shellfish, with peak doses possibly reaching 2.5 to 3.0 mSv year(-1). Latterly, doses to all marine-related groups have declined to less than 150 to 200 microSv year(-1). At all times, doses have been within the appropriate limits set for members of the public.

Epidemic nephritis in Nova Serrana, Brazil

BACKGROUND

Outbreaks of nephritis have been rare since the 1970s. From December, 1997, to July, 1998, 253 cases of acute nephritis were identified in Nova Serrana, Brazil. Seven patients required dialysis, and three patients died. We did a case-control study to investigate the cause of the outbreak.

METHODS

Using a matched cluster design, we examined seven recent patients, their family members (n=23), and members of neighbourhood-matched control households (n=22). We subsequently interviewed 50 patients and 50 matched controls about exposure to various dairy products. We also cultured dairy foods and took udder-swab and milk samples from cows.

FINDINGS

Throat cultures indicated that nephritis was associated with group C Streptococcus equi subspecies zooepidemicus, a cause of bovine mastitis. S. zooepidemicus was detected in four of seven case households (six of 30 people) and no control households (p=0.09). Patients were more likely than matched controls to have consumed a locally produced cheese called queijo fresco (matched odds ratio 2.1, p=0.05). The nephritis attack rate was 4.5 per 1000 in Nova Serrana but 18 per 1000 in the village Quilombo do Gaia (p=0.003). The largest supplier of unpasteurized queijo fresco was a farm in Quilombo do Gaia. S. zooepidemicus was not detected in food samples or in swabs collected from cows in August, 1998, although mastitis was evident among cows on the suspected farm. Throat cultures of the two women who prepared cheese on this farm yielded the outbreak strain of S. zooepidemicus. After the cheese was removed from the distribution system, no further cases were reported.

INTERPRETATION

A large outbreak of glomerulonephritis was attributed to S. zooepidemicus in unpasteurised cheese. This outbreak highlights the dangers of consuming unpasteurized dairy products and need for global efforts to promote food safety.

Prenatal cocaine exposure increases serotonergic inhibition of electrically evoked acetylcholine release from rat striatal slices at adulthood

This study tests the hypothesis that prenatal cocaine (pCOC) exposure (20 mg/kg, bidaily from embryonic days 15-21) modifies 5-HT(3) receptor regulation of electrically-evoked [(3)H]acetylcholine (ACh) overflow from adult male and female (proestrus, diestrus) rat striatal slices. Also, the influence of endogenous dopamine (DA) on serotonin (5-HT) regulation of ACh overflow was determined by assessing the effects alpha-methyl-para-tyrosine (AMPT) pretreatment or sulpiride. Phenylbiguanide (PBG, 5-HT(3) agonist) superfusion dose-dependently inhibited ACh overflow in all groups except the diestrus pCOC group in which there was an enhanced sensitivity to PBG. PBG (10, 30, and 60 microM) produced greater effects in the pCOC male than in the prenatal saline (pSAL) group. The pCOC male group also exhibited greater sensitivity to PBG (30 and 60 microM) than the pCOC proestrus group. PBG inhibition of ACh overflow was comparable in the pSAL male and female (proestrus) groups. PBG inhibition of ACh overflow was greater in the pCOC diestrus group than in the pCOC proestrus (10, 30, and 60 microM), the pSAL diestrus (10 and 30 microM), and the pCOC male (10 microM) conditions. In slices from untreated rats superfused with 30 microM PBG, AMPT pretreatment (68% DA loss) reduced inhibition of ACh overflow, and 1 microM sulpiride increased ACh overflow. ICS205-930 (5-HT(3) antagonist) reduced effectiveness of PBG indicating 5-HT(3) receptor specificity for PBG. In summary, pCOC exposure enhances modulatory effects of 5-HT (via 5-HT(3) receptors) on striatal ACh release in male and females rats and the inhibitory actions of 5-HT(3) receptors are mediated by DA.

Environmental effects of radionuclides--observations on natural ecosystems

To better quantify risk to non-human species from exposure to environmental radioactivity, understanding of the behaviour of radionuclides in the biosphere needs to be increased. This study outlines current thinking on ecological risk assessment (ERA) methodology and applies the indicator species or critical groups approach to biota inhabiting a semi-natural coniferous woodland contaminated with the radionuclides 137Cs, 238Pu, 239+240Pu and 241Am. The majority of these radionuclides originate from routine aerial emissions from the nuclear fuel reprocessing plant at BNFL, Sellafield, Cumbria, UK. Radionuclide activity concentrations have been determined in biota from the woodland and estimates of absorbed dose rates (mGy d(-1)) have been calculated using the dosimetric models outlined. Dose rates to the key indicator species, Oniscus asellus, Carabus violaceous and Apodemus sylvaticus (detritivorous invertebrate, predatory invertebrate and the granivorous wood mouse) have been determined at 3.0 x 10(-3) mGy d(-1), 2.2 x 10(-3) mGy d(-1) and 1.0 x 10(-3) mGy d(-1) respectively. The values are at least three orders of magnitude lower than the 1 mGy d(-1) level below which no observable effects on populations in a terrestrial ecosystem are thought to occur. Limitations of this approach are discussed.

Prenatal cocaine exposure alters behavioral and neurochemical sensitization to amphetamine in adult rats

This study examined the neurochemical correlates of amphetamine (AMPH)-induced behavioral effects in prenatally saline (PSAL)-exposed or cocaine (PCOC)-exposed male rats. Pregnant Long-Evans rats received saline or saline containing cocaine hydrochloride (20 mg/kg s.c., b.i.d.) from gestational days 15-21. Animals were left with their biological mothers. Adult offspring were exposed to daily saline or AMPH (0.5, 1.5, or 5 mg/kg, i.p.) injections for 7 days. Behaviors were recorded in an open field during the first hour post-injection. PCOC rats did not exhibit behavioral anomalies during habituation to injection-stress or placement in the open field. PCOC rats displayed significant alterations in stereotyped responses to acute or intermittent exposure to various doses of AMPH. Within 48 h of the final testing day, striatal tissue was obtained from these animals and electrically-evoked [3H]acetylcholine (ACh) release was measured from striatal slices. Superfusion of tissue slices with various concentrations of AMPH (1-1000 nM) produced dose-dependent inhibition of ACh release in both PSAL and PCOC rats repeatedly injected with saline as adults. However, AMPH-induced inhibition of ACh release was decreased in PCOC rats repeatedly injected with AMPH as adults. At 5 mg/kg AMPH, PCOC rats exhibited increased mortality compared to PSAL rats. These data suggest that PCOC exposure produces long-lasting alterations in nigrostriatal transmission and behaviors mediated by this system.

Health care support workers in the critical care setting

The 1999/2000 winter demands on the NHS have once again highlighted deficits in UK critical care provision (Daily Telegraph, 2000; London Evening Standard, 2000) Recent years have seen the development of the role of health care support workers in the NHS; some critical care units now employ health care support workers This research examined the views of critical care unit staff on the introduction of health care support workers into the critical care unit It is concluded that the role is viable within the setting of this study A framework is outlined that could form the basis for a critical care health care support worker training programme

Health status, perceptions of coping, and social support immediately after discharge of survivors of acute myocardial infarction

BACKGROUND: The period immediately after discharge from the hospital after an acute myocardial infarction is a stressful and vulnerable time about which little is known. OBJECTIVE: To explore health status, perceptions of coping, and social support among survivors of a recent myocardial infarction in the first 3 weeks after discharge from hospitals in southwestern Sydney, Australia. METHODS: A descriptive, exploratory approach with a triangulated methodology was used to assess the experiences of 38 survivors, detect patterns in these experiences, explore the health-support needs of survivors, and determine changes in health status in the first 3 weeks after discharge. Quantitative data were collected with the Medical Outcomes Study SF-36, New York Heart Association classification, Canadian Cardiovascular Society Angina Scale, and the Jalowiec Coping Scale. A semistructured interview schedule provided additional qualitative data about the experiences of the survivors. RESULTS: The health status of participants was relatively stable during the 3-week period; most had no activity limitation due to dyspnea or angina. However, the subjects' health status was considerably lower than that of their age-matched population. The most common and most effective coping strategies adopted during this period were confrontation, optimism, and self-reliance. In addition, the subjects experienced anxiety, depression, ambiguity and uncertainty, fear of recurrence of the infarction and of deterioration in health, of boredom and of inertia. CONCLUSION: These findings can help nurses in hospital and community settings assist survivors of acute myocardial infarction to prepare for and deal effectively with experiences during convalescence.

Health status, perceptions of coping, and social support immediately after discharge of survivors of acute myocardial infarction

BACKGROUND

The period immediately after discharge from the hospital after an acute myocardial infarction is a stressful and vulnerable time about which little is known.

OBJECTIVE

To explore health status, perceptions of coping, and social support among survivors of a recent myocardial infarction in the first 3 weeks after discharge from hospitals in southwestern Sydney, Australia.

METHODS

A descriptive, exploratory approach with a triangulated methodology was used to assess the experiences of 38 survivors, detect patterns in these experiences, explore the health-support needs of survivors, and determine changes in health status in the first 3 weeks after discharge. Quantitative data were collected with the Medical Outcomes Study SF-36, New York Heart Association classification, Canadian Cardiovascular Society Angina Scale, and the Jalowiec Coping Scale. A semistructured interview schedule provided additional qualitative data about the experiences of the survivors.

RESULTS

The health status of participants was relatively stable during the 3-week period; most had no activity limitation due to dyspnea or angina. However, the subjects' health status was considerably lower than that of their age-matched population. The most common and most effective coping strategies adopted during this period were confrontation, optimism, and self-reliance. In addition, the subjects experienced anxiety, depression, ambiguity and uncertainty, fear of recurrence of the infarction and of deterioration in health, of boredom and of inertia.

CONCLUSION

These findings can help nurses in hospital and community settings assist survivors of acute myocardial infarction to prepare for and deal effectively with experiences during convalescence.

Radionuclide behaviour and transport in a coniferous woodland ecosystem: vegetation, invertebrates and wood mice, Apodemus sylvaticus

Activity concentrations of radionuclides (134Cs, 137Cs, 238Pu, 239 + 240Pu and 241Am) were measured in vegetation, invertebrates and wood mice, Apodemus sylvaticus, collected in Lady Wood, a coniferous woodland in the vicinity of the British Nuclear Fuels reprocessing plant at Sellafield, Cumbria, UK. Vegetation was of low diversity and biomass with activity concentrations ranging from 1 to 5 Bq kg-1 (134Cs), 0.3-0.5 Bq kg-1 (238Pu), 0.8-8 Bq kg-1 (239 + 240Pu), and 0.6-16 Bq kg-1 (241Am), dry wt. Caesium-137 activity concentrations were high compared to the reference site in Cheshire, varying between 65 and 280 Bq kg-1. Marked inter-specific and temporal differences in radionuclide activity concentrations were recorded for invertebrate populations. Caesium-137, 238Pu, 239 + 240Pu and 241Am activity concentrations in detritivorous invertebrates were consistently higher than in all other invertebrate groups reflecting contamination of the leaf litter. The activity concentrations in detritivores increased during the autumn and winter, reflecting changes in diet as food sources varied throughout the year. Activity concentrations in invertebrates caught in Lady Wood were generally an order of magnitude higher than for the reference site. Activity concentrations in wood mice varied between 7 and 150 Bq kg-1 (137Cs), 0.1-0.3 Bq kg-1 (238Pu), 0.1-0.6 Bq kg-1 (239 + 240Pu) and 0.2-0.4 Bq kg-1 (241Am). There were clear differences in the activity concentration of 137Cs (P < 0.01), 239 + 240Pu (P < 0.05) and 241Am (P < 0.05) in animals caught in Lady Wood compared to the reference site. However, the activity concentrations for 238Pu were similar at both sites, reflecting a low gastrointestinal transfer. Seasonal variation in activity concentrations was observed for 137Cs, 238Pu and 241Am. This variation is attributed to changes in the age structure of the population and diet throughout the year.

The healthy start renal clinic: benefits of tracking and early intervention in pre-end stage renal disease patients

Several studies have demonstrated a strong association between the benefits of pre-end stage renal disease (ESRD) education and decreased length of hospital stay (LOS) and hospital charges, delay of renal replacement therapy (RRT), and a smooth transition to RRT. The Ochsner Healthy Start Renal Clinic (HSRC) is a multidisciplinary early education and tracking program for pre-ESRD patients and their families. We identified and educated pre-ESRD patients about kidney disease, allowing them to discuss and make informed decisions about their treatment and be better prepared to cope with the transition to RRT and the changes in their lives resulting from kidney failure. HSRC patients demonstrated a significant decrease in length of hospital stay (p = 0.05), a trend towards decreased hospital episodes and charges, decreased use of temporary venous access, and a smooth transition to RRT. The control group was made up of patients who had either refused the structured education or had been referred to HSRC late and received only conventional instruction by a social worker at the point where dialysis was imminent. We compared the number of episodes of hospitalization, LOS, and overall hospital charges for the period immediately surrounding initiation of chronic dialysis (2 months before and 1 month following onset) of all 36 patients who began chronic hemodialysis in our facility between November 1997 and November 1998. HSRC patients had LOS half as long (p=0.05), fewer hospital episodes, and hospital charges of $5,000 less per patient than the non-HSRC group. Initial data strongly suggest that early education and intervention through the coordination of a multidisciplinary team maximize the continuity of patient care.

Integrating the creative arts into a midwifery curriculum: a teaching innovation report

The practice of midwifery has long been recognized as both art and science. However, educational programmes for midwifery are most often undertaken within an academic health sciences environment, and tend to be based on knowledge derived from the sciences (e.g. life sciences, biomedical sciences, behavioural sciences and social sciences). These scientific perspectives, while essential to the preparatory and on-going education of midwives, do not necessarily fully prepare midwives to fulfil their practice roles. This paper reports a teaching innovation aimed at facilitating student exploration of fundamental, complex and ethereal concepts which are essential to the effective and skillful practice of midwifery. Through the exploration of the arts and humanities, students were encouraged to engage with concepts such as 'caring', 'empathy', 'suffering', 'motherhood', 'pain', 'love', 'attachment', 'health' and 'illness'. Students were also encouraged to explore cultural and social symbols pertaining to parenthood and family life. Evaluation revealed that students valued the course, and that they gained insights which assisted them to develop understanding of key concepts. Implications for practice and education are drawn from this paper.

Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences

OBJECTIVE

To evaluate effectiveness of an exercise programme in a community setting for patients with low back pain to encourage a return to normal activities.

DESIGN

Randomised controlled trial of progressive exercise programme compared with usual primary care management. Patients' preferences for type of management were elicited independently of randomisation.

PARTICIPANTS

187 patients aged 18-60 years with mechanical low back pain of 4 weeks to 6 months' duration.

INTERVENTIONS

Exercise classes led by a physiotherapist that included strengthening exercises for all main muscle groups, stretching exercises, relaxation session, and brief education on back care. A cognitive-behavioural approach was used.

MAIN OUTCOME MEASURES

Assessments of debilitating effects of back pain before and after intervention and at 6 months and 1 year later. Measures included Roland disability questionnaire, Aberdeen back pain scale, pain diaries, and use of healthcare services.

RESULTS

At 6 weeks after randomisation, the intervention group improved marginally more than the control group on the disability questionnaire and reported less distressing pain. At 6 months and 1 year, the intervention group showed significantly greater improvement in the disability questionnaire score (mean difference in changes 1.35, 95% confidence interval 0.13 to 2.57). At 1 year, the intervention group also showed significantly greater improvement in the Aberdeen back pain scale (4.44, 1.01 to 7.87) and reported only 378 days off work compared with 607 in the control group. The intervention group used fewer healthcare resources. Outcome was not influenced by patients' preferences.

CONCLUSIONS

The exercise class was more clinically effective than traditional general practitioner management, regardless of patient preference, and was cost effective.

Investigating and implementing change within the primary health care nursing team

Primary care is developing rapidly with significant impacts on the nursing team. Such changes have brought inter-professional team-working into sharper focus, particularly community care and collaborative working. This paper: examines the nursing roles within a general practice; describes the perspectives of service users; identifies areas of change; clarifies core and specialist skills; defines new roles among the primary health care nursing team; proposes a new model of working; and identifies appropriate education. The project was set in a general practice in south-west England and used an action research methodology. The objectives were to create a change in practice and to develop and refine existing theory to underpin nursing roles. Throughout the research regular team meetings allowed reflection and discussion about research findings and progress. Data were collected from multiple sources, including team workshops, patient focus group interviews, and individual interviews with GPs, practice managers and area managers. Reflective diaries and a patient survey were also used. The analysis of the quantitative and qualitative data collected from patients formed a basis for practice development and facilitated the team's reflection on the areas of change. Overall high satisfaction with services and care was expressed in the patient interviews and the questionnaire. The themes from the data highlighted areas important for patients and helped in shaping the new roles and responsibilities for team members. Regarding the team perspective, the data indicated many areas that could be considered for development. The community nursing team decided to concentrate on three key areas: child health, leg ulcer management, and cardiovascular health. The research concludes that action research presents some problems and challenges but is a useful approach to developing team-working in primary health care.