Clinical governance is "ACE"--using the EFQM excellence model to support baseline assessment

The introduction of clinical governance in the "new NHS" means that National Health Service (NHS) organisations are now accountable for the quality of the services they provide to their local communities. As part of the implementation of clinical governance in the NHS, Trusts and health authorities had to complete a baseline assessment of their capability and capacity by September 1999. Describes one Trust's approach to developing and implementing its baseline assessment tool, based upon its existing use of the European Foundation for Quality Management (EFQM) Excellence Model. An initial review of the process suggests that the model provides an adaptable framework for the development of a comprehensive and practical assessment tool and that self-assessment ensures ownership of action plans at service level.

A journey to becoming: the student nurse in transition

The study reported in this paper explored the nature of the transition experienced by student nurses in their journey to becoming qualified nurses. In keeping with the developing relationship between the disciplines of anthropology and nursing, the methodology of choice was ethnography. Data were collected by open-ended questionnaires and interviews with key informants from one English College of Nursing undertaking Diploma level Project 2000 Adult Branch Studies. Thematic analysis of the data revealed an ill-defined transition for the student nurse and this lack of clarity was being perpetuated for many by their dual role as both student nurse and worker. This was also creating a potential role conflict and a blurring of the boundaries between professional nursing and skilled health care work. The data also revealed two 'in limbo' states, a ritualized transition phase, and that the rationale for 'learning to become a nurse' retains the idealized and vocational imagery of nursing as helping and caring for sick people.

Alternatives to traditional illness models. Interview by Cheryl Slagle King

The Center for Human Caring at the School of Nursing, University of Colorado Health Sciences Center embraces complementary care modalities. The author interviews Karen Holland, Executive Director for the Center.

Interaction of thyroxine and estrogen on the expression of estrogen receptor alpha, cholecystokinin, and preproenkephalin messenger ribonucleic acid in the limbic-hypothalamic circuit

To study thyroid hormone and estrogen interactions in the central nervous system (CNS), the expression of estrogen sensitive genes was examined within the limbic-hypothalamic circuit. Estrogen up-regulates the expression of reproductively relevant neuropeptide messenger RNAs (mRNAs) encoding cholecystokinin (CCK) and enkephalin, peptides that stimulate lordosis. Estrogen down-regulates the expression of the estrogen receptor alpha (ER alpha) mRNA in the nuclei of the circuit. We examined the possibility that thyroid hormone treatment would block the estrogen modulation of these messages. Estradiol benzoate (EB), EB + thyroxine (T4), T4, or oil were administered to ovariectomized, adult female rats for 10 days. Isotopic in situ hybridization histochemistry revealed that within the limbic-hypothalamic nuclei, levels of CCK and preproenkephalin (PPE) mRNA levels were significantly higher in EB and EB + T4-treated animals compared with T4 or oil-treated animals. ER alpha mRNA levels were low in EB treated animals, elevated in T4 or oil-treated animals and further elevated in EB + T4-treated animals. In summary, T4 treatment had neither an independent nor an antagonistic effect on estrogen induced expression of CCK or PPE mRNA in the circuit. However, T4 did prevent the normal estrogenic decrease of ER alpha mRNA levels in the nuclei of the limbic-hypothalamic circuit.

A prospective randomized trial of buffy coat versus CD34-selected autologous bone marrow support in high-risk breast cancer patients receiving high-dose chemotherapy

High-dose chemotherapy with hematopoietic progenitor cell support is administered increasingly to selected categories of patients with high-risk malignancies. Bone marrow and/or peripheral blood progenitor cells (PBPCs) are commonly cryopreserved with the cryoprotectant dimethyl sulfoxide (DMSO), which can cause a variety of systemic side effects when the graft is thawed and infused. The progenitor cells thought to be responsible for hematopoietic recovery express the CD34 antigen and constitute 1% to 3% of the marrow cells and 0.5% of the PBPC fraction. Transplantation of a CD34(+) graft would markedly reduce the volume and thus the amount of DMSO required, thereby decreasing the infusion-related toxicities. In this study, 89 high-risk breast cancer patients received high-dose therapy and were randomized to receive an autologous CD34(+) marrow graft (Arm A) versus a standard buffy coat fraction (Arm B). After marrow infusion, significant increases in diastolic and systolic blood pressure, as well as significant decreases in heart rate, were documented in Arm B compared to Arm A patients (P < .001). None of the patients in Arm A experienced any clinically serious adverse events associated with the marrow infusion compared to 6% of the Arm B patients. The median time to neutrophil engraftment was 13 days for Arm A and 11 days for Arm B patients (P = .218). The median time to platelet engraftment was 27 days for Arm A and 20 days for Arm B patients (0.051). There were no other significant differences between the two arms of the study with respect to thrombocytopenia-related complications or immune function reconstitution. Additionally, patients on Arm A who received >/=1.2 x 10(6) CD34(+) cells/kg had no delay in platelet recovery (22 days), compared to patients on Arm B, who also received greater than 1.2 x 10(6) CD34(+) cells/kg (20 days) (P = .604). In conclusion, this prospective randomized study demonstrates that breast cancer patients who receive high-dose therapy with autologous CD34(+) marrow support have reduced marrow infusion-related toxicity, comparable time to neutrophil engraftment and immune function recovery posttransplant, and for those who receive <1.2 x 10(6) CD34(+) cells/kg, comparable time to platelet engraftment compared to women who receive buffy coat fractions of marrow.

The effect of noncontingent sensory reinforcement, contingent sensory reinforcement, and response interruption on stereotypical and self-injurious behavior

Three analyses were conducted to assess the effects of different consequent stimuli on the rate of stereotypical and self-injurious behavior performed by two individuals with severe developmental disabilities and dual sensory impairments. An analogue functional analysis documented an undifferentiated pattern of problem behavior across all conditions for Participant 1. Data for Participant 2 indicated an undifferentiated pattern with lower frequencies in the demand condition. Stimuli chosen to compete with the type of sensory stimulation produced by the stereotypy and self-injurious behavior were presented noncontingently during play conditions. Noncontingent presentation of the specially selected stimuli resulted in reductions in stereotypy and self-injurious behavior. Finally, contingent presentation of the same stimuli with and without response interruption was assessed in a demand context. Contingent presentation of the specially selected stimuli plus response interruption resulted in more suppression than contingent sensory stimulus presentation alone. Results are discussed as to competing and concurrent schedules of reinforcement.

Transjugular intrahepatic portosystemic shunt for the management of severe venoocclusive disease following bone marrow transplantation

Hepatic venoocclusive disease (VOD) is a common, life-threatening complication of bone marrow transplantation (BMT). Portal hypertension is usually present and accounts for many of the clinical manifestations of this syndrome. We describe the results of transjugular intrahepatic portosystemic shunt (TIPS) for the management of VOD after BMT TIPS was performed in six patients with histologically confirmed VOD who had progressive jaundice and ascites. Portal hypertension was improved by TIPS in all patients (mean portal pressure gradient before TIPS, 20.2 +/- 4.6 vs. 6.7 +/- 1.9 mm Hg post-TIPS, P < .004). Three patients who underwent TIPS late in the course of VOD did not demonstrate any clinical improvement after TIPS and expired within 2 weeks of the procedure. The remaining three patients had less advanced disease and demonstrated decreases in serum bilirubin, improvement in coagulopathy, and decreased ascites after TIPS. Two patients subsequently expired, one with persistent histological changes of VOD. The lone survivor continues to do well with resolution of ascites, jaundice, and coagulopathy as of her last outpatient visit. TIPS was an effective method for portal decompression in patients with VOD after BMT, and was associated with clinical improvement in some patients. However, these effects may be transient and may not improve overall survival.

Induction of CCK mRNA levels in the limbic-hypothalamic circuit: time course and site-specific effects of estrogen

Estrogenic regulation of cholecystokinin (CCK) and its receptors is correlated with the initiation and termination of lordosis behavior. To understand the effect of circulating estrogen concentration on the temporal aspects of CCK mRNA expression in the posterodorsal medial amygdaloid nucleus (MeApd) and the central part of the medial preoptic nucleus (MPNc) of the limbic-hypothalamic circuit, ovariectomized female rats were treated with a 10 mm Silastic capsule filled with estradiol, a bolus injection of 50 micrograms estradiol benzoate or 2 micrograms estradiol benzoate every 4 days for five "cycles." In situ hybridization was used to compare the relative changes of CCK mRNA levels at 0 h to levels measured at 6, 12, 24, 48, 72, or 96 h after estrogen administration. In the MPNc and the MeApd, the 10-mm capsule significantly increased and maintained CCK mRNA levels from 6 to 96 h. The range of the increase was 3.0-5.1-fold in the MPNc and 2.8-5.0 in the MeApd. The 50-micrograms injections significantly increased and maintained CCK mRNA levels in the MPNc from 12 to 96 h (range of the increase 2.4-4.1-fold) and in the MeApd from 24 to 96 h (range of the increase 2.2-2.8-fold). The repeated administration of 2 micrograms estrogen induced a significant increase of message levels in the MPNc at 12 and 24 h that were 4.2- and 4.7-fold, respectively. In the MeApd this estrogen treatment did not significantly increase CCK mRNA. These studies demonstrate that small doses (2 micrograms) of estrogen that mimic the pattern and circulating levels of estrogen dramatically stimulate CCK mRNA levels in the limbic-hypothalamic circuit. To further study this steroid stimulation, ovariectomized female rats were implanted with estradiol-filled cannulae into the bed nucleus of the stria terminalis or MeA. Estrogen elevated CCK mRNA levels locally in each nucleus. Implants in the bed nucleus also elevated CCK mRNA levels in the MeApd indicating that physiologic estrogen stimulation of CCK in the MeApd is the result of both local and distal transsynaptic elevation of CCK mRNA levels. The sitespecific induction of CCK mRNA levels within the limbic-hypothalamic nuclei provides another important facet of estrogenic modulation of CCK induction.

[Prevention of thrombosis with fraxiparin 0.3 after arthroscopic interventions]

METHODS

During a drug monitoring 101 men and women between 13 and 67 years underwent arthroscopic interventions on the knee on an outpatient basis and received the low-molecular-weight heparin, Fraxiparin 0.3, as prophylaxis of thromboembolism. In general the drug was administered the day before operation, two hours prior to operation and for five to six days postoperatively as a single daily s.c. dose.

RESULTS

During the period of treatment, one patient developed a deep venous thrombosis of the leg; on completion of observation time four more cases of venous thrombosis of the leg occurred. In contrast, no pulmonary embolisms were observed. Fraxiparin 0.3 has proved to be very well tolerated, undesired side effects did not occur, and in no case was the preventive treatment interrupted.

Preliminary observations concerning treatment of visual discomfort and associated perceptual distortion

A system for therapeutic precision tinting is described. Some individuals who are subject to perceptual distortion of text no longer perceive the distortion when the text has a particular colour. A simple colorimeter enables an observer to illuminate text with light of a particular chromaticity, varying first CIE 1976 hue angle (huv), then saturation (suv), and then luminance, to obtain a setting that maximizes visual comfort and reduces any perceptual distortion. The colorimeter setting is then matched by a combination of tinted trial lenses. The combination uses only two dyes at a time from a selection of seven, unless a dark lens is required, when a third neutral (grey) dye is added. The subject observes both text and a normal scene when wearing tinted trial lenses. A variety of trial lenses are compared including those that match the colorimeter setting and others with similar hue angle. Spectacle lenses are then tinted so as to have a spectral transmission identical to that of the chosen combination of trial lenses. Certain patients with reading disorders, eye-strain, headaches or photosensitivity epilepsy report benefit when wearing spectacles tinted according to the above techniques. The physiological basis for the therapeutic effects is uncertain, but may involve a selective impairment of luminance or colour-difference channels.

Incidence of numerical chromosome anomalies in human pregnancy estimation from induced and spontaneous abortion data

Induced abortion data provided an estimate of 4.7% numerical chromosome anomalies for women with a clinically recognized pregnancy at the end of the 7th week after the last menstrual period (LMP). This frequency requires that 51.9% of spontaneous abortions occurring after the 7th week should be chromosomally abnormal if the frequency of numerical chromosome anomalies at term (live and stillbirths combined) is 0.53%. Cytogenetic data from surveys of spontaneous abortion suggested a lower incidence of 39.7%. However, this figure is likely to be an underestimate because chromosome anomalies are almost certainly over-represented among the many early abortuses which lack embryonic tissue and hence are not karyotyped. The frequency of numerical chromosome anomalies at conception, arising from meiotic errors, was estimated from sperm karyotype data combined with information on the relative frequencies of maternal and paternal errors in the aetiology of trisomies. This provided a minimum estimate of 20%.

Vancomycin-resistant Corynebacterium species causing prosthetic valve endocarditis successfully treated with imipenem and ciprofloxacin

Endocarditis caused by a Corynebacterium sp. resistant to vancomycin, penicillin G, erythromycin, gentamicin and rifampicin arose in a 44-year-old woman 4 months after replacement of the mitral valve with a prosthesis. She was successfully treated with a 79-day course of intravenous imipenem and ciprofloxacin and replacement of the prosthesis 48 days after treatment began.

XO monosomy is associated with reduced birthweight and lowered weight gain in the mouse

The growth of XO mice and their XX sisters was followed from the day of birth up to 15 weeks post partum. XO mice were underweight at birth, and grew more slowly than XX mice in the preweaning period. Some, but not all, of this decrease in growth rate was attributable to an effect of the reduced birth weight.