A cost-effectiveness analysis of two community models of care for patients with venous leg ulcers

AIM

To conduct a cost-effectiveness analysis based on data from a randomised controlled trial comparing traditional community home nursing with a community Leg Club model for chronic venous leg ulcer management in the south-east metropolitan area of Queensland, Australia.

METHOD

Participants were randomised to the Leg Club (n=28) or home visits (n=28). Data were obtained on resources/related costs incurred by the service provider, clients and carers, and the community.

RESULTS

From the collective perspective (service provider, clients and carers, and the community), at six months the incremental cost per healed ulcer was dollars AU515 (Euros 318) and the incremental cost per reduced pain score was dollars AU322 (Euros 199). For the service provider, Leg Club intervention resulted in cost savings and better health effects when compared with home nursing.

CONCLUSION

On both clinical and economic grounds, the Leg Club model appears to be more cost-effective than traditional home nursing for the treatment of chronic venous leg ulcers. However, clients and the local community contribute substantial financial and in-kind support to the operation of both services.

Group 3 chromosome bin maps of wheat and their relationship to rice chromosome 1

The focus of this study was to analyze the content, distribution, and comparative genome relationships of 996 chromosome bin-mapped expressed sequence tags (ESTs) accounting for 2266 restriction fragments (loci) on the homoeologous group 3 chromosomes of hexaploid wheat (Triticum aestivum L.). Of these loci, 634, 884, and 748 were mapped on chromosomes 3A, 3B, and 3D, respectively. The individual chromosome bin maps revealed bins with a high density of mapped ESTs in the distal region and bins of low density in the proximal region of the chromosome arms, with the exception of 3DS and 3DL. These distributions were more localized on the higher-resolution group 3 consensus map with intermediate regions of high-mapped-EST density on both chromosome arms. Gene ontology (GO) classification of mapped ESTs was not significantly different for homoeologous group 3 chromosomes compared to the other groups. A combined analysis of the individual bin maps using 537 of the mapped ESTs revealed rearrangements between the group 3 chromosomes. Approximately 232 (44%) of the consensus mapped ESTs matched sequences on rice chromosome 1 and revealed large- and small-scale differences in gene order. Of the group 3 mapped EST unigenes approximately 21 and 32% matched the Arabidopsis coding regions and proteins, respectively, but no chromosome-level gene order conservation was detected.

Development of an expressed sequence tag (EST) resource for wheat (Triticum aestivum L.): EST generation, unigene analysis, probe selection and bioinformatics for a 16,000-locus bin-delineated map

This report describes the rationale, approaches, organization, and resource development leading to a large-scale deletion bin map of the hexaploid (2n = 6x = 42) wheat genome (Triticum aestivum L.). Accompanying reports in this issue detail results from chromosome bin-mapping of expressed sequence tags (ESTs) representing genes onto the seven homoeologous chromosome groups and a global analysis of the entire mapped wheat EST data set. Among the resources developed were the first extensive public wheat EST collection (113,220 ESTs). Described are protocols for sequencing, sequence processing, EST nomenclature, and the assembly of ESTs into contigs. These contigs plus singletons (unassembled ESTs) were used for selection of distinct sequence motif unigenes. Selected ESTs were rearrayed, validated by 5' and 3' sequencing, and amplified for probing a series of wheat aneuploid and deletion stocks. Images and data for all Southern hybridizations were deposited in databases and were used by the coordinators for each of the seven homoeologous chromosome groups to validate the mapping results. Results from this project have established the foundation for future developments in wheat genomics.

Barriers to effective cancer pain management: a survey of Australian family caregivers

Cancer pain continues to be an important focus of health research and intervention development. The continuing shift of cancer care to the community increases the family caregiver's role in pain management and highlights the need to understand family experiences and also family barriers to effective pain management. This paper presents the findings of an Australian study exploring attitudinal barriers to effective pain management amongst 75 family caregivers of people with cancer attending an outpatient clinic. Approximately 75% of the caregivers demonstrated concerns or were unsure about addiction, a belief likely to impact on the use of prescribed opioids in the home. Caregivers demonstrated similar levels of concern about side-effects or whether the presence of pain indicated disease progression. These findings support research in other populations and are further evidence of the need to include family caregivers, along with patients, in intervention studies aimed at reducing the impact of these barriers on effective pain management.

External quality assessment schemes raise standards: evidence from the UKNEQAS parasitology subschemes

BACKGROUND

The burden of parasitic disease imported into the temperate zone is increasing, and in the tropics remains very high. Thus, high quality diagnostic parasitology services are needed, but to implement clinical governance a measure of quality of service is required.

AIM

To examine performance in the United Kingdom National External Quality Assessment Scheme for Parasitology for evidence of improved standards in parasite diagnosis in clinical specimens.

METHODS

Analysis of performance was made for the period 1986 to 2001, to look for trends in performance scores.

RESULTS

An overall rise in performance in faecal and blood parasitology schemes was found from 1986 to 2001. This was seen particularly in the identification of ova, cysts, and larvae in the faecal scheme, the detection of Plasmodium ovale and Plasmodium vivax in the blood scheme, and also in the correct identification of non-malarial blood parasites. Despite this improvement, there are still problems. In the faecal scheme, participants still experience difficulty in recognising small protozoan cysts, differentiating vegetable matter from cysts, and detecting ova and cysts when more than one species is present. In the blood scheme, participants have problems in identifying mixed malarial infections, distinguishing between P ovale and P vivax, and estimating the percentage parasitaemia. The reasons underlying these problems have been identified via the educational part of the scheme, and have been dealt with by distributing teaching sheets and undertaking practical sessions.

CONCLUSIONS

UK NEQAS for Parasitology has helped to raise the standard of diagnostic parasitology in the UK.

Single mutation (A162H) in human cardiac troponin I corrects acid pH sensitivity of Ca2+-regulated actomyosin S1 ATPase

In contrast to skeletal muscle, the efficiency of the contractile apparatus of cardiac tissue has long been known to be severely compromised by acid pH as in the ischemia of myocardial infarction and other cardiac myopathies. Recent reports (Westfall, M. V., and Metzger, J. M. (2001) News Physiol. Sci. 16, 278-281; Li, G., Martin, A. F., and Solaro, R. J. (2001) J. Mol. Cell. Cardiol. 33, 1309-1320) have indicated that the reduced Ca(2+) sensitivity of cardiac contractility at low pH (<or=pH 6.5) is attributable to structural difference(s) in the cardiac and skeletal inhibitory components (TnIs) of their troponins. Here, using a reconstituted Ca(2+)-regulated human cardiac troponin-tropomyosin actomyosin S1 ATPase assay, we report that a single TnI mutation, A162H, restores Ca(2+) sensitivity at pH 6.5 to that at pH 7.0. Levels of inhibition (pCa 7.0), activation (pCa 4.0), and cooperativity of ATPase activity were minimally affected. Two other mutations (Q155R and E164V) also previously suggested by us (Pearlstone, J. R., Sykes, B. D., and Smillie, L. B. (1997) Biochemistry 36, 7601-7606) and involving charged residues showed no such effects. With fast skeletal muscle troponin, a single TnI H130A mutation reduced Ca(2+) sensitivity at pH 6.5 to levels approaching the cardiac system at pH 6.5. These observations provide structural insight into long-standing physiological and clinical phenomena and are of potential relevance to therapeutic treatments of heart disease by gene transfer, stem cell, and cell transplantation approaches.

Factors influencing student nurses in their choice of a rural clinical placement site

INTRODUCTION

Rural health and government bodies have identified the need for greater numbers of health professionals in rural and remote health care settings. Providing students with the opportunity to experience a rural clinical placement has been suggested as one strategy for future health professionals to gain familiarity with the rural workplace and an awareness of the employment opportunities available in these areas. Although substantial numbers of student nurses have participated in a rural undergraduate clinical placement program at Queensland University of Technology, Australia, since 1996, available places remain unfilled. This study aimed to investigate the factors influencing student nurses in their choice of a rural or metropolitan clinical placement.

METHODS

This study utilised a descriptive survey design. In the 24-item questionnaire, questions related to demographics, previous experience of a rural lifestyle, previous work experience and issues of importance regarding the clinical placement experience. All final-year Bachelor of Nursing students in the year 2000 (n = 212) were included in the sample, with a 65% response rate for the pre-test (n = 137). Frequency distributions, chi2 analysis (for nominal data) and ANOVA (for interval data) were used to describe differences between the characteristics of students choosing a rural or remote placement and students choosing a metropolitan placement.

RESULTS

Findings demonstrated that possession of a rural background, previous work experience in a rural community and family, financial and/or employment commitments all influenced students' choice of undertaking a rural clinical placement.

CONCLUSION

Students who have previously lived and/or worked in a rural area are more likely to choose a rural setting for clinical placements or postgraduate employment. However, the value of rural clinical placements as a method of increasing awareness of employment opportunities in the rural setting is considerable. Family, financial and employment commitments should be considered in the development of recruitment and retention strategies for health professionals to rural areas.

Nuclear-labeling index analysis (NLIA), a software package used to perform accurate automation of cell nuclear-labeling index analysis on immunohistochemically stained rat liver samples

The nuclear labeling index (labeled nuclei/100 nuclei) and the apoptotic index (apoptotic cells/100 cells) are important parameters of cell growth and death. Automatic counting of labeled nuclei is desirable since manual counting is tedious, time-consuming, and with a greater potential for inaccuracies. A nuclear-labeling index analysis (NLIA) software package was developed in this laboratory to perform the counting process automatically and accurately. This software package consists of an application program NLIA and a set of macros for obtaining nuclear data that is used in Scion Image. It is designed to work cooperatively with Scion Image, Adobe Photoshop, and Microsoft Office. NLIA has two basic functions: building nuclear data files and analyzing nuclear data. A color image captured from an immunohistochemically stained or autoradiographic sample is loaded into NLIA. Nuclear data can be entered into the program manually, automatically, or in combination. In the manual data entering mode, NLIA acts as an object-counting tool, while in the automatic mode it acts as a data picker: picking up the data generated by Scion Image into memory. A method to enter nuclear data (both labeled nuclei and unlabeled nuclei) in the automatic mode is described. The color image is processed in Adobe Photoshop, where the interested color ranges are selected and separated. These are then analyzed in Scion Image with the help of the macros for obtaining nuclear data. Since the advanced particle analysis function is used, the counting process is automatic and rapid. Data from thousands of nuclei can be obtained within seconds. To ensure the accuracy of the analysis, a nuclear data checking and edit feature is employed in NLIA: results of computer-generated counting can be compared with the original color image by overlaying the plot of counting results onto the original color image. In this way any computer counting mistakes can be easily discovered and corrected by the operator. Corrected nuclear data (including nuclear size, location, shape) are then stored in data files. These data files can be used in NLIA to obtain cell density and nuclear labeling indices. Because criteria for obtaining nuclear data (truncation diameter, shape factor) can be set by the operator in NLIA, nuclear size distribution and shape variation can be analyzed. This method provides a fast and accurate way to determine cell nuclear-labeling indices. Currently, Scion Image is a freeware on the internet, and NLIA software package is available from our lab home page. Methods presented here expand the Scion Image ability to analyze color images by using color separation techniques in a commercial graphic application. The instrumentation required can be relatively inexpensive, and the methods described may be useful in studies of cell kinetics, lesion growth, and tumor therapy.

Inhibition of EGF-dependent calcium influx by annexin VI is splice form-specific

Annexin VI is a widely expressed calcium- and phospholipid-binding protein that lacks a clear physiological role. We now report that A431 cells expressing annexin VI are defective in their ability to sustain elevated levels of cytosolic Ca(2+) following stimulation with EGF. Other aspects of EGF receptor signaling, such as protein tyrosine phosphorylation and induction of c-fos are normal in these cells. However, EGF-mediated membrane hyperpolarization is attenuated and Ca(2+) entry abolished in cells expressing annexin VI. This effect of annexin VI was only observed for the larger of the two annexin VI splice forms, the smaller splice variant had no discernable effect on either cellular phenotype or growth rate. Inhibition of Ca(2+) influx was specific for the EGF-induced pathway; capacitative Ca(2+) influx initiated by emptying of intracellular stores was unaffected. These results provide the first evidence that the two splice forms of annexin VI have different functions.

Avoidance of issues in family caregiving

Effective communication between older people and their family carers is necessary for providing appropriate and quality care. However, family carers and carereceivers may avoid discussing issues of concern and this may adversely affect the quality of the caring relationship. This study investigated the content of, and avoidance of issues in communication between 84 spousal and filial carers and carereceivers. The study findings indicate that family carers and carereceivers do avoid discussing issues of concern. Nurses working with families are well placed to promote more effective communication in the caring context to augment more satisfying caring relationships for both carers and carereceivers.

Pain and the administration of analgesia: what nurses say

Pain of moderate to severe intensity continues to be an important problem for many hospitalized patients. Nurses spend more time with patients than any other health professional group and have a key role to play in the management of patients' pain. This paper reports the findings from a series of focus group interviews which were undertaken to explore nurses' perceptions regarding pain and the administration of narcotic analgesia. Themes identified from participants' comments related to (1) the pivotal role of nurses in pain management; (2) nursing assessment and pain management decisions (3) individual factors influencing nurses' pain management decisions and (4) the influence of others on nurses' pain management decisions.

The prevalence and perception of pain amongst hospital in-patients

The aim of this paper is to describe the prevalence and perceptions of pain and pain management amongst hospital in-patients. A cross-sectional descriptive survey of 205 patients was conducted. Presence and severity of pain was assessed using verbal descriptor and visual analogue scales, and perceptions of pain were assessed using multi-item scales. Although the severity of pain reported was consistent across age groups and clinical areas, women in the study sample were significantly more likely to report high levels of pain than men. Differences in how men and women communicate their pain were observed, with women indicating that they were less willing to ask for help with their pain. Results suggest that pain continues to be an important problem for a large number of men and women in hospital, and that the experience of pain impacts negatively upon their well-being. Gender differences in the experience of and response to pain remain important considerations for clinical nurses who have major responsibilities for the management of pain in hospitalized patients.

Perceived social support and community adaptation in schizophrenia

Prompted by the continuing transition to community care, mental health nurses are considering the role of social support in community adaptation. This article demonstrates the importance of distinguishing between kinds of social support and presents findings from the first round data of a longitudinal study of community adaptation in 156 people with schizophrenia conducted in Brisbane, Australia. All clients were interviewed using the relevant subscales of the Diagnostic Interview Schedule to confirm a primary diagnosis of schizophrenia. The study set out to investigate the relationship between community adaptation and social support. Community adaptation was measured with the Brief Psychiatric Rating Scale (BPRS), the Life Skills Profile (LSP) and measures of dissatisfaction with life and problems in daily living developed by the authors. Social support was measured with the Arizona Social Support Interview Schedule (ASSIS). The BPRS and ASSIS were incorporated into a client interview conducted by trained interviewers. The LSP was completed on each client by an informal carer (parent, relative or friend) or a professional carer (case manager or other health professional) nominated by the client. Hierarchical regression analysis was used to examine the relationship between community adaptation and four sets of social support variables. Given the order in which variables were entered in regression equations, a set of perceived social support variables was found to account for the largest unique variance of four measures of community adaptation in 96 people with schizophrenia for whom complete data are available from the first round of the three-wave longitudinal study. A set of the subjective experiences of the clients accounted for the largest unique variance in measures of symptomatology, life skills, dissatisfaction with life, and problems in daily living. Sets of community support, household support and functional variables accounted for less variance. Implications for mental health nursing practice are considered.

Why "sounds are judged longer than lights": application of a model of the internal clock in humans

Three experiments, using temporal generalization and verbal estimation methods, studied judgements of durations of auditory (500-Hz tone) and visual (14-cm blue square) stimuli. With both methods, auditory stimuli were judged longer, and less variable, than visual ones. The verbal estimation experiments used stimuli from 77 to 1183 msec in length, and the slope of the function relating mean estimate to real length differed between modalities (but the intercept did not), consistent with the idea that a pacemaker generating duration representations ran faster for auditory than for visual stimuli. The different variability of auditory and visual stimuli was attributed to differential variability in the operation of a switch of a pacemaker-accumulator clock, and experimental data suggested that such switch effects were separable from changes in pacemaker speed. Overall, the work showed how a clock model consistent with scalar timing theory, the leading account of animal timing, can address an issue derived from the classical literature on human time perception.

Treating skin tears in nursing home residents: a pilot study comparing four types of dressings

A pilot study was conducted to compare four types of dressings used to treat skin tears in nursing home residents. Wounds treated with a non-occlusive dressing healed more quickly than those dressed with occlusive dressings. The results suggest that ease of use and product wastage are important considerations when treating skin tears. The pilot study also highlights the need for further research into skin tear management and the need for ongoing education for nurses regarding skin integrity risk assessment and product information.

Can cocaine addicts with severe mental illness be treated along with singly diagnosed addicts?

Large numbers of indigent cocaine abusers now present in center-city hospitals. Since many are also diagnosed for severe mental illness, options for their effective treatment are needed. The authors investigated the feasibility of treating these dually diagnosed patients along with the majority of abusers who were not severely impaired in a program that combines peerled treatment with psychiatric management and pharmacotherapy. Although group confrontation techniques were used, schizophrenics (N = 71) and patients with major depressive disorder (N = 50) experienced an outcome as good or better than the less impaired (N = 177) on retention, visit rates, and urinalysis results.

Speeding up an internal clock in humans? Effects of click trains on subjective duration

Four experiments investigated the effect of trains of clicks (usually 5 s long and at 5 or 25 Hz) on subjective duration in humans, as previous research had suggested that such a manipulation would speed up the pacemaker of an internal clock by increasing participants' arousal. The four experiments used temporal generalization, pair comparison of duration, verbal estimation, and production of short durations. In all cases, preceding the durations to be judged by clicks changed their subjective length in a manner broadly consistent with the idea that pacemaker speed was increased, by an average of about 10%.

Speeding up an internal clock in humans? Effects of click trains on subjective duration

Four experiments investigated the effect of trains of clicks (usually 5 s long and at 5 or 25 Hz) on subjective duration in humans, as previous research had suggested that such a manipulation would speed up the pacemaker of an internal clock by increasing participants' arousal. The four experiments used temporal generalization, pair comparison of duration, verbal estimation, and production of short durations. In all cases, preceding the durations to be judged by clicks changed their subjective length in a manner broadly consistent with the idea that pacemaker speed was increased, by an average of about 10%.

Treatment of perinatal cocaine addiction: use of the modified therapeutic community

Treatment outcome was evaluated for perinatal cocaine addicts admitted to a hospital-based day treatment clinic, organized as a modified therapeutic community (TC) modality. The perinatal program consisted of a specialized track for women embedded within this larger coed day treatment clinic. A total of 87 perinatal women (28 pregnant at intake, the remaining 59 postpartum) were compared with cohorts of nonperinatal women (N = 63) and men (N = 158) admitted during the period of evaluation (September 1989 through December 1993). In logistic regression analysis, successful discharge urine status (last three urines prior to discharge drug-free) was associated with current child custody involvement (odds ratio = 2.80, 95% C.I. = 1.16-6.72), entering treatment when not postpartum (odds ratio = 0.15, 95% C.I. = 0.05-0.42), and taking psychiatric medication (odds ratio = 2.04, 95% C.I. = 1.11-3.72). Both pregnant and postpartum perinatal women showed a similar pattern of shorter treatment as compared with nonperinatal women and male clients, averaging 2 months of treatment as compared with 4 months for nonperinatal clients. Factoring out pregnancy and postpartum status, the women in treatment fared as well as men with respect to both retention and discharge urine standings. This finding indicates that programmatic modifications need to address specific perinatal issues and not gender issues per se. Also, a differential pattern in discharge urine status of women who enter treatment while pregnant vs. those who enter when postpartum suggests that outreach and recruitment be targeted, but not limited, to pregnant women.

Effects of a minor isoleucyl tRNA on heterologous protein translation in Escherichia coli

In Escherichia coli, the isoleucine codon AUA occurs at a frequency of about 0.4% and is the fifth rarest codon in E. coli mRNA. Since there is a correlation between the frequency of codon usage and the level of its cognate tRNA, translational problems might be expected when the mRNA contains high levels of AUA codons. When a hemagglutinin from the influenza virus, a 304-amino-acid protein with 12 (3.9%) AUA codons and 1 tandem codon, and a mupirocin-resistant isoleucyl tRNA synthetase, a 1,024-amino-acid protein, with 33 (3.2%) AUA codons and 2 tandem codons, were expressed in E. coli, product accumulation was highly variable and dependent to some degree on the growth medium. In rich medium, the flu antigen represented about 16% of total cell protein, whereas in minimal medium, it was only 2 to 3% of total cell protein. In the presence of the cloned ileX, which encodes the cognate tRNA for AUA, however, the antigen was 25 to 30% of total cell protein in cells grown in minimal medium. Alternatively, the isoleucyl tRNA synthetase did not accumulate to detectable levels in cells grown in Luria broth unless the ileX tRNA was coexpressed when it accounted for 7 to 9% of total cell protein. These results indicate that the rare isoleucine AUA codon, like the rare arginine codons AGG and AGA, can interfere with the efficient expression of cloned proteins.

Perceptions of stressors and reported coping strategies in nurses caring for residents with Alzheimer's disease in a dementia unit

A study was undertaken on the perceptions of stressors and coping behaviours in a group of nurses caring for residents with Alzheimer's disease in a dementia unit. The purpose of this paper is to report on the preliminary findings of the study. Repertory grid data were used to explore how nurses perceive residents, the stressors nurses experience in their work, and the coping strategies nurses use when caring for residents. The nurses identified 92 sources of stress, 683 coping behaviours and 708 coping strategies. Analyses of selected repertory grid data are presented and the stressors reported by the nurses are summarized. The coping strategies the nurses report using are classified into categories of adaptive and maladaptive responses to stress. In addition, the nursing implications of the coping strategies used by the nurses are also considered.