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.

Zebrafish genetic map with 2000 microsatellite markers

The zebrafish is the first vertebrate organism used for large-scale genetic screens seeking genes critical to development. These screens have been quite successful, with more than 1800 recessive mutations discovered that speak to morphogenesis of the vertebrate embryo. The cloning of the mutant genes depends on a dense genetic map. The 2000 markers we present here, using microsatellite (CA) repeats, provides 1.2-cM average resolution. One centimorgan in zebrafish is about 0. 74 megabase, so, for many mutations, these markers are close enough to begin positional cloning by YAC walks.

Guidelines for low back pain: changes in GP management

BACKGROUND

Management guidelines are aimed at reducing inappropriate practice and improving efficiency; however, the effectiveness of many guidelines has yet to be confirmed. This study targets GPs' management of back pain and its relationship with the recent management guidelines.

OBJECTIVES

We aimed to investigate changes in GP management of low back pain, low back pain episode duration and time before consultation, over a 5-year period.

METHOD

A case series report of 574 patient notes was collected from a large practice in North Yorkshire (January 1992-March 1997). In addition, 713 referral notes from 26 practices across North Yorkshire were collected. The patients were potential subjects for a larger randomized controlled trial evaluating the effectiveness of an exercise programme. Both groups of data were analysed by identifying trends over time and using log linear regression.

RESULTS

Recommendation of activity or exercise was found to be a trend increasing over time. In contrast, recommendation to rest was found to be a trend decreasing over time. Activity or exercise was more frequently recommended to younger patients. There was evidence that individuals are seeking a GP consultation more quickly.

CONCLUSIONS

The gap between GP practice and the recent guidelines appears to be reducing. However, many variations in practice still exist. Evidence of decreasing time before consultations may indicate that the level of self-care by low back pain patients is decreasing. Although management guidelines may have some effect, there is some way to go before back pain management is optimized.

Exploring the expanded role of nurses in critical care

This paper reports on a small research study that explored the perceptions of staff in an intensive/coronary/high-dependency care unit on the expanded role of nurses in critical care. The research was undertaken in two phases. In the first phase, focus groups and interviews of nursing and medical staff were used as methods to explore their perceptions. Data were analysed by thematic content analysis and generated four categories: specialized skills; maintaining competence; how far nurses can go; and training and education. Using verbatim examples from the participants, these categories are described. In summary, it was found that both doctors and nurses were in favour of nursing role developments, and for the nurses this was driven by their desire to meet the patients' needs. In a smaller second phase, a questionnaire was developed based on information gained in the first phase. It was utilized to seek the views of all the nursing staff on specific role-expansion activities. Findings revealed substantial support for developing the role of critical care nurses in a number of activities: cannulation; venepuncture; ordering blood tests and X-rays; performing physiotherapy; inserting arterial lines; performing elective cardioversion; thrombolysis treatment and intubation. This research study has yielded important information. However, it is recognized that, whilst these roles may be new to this particular critical care unit, there are many other units where they may already be common practice. Whenever new roles are developed, it is important to evaluate their effectiveness in measurable terms and regular audit is advisable. Further research is therefore recommended on both the development and evaluation of new roles in critical care.

Leaf senescence is delayed in tobacco plants expressing the maize homeobox gene knotted1 under the control of a senescence-activated promoter

Leaf senescence is an active process involving remobilization of nutrients from senescing leaves to other parts of the plant. Whereas senescence is accompanied by a decline in leaf cytokinin content, supplemental cytokinin delays senescence. Plants that overexpress isopentenyl transferase (ipt), a cytokinin-producing gene, or knotted1 (kn1), a homeobox gene, have many phenotypes in common. Many of these phenotypes are characteristic of altered cytokinin physiology. The effect of kn1 on leaf senescence was tested by driving its expression using the promoter of the senescence-associated gene SAG12. SAG:kn1 tobacco plants showed a marked delay in leaf senescence but otherwise developed normally. The delay in senescence was revealed by an increase in chlorophyll content in SAG:kn1 leaves relative to leaves of the control plants and by a decrease in the number of dead leaves. Senescence was also delayed in detached leaves of SAG:kn1 plants. Delayed senescence was accompanied by increased leaf cytokinin content in older leaves expressing kn1. These experiments extend the current understanding of kn1 function and suggest that in addition to mediating meristem maintenance, kn1 is capable of regulating the onset of senescence in leaves.

Studies of human immunodeficiency virus type 1 mucosal viral shedding and transmission in Kenya

If human immunodeficiency virus type 1 (HIV-1) vaccines are to be highly effective, it is essential to understand the virologic factors that contribute to HIV-1 transmission. It is likely that transmission is determined, in part, by the genotype or phenotype (or both) of infectious virus present in the index case, which in turn will influence the quantity of virus that may be exchanged during sexual contact. Transmission may also depend on the fitness of the virus for replication in the exposed individual, which may be influenced by whether a virus encounters a target cell that is susceptible to infection by that specific variant. Of interest, our data suggest that the complexity of the virus that is transmitted may be different in female and male sexual exposures.

Cofactors for the acquisition of HIV-1 among heterosexual men: prospective cohort study of trucking company workers in Kenya

OBJECTIVE

To determine the prevalence, incidence, and correlates of HIV-1 infection in a cohort of east African trucking company employees.

METHODS

HIV-1-seronegative trucking company employees were enrolled in a prospective cohort study and evaluated at 3 monthly intervals for HIV-1 seroconversion, sexually transmitted diseases, and sexual behavior.

RESULTS

The baseline seroprevalence of HIV-1 among 1500 trucking company employees was 17.8%. Among 752 HIV-1-seronegative men who were followed, the HIV-1 annual seroincidence was 3.1%. In univariate analysis, HIV-1 acquisition was associated with age under 25 years, 10 years or less of sexual activity, occupation as a driver/driver's assistant, occupational travel for more than 14 days per month, religion other than Christian or Muslim, uncircumcised status, sex with a prostitute, sex with a girlfriend/casual partner, extramarital sex, and enrollment seropositivity to Treponema pallidum, Haemophilus ducreyi, and Herpes simplex virus type 2 (all P values < or = 0.05). Using multivariate analysis, HIV-1 acquisition was independently associated with 10 years or less of sexual activity (hazard rate ratio (HRR) 2.0, 95% confidence interval (CI) 1.0-4.3), occupation as a driver/driver's assistant (HRR 3.9, 95% CI 1.7-9.0), religion other than Christian or Muslim (HRR 6.1, 95% CI 1.4-25.7), uncircumcised status (HRR 2.3, 95% CI 1.0-5.0), and unprotected sex with a prostitute (HRR 2.8, 95% CI 1.1-7.0).

CONCLUSIONS

Trucking company employees had a high HIV-1 seroprevalence rate at enrollment and a high HIV-1 seroincidence during follow-up. Risk factors for HIV-1 seroconversion included years of sexual activity, occupation, religion, uncircumcised status, and unprotected sex with a prostitute. This population is an appropriate target for HIV-1 prevention trials and behavioral interventions.

Ovarian cancer: an update for nursing practice

A diagnosis of ovarian cancer is a crisis for any woman. Ovarian cancer has the highest mortality of all the gynaecological cancers. In addition to the very real threat of death, such a diagnosis raises critical issues concerning femininity, motherhood and sexuality. The high mortality associated with this disease is due (in part) to problems associated with early diagnosis. Women frequently experience non-specific symptoms, which may be attributed to other, less alarming causes. The lack of specific symptoms experienced by women, as well as the lack of effective mass screening strategies, make early detection difficult. This makes it crucial that nurses involved in the care of women be alert to the insidious and non-specific onset of this serious condition.

The experience of hope for survivors of acute myocardial infarction (AMI): a qualitative research study

This qualitative study was undertaken to explore the relevance and meaning of the experience of hope for survivors of acute myocardial infarction (AMI). Depth interviews were conducted with eight survivors (n = 8) of AMI at four weeks following discharge from hospital. Analysis of transcribed interviews revealed three distinct narrative themes. These were holding on to human connectedness, finding and harnessing the 'will' to live, and, having faith in the primacy of a higher power. Study findings are discussed in relation to the literature. Findings of the study assist in building knowledge and understanding of the complex phenomenon of hope. Implications for nursing practice and research are drawn from study findings.

Postacute care for older aboriginal people: an exploratory-descriptive study

Many Aboriginal people reside in rural and remote Australia. Aboriginal health workers were the informants in this exploratory-descriptive study, which explored issues pertaining to postacute care for older Aboriginal people. Qualitative analysis of interview data revealed several issues were viewed as being of crucial importance in the provision of effective postacute services to older Aboriginal people. These were: (i) identification of Aboriginality; (ii) perceived racism and stereotypical attitudes among hospital staff and healthcare workers; and (iii) effective discharge planning. Other issues which were believed to impact upon service use were identified as: (i) availability of services; (ii) knowledge of services and level of use; and (iii) the notion of mainstream versus Aboriginal-specific services. Findings are discussed in relation to available literature. Implications for further research are drawn from the findings of this exploratory study.

Control of phyllotaxy in maize by the abphyl1 gene

Organogenesis in plants occurs at the shoot apical meristem, a group of indeterminate stem cells that are organized during embryogenesis. Regulated initiation of leaves or flowers from the shoot meristem gives rise to the familiar geometric patterns observed throughout the plant kingdom. The mechanism by which these patterns, termed phyllotaxies, are generated, remains unclear. Maize plants initiate leaves singly, alternating from one side to the other in a regular pattern. Here we describe a recessive maize mutant, abphyl1, that initiates leaves in opposite pairs, in a pattern termed decussate phyllotaxy. The decussate shoot meristems are larger than normal throughout development, though the general structure and organization of the meristem is not altered. abph1 mutants are first distinguished during embryogenesis, prior to true leaf initiation, by a larger shoot meristem and coincident larger expression domain of the homeobox gene knotted1. Therefore, the abph1 gene regulates morphogenesis in the embryo, and plays a role in determining the phyllotaxy of the shoot.

Towards (re)conciliation: (re)constructing relationships between indigenous health workers and nurses

Currently in Australia, both Aboriginal and non-Aboriginal Australians are attempting to reconcile themselves with a history of colonization/invasion, which resulted in human rights violations against Australia's indigenous people. Australian nursing has to examine its past in relation to the treatment of Aboriginal Australians. Relationships between nurses and Aboriginal health workers are the most commonly occurring professional relationships between nurses and Aboriginal people and are of key importance to the successful delivery of health services to Aboriginal communities. This qualitative study, grounded in feminism, aimed to explore the professional relationships between Aboriginal health workers and nurses and to develop insights which could assist the Australian nursing profession through a process of reconciliation with Aboriginal Australians. Feminist analysis of narrative text revealed several key themes as being crucial to this process. These were: learning to know and understand; towards workplace equity; and skill sharing -- learning from each other. Implications for nursing, in its journey toward reconciliation with Aboriginal Australians, are drawn from this study.

The experiences of female spouses of survivors of acute myocardial infarction: a pilot study of Lebanese-born women in south-western Sydney, Australia

Lebanese migrants form a significant proportion of the population in southwestern Sydney (SWS), and in New South Wales, Australia. This pilot study was undertaken in south-western Sydney, a rapidly expanding and socioeconomically disadvantaged region, to explore the experiences of English speaking women of Lebanese origin whose spouses had recently experienced an acute myocardial infarction (AMI). Semi-structured interviews were conducted with seven Lebanese-born women at 2- and 4-week intervals, following the discharge of their husbands from hospital. Qualitative analysis of narrative text revealed four distinct themes. These were: struggle to resolve distress; intensive monitoring of the AMI survivor; searching for avenues of support; and reflecting on the future. Study findings are discussed in relation to the literature. Implications for nursing practice and research are drawn from study findings.

Occurrence of hemophilia in the United States. The Hemophilia Surveillance System Project Investigators

An active surveillance system was used to identify all residents with hemophilia in six U.S. states (Colorado, Georgia, Louisiana, Massachusetts, New York, and Oklahoma). A hemophilia case was defined as a person with physician-diagnosed hemophilia A or B and/or a measured baseline factor VIII or IX activity (FA) of 30% or less. Case-finding methods included patient reports from physicians, clinical laboratories, hospitals, and hemophilia treatment centers. Once identified, trained data abstractors collected clinical and outcome data retrospectively from medical records. Among cases identified in 1993-1995, 2,743 were residents of the six states in 1994, of whom 2,156 (79%) had hemophilia A. Of those with available FA measurements, 1,140 (43%) had severe (FA < 1%), 684 (26%) had moderate (FA 1%-5%), and 848 (31%) had mild (FA 6%-30%) disease. The mean and median age was 25.4 and 23 years, respectively. The age-adjusted prevalence of hemophilia in all six states in 1994 was 13.4 cases/100,000 males (10.5 for hemophilia A and 2.9 for B). The prevalence by race/ethnicity was 13.2 cases/100,000 among white, 11.0 among African American, and 11.5 among Hispanic males. Application of age-specific prevalence rates from the six surveillance states to the U.S. population resulted in an estimated national population of 13,320 cases of hemophilia A and 3,640 cases of hemophilia B. For the 10-year period 1982-1991, the average incidence of hemophilia A and B in the hemophilia surveillance system (HSS) states was estimated to be 1 in 5,032 live male births.

Subsensitivity to dopaminergic drugs in periadolescent rats: a behavioral and neurochemical analysis

It has been reported that post-natal day (PD) 30-40 rats respond differently to the behavioral effects of dopaminergic drugs when compared to younger or older rats. In this study, the behavioral effects of amphetamine (AMPH) on motor behavior and the effects of dopaminergic drugs on striatal acetylcholine (ACh) release were evaluated in periadolescent (PD35) and adult rats. AMPH increased dopamine (DA)-mediated motor behaviors (locomotor activity and stereotypy) in periadolescent and adult rats; however, these responses were of a lesser magnitude in periadolescent rats. In adult rats, cocaine and nomifensine inhibited ACh overflow in a dose-dependent manner. In periadolescent rats, ACh overflow was maximally inhibited at a lower drug concentration (5 microM) than in adult rats (10 microM) signifying increased sensitivity in these rats. Apomorphine inhibited ACh overflow in a dose-dependent fashion in slices from adult rats. In contrast, apomorphine did not consistently inhibit ACh overflow in striatal slices prepared from periadolescent rats. Collectively, the results of this study demonstrate behavioral subsensitivity to AMPH in periadolescent rats. Examination of the effects of DA reuptake blockers on DA modulation of striatal cholinergic neurons failed to reveal a corresponding subsensitivity. In fact, ACh release was more sensitive to DA reuptake blockers in periadolescent rats. This latter finding suggests that undisclosed factors override dopaminergic modulation of striatal neurons in the mediation of behavior in periadolescent rats. We propose that during periadolescence, DA transmission is transiently elevated. This results in post-synaptic supersensitivity of cholinergic receptors and consequently induces behavioral subsensitivity when challenged with dopaminergic drugs. Increased cholinergic tone may mediate behavioral subsensitivity despite drug-induced elevations in DA.

Streptococcal emm types associated with T-agglutination types and the use of conserved emm gene restriction fragment patterns for subtyping group A streptococci

The T-agglutination types were determined for a diverse collection of 1531 group A streptococci for which the 5' M protein gene (emm) sequences had been analysed. The majority of the T-agglutination types correlated with previously seen M/emm/T-type associations; however, several new associations were found. Analysis of a subset of this collection -- which included 1157 clinical isolates with multiply encountered emm types -- found that emm amplicon restriction profiles of isolates sharing identical T types and opacity factor phenotypes are useful for detecting groups of isolates with identical emm genes. Many emm genes of known 5' sequence display a highly conserved restriction pattern amongst clinical isolates widely separated both geographically and temporally.

Differential onset of median nerve block: randomized, double-blind comparison of mepivacaine and bupivacaine in healthy volunteers

We have compared the delay in onset of 1% mepivacaine and 0.33% bupivacaine in different nerve fibre types in 10 volunteers undergoing median nerve blocks, in a randomized, double-blind, crossover study. Hot, cold, pinprick and light touch sensations, compound motor action potentials (CMAP), sensory nerve action potentials (SNAP) and skin temperature were recorded at 2-min intervals. Hot, cold, pinprick, light touch sensations, SNAP and CMAP were significantly inhibited, and skin temperature was significantly increased after administration of both agents. The first noticeable reduction in cold sensation was detected later after bupivacaine compared with mepivacaine, but after a delay similar to that of other nerve functions. Bupivacaine and mepivacaine inhibited SNAP and CMAP with a similar time delay to steady-state. Bupivacaine produced steady-state inhibition of hot and cold sensations significantly later than mepivacaine; nevertheless, the sequence that sensory modalities failed, with few exceptions, and the extent of anaesthesia at 40 min were similar for both agents. Our technique provides a novel, multi-modal method of comparing local anaesthetics and related agents over time.

Idealised versus tainted femininity: discourses of the menstrual experience in Australian magazines that target young women

Information and messages concerning health-related issues are not confined to material provided by official figures or sources. Much information exists in the community and comes from a variety of sources. One such source is the media. This paper reports the findings of a study conducted over a 12-month period of advertisements for menstrual products in a selection of four monthly Australian magazines (n = 48) directed towards young women. The study examined the way in which menstruation and the menstrual experience were depicted in terms of page space, textual content and visual images. Findings revealed that advertisements for menstrual products provided confusing, conflicting and paradoxical messages. These included stressing the normality of menstruation while also emphasising the importance of keeping it hidden and secret. Menstruation was depicted as being a state of tainted (idealised) femininity because of the potential for the menstrual silence to be shattered by people finding out. Protection failure was depicted as being the ultimate in tainted femininity and a result of a woman's incorrect choice of product. Choosing menstrual-care products was depicted as simple but, paradoxically, complex and confusing. Women were depicted as liberated and sophisticated but images and language related to infancy were used. Freedom and liberation were conferred by the use of the advertised product. Overall, in common with previous studies, menstruation was depicted as a crisis of hygiene that is a risk to femininity. Advertisements for pantyliners suggest that femininity itself poses a threat to (idealised) femininity. This study demonstrates the crucial role of the media as a source of health information for young women.

Vancomycin resistant enterococcus in a hospital-based dialysis unit

OBJECTIVE

The emergence of vancomycin resistant enterococcus (VRE) poses a serious threat to the health care community. Reservoirs of VRE are thought to exist in certain high-risk patient groups who reintroduce the organism into the hospital environment. The frequent use of vancomycin in dialysis patients may place this population at higher risk of developing VRE. This article describes the development of VRE and a point prevalence study conducted in a hospital-based dialysis unit.

SETTING/SAMPLE

A dialysis unit of a tertiary care center in the eastern United States was selected as the study site. Patients who agreed to participate in the study after giving informed consent were included. Of the 85 members of this target population 33 (38.8%) agreed to participate in the study. The duration of the study was 30 days.

DESIGN

After the literature was reviewed, a point prevalence study was completed at the study site. Stool samples or rectal swabs were collected from the study participants and analyzed for the presence of VRE. A chart review of patient demographic and prior treatment information was completed in order to help identify factors that correlate to the presence of VRE.

METHODS

Stool or rectal swab samples were cultured on selective media and sensitivity to vancomycin was measured.

RESULTS

A 9.1% prevalence of VRE was detected within the study group. The number of VRE positive subjects (3) did not allow statistically significant correlation with the demographic and prior treatment data collected.

CONCLUSION

Although VRE remains a serious threat to the health care community, the prevalence of VRE within the study group does not vary markedly from rates previously reported.

The BirthPlace collaborative practice model: results from the San Diego Birth Center Study

Objective: The search for quality, cost-effective health care programs in the United States is now a major focus in the era of health care reform. New programs need to be evaluated as alternatives are developed in the health care system. The BirthPlace program provides comprehensive perinatal services with certified nurse-midwives and obstetricians working together in an integrated collaborative practice serving a primarily low-income population. Low-risk women are delivered by nurse-midwives in a freestanding birth center (The BirthPlace), which is one component of a larger integrated health network. All others are delivered by team obstetricians at the affiliated tertiary hospital. Wellness, preventive measures, early intervention, and family involvement are emphasized. The San Diego Birth Center Study is a 4-year research project funded by the U.S. Federal Agency for Health Care Policy and Research (#R01-HS07161) to evaluate this program. The National Birth Center Study (NEJM, 1989; 321(26): 1801-11) described the advantages and safety of freestanding birth centers. However, a prospective cohort study with a concurrent comparison group of comparable risk had not been conducted on a collaborative practice-freestanding birth center model to address questions of safety, cost, and patient satisfaction.Methods: The specific aims of this study are to compare this collaborative practice model to the traditional model of perinatal health care (physician providers and hospital delivery). A prospective cohort study comparing these two health care models was conducted with a final expected sample size of approximately 2,000 birth center and 1,350 traditional care subjects. Women were recruited from both the birth center and traditional care programs (private physicians offices and hospital based clinics) at the beginning of prenatal care and followed through the end of the perinatal period. Prenatal, intrapartum, postpartum and infant morbidity and mortality are being compared along with cost-effectiveness and acceptance of the model by patients. Data collection occurred primarily through medical record abstraction with the addition of two patient questionnaires. Comparability of the cohorts was established by using a validated methodology to determine medical/perinatal risk and birth center eligibility, which included assessment by two CNMs and an independent blind review by a perinatologist. The cost analysis uses a resource-utilization approach and new methodologies such as activity-based-costing to compare costs from both the perspective of the payor and the health care provider. Patient satisfaction was measured using a self-administered patient questionnaire.Results: Current preliminary results from approximately 38% of the final expected study sample are available. Crude and adjusted analysis have been conducted. Overall, the preliminary results suggest similar morbidity and mortality in the two groups. Fetal deaths are 0.75% in the index and 0.64% in the comparison group, with early neonatal deaths at 0.26% and 0.23%, respectively. The traditional care group showed adjusted rate differences of 5.83% more major maternal intrapartum complications and 9% more NICU admissions. While the birth center group showed adjusted rate differences of 5.5% more low birth weight and 0.95% more preterm birth. For other outcomes, the birth center group showed an adjusted rate difference of 22.34% more exclusive breastfeeding at discharge. Also, there was less utilization of cesarean section and assisted delivery in the birth center group as compared to the traditional care group. The adjusted rate difference for normal spontaneous vaginal deliveries in nulliparas was 10.23% more in the birth center group, with similar results in multiparas with and without history of cesarean (28.88% and 7.84%, respectively). Preliminary results also show that the average total cost for pregnancy-related services paid by California Medicaid was $4,550 for the birth center and $5,535 for the traditional care group. Final results based on the full study sample (full data available February 1998) details of payor costs such as provider, facility, NICU, and ancillary along with costs from the health care system perspective and patient satisfaction results will be presented.Conclusion: Current results suggest similar morbidity and mortality between the birth center program and traditional care groups, with less resource utilization translating to lower costs in the collaborative practice model. Results suggest that collaborative practice using a freestanding birth center as an adjunct to an integrated perinatal health care system may provide a quality, lower-cost alternative for the provision of perinatal services.

Definition of T cell epitopes within the 19 kDa carboxylterminal fragment of Plasmodium yoelii merozoite surface protein 1 (MSP1(19)) and their role in immunity to malaria

MSP1(19) is one of the leading malaria vaccine candidates. However, the mechanism of protection is not clear. To determine whether MSP1(19)-specific effector T cells can control parasitaemia, we analysed the specificity of T cells induced following immunization with recombinant forms of P. yoelii MSP1(19) and asked whether they could protect mice. There was no evidence that effector T cells were capable of protecting since: (1) immunization of mice with yMSP1(19), but not defined epitopes, was able to induce protection; and (2) long term MSP1(19)-specific CD4+ T cell lines were incapable of adoptively transferring protection. In contrast, priming mice with the T cell epitopes resulted in a rapid anamnestic antibody response to MSP1(19) after either challenge with MSP1(19) or parasite. Thus, MSP1(19) contains multiple T cell epitopes but such epitopes are the targets of helper T cells for antibody response but not of identified effector T cells capable of controlling parasitaemia.

Discharges of krypton from Sellafield, 1951-1997, and the resultant doses to members of the public

The radionulide 85Kr, which has a half-life of 10.72 years, is produced, almost exclusively, by reprocessing operations during which the fission product is released from irradiated nuclear fuel by chemical dissolution. Reprocessing plants at Sellafield, in Cumbria, have released the noble gas to atmosphere since operations commenced in 1952. Historically, krypton discharges were classified for security reasons, although these have been monitored and published by BNFL for each year since 1977. This paper reviews discharges of 85Kr from Sellafield, and consequent radiation doses, since its earliest operations. Over the past three years, discharges of 85Kr have increased due to the operation of the Thermal Oxide Fuel Reprocessing Plant (Thorp). Nonetheless, the associated annual committed effective dose to individuals remains low, peaking around 1.5 microSv a-1 to the identified critical groups, which compares with typical annual committed effective doses from natural sources of radiation of 2200 microSv. Maximum collective doses predicted from any single year of operations are 0.6 man Sv, 2 man Sv and 42 man Sv to the UK, Europe and the world respectively. Comparison may be made to natural background committed effective doses, which are of the order of 130,000 man Sva-1, 750,000 man Sva-1 and 13,000,000 man Sva-1 to the UK, EU and world populations respectively.

Expression of CDC2Zm and KNOTTED1 during in-vitro axillary shoot meristem proliferation and adventitious shoot meristem formation in maize (Zea mays L.) and barley (Hordeum vulgare L.)

Expression of CDC2Zm and KNOTTED1 (KN1) in maize (Zea mays L.) and their cross-reacting proteins in barley (Hordeum vulgare L.) was studied using immunolocalization during in-vitro axillary shoot meristem proliferation and adventitious shoot meristem formation. Expression of CDC2Zm, a protein involved in cell division, roughly correlated with in-vitro cell proliferation and in the meristematic domes CDC2Zm expression was triggered during in-vitro proliferation. Analysis of the expression of KN1, a protein necessary for maintenance of the shoot meristem, showed that KN1 or KN1-homologue(s) expression was retained in meristematic cells during in-vitro proliferation of axillary shoot meristems. Multiple adventitious shoot meristems appeared to form directly from the KN1- or KN1 homologue(s)-expressing meristematic cells in the invitro proliferating meristematic domes. However, unlike Arabidopsis (Arabidopsis thaliana) and tobacco (Nicotiana tabacum) leaves ectopically expressing KN1 (G. Chuck et al., 1996 Plant Cell 8: 1277-1289; N. Sinha et al., 1993 Genes Dev. 7: 787-797), transgenic maize leaves over-expressing KN1 were unable to initiate adventitious shoot meristems on their surfaces either in planta or in vitro. Therefore, expression of KN1 is not the sole triggering factor responsible for inducing adventitious shoot meristem formation from in-vitro proliferating axillary shoot meristems in maize. Our results show that genes critical to cell division and plant development have utility in defining in-vitro plant morphogenesis at the molecular level and, in combination with transformation technologies, will be powerful tools in identifying the fundamental molecular and-or genetic triggering factor(s) responsible for reprogramming of plant cells during plant morphogenesis in-vitro.

Dose due to man-made radionuclides in terrestrial wild foods near Sellafield

Radiological dose implications for consumers of wild foods around Sellafield have been assessed. Habits were surveyed from 72 households, mostly within a few kilometres of Sellafield. A few people were included who lived further away but collect wild foods close to Sellafield. Dose estimates were based on measured gamma emitters, as well as 239Pu, 241Am, 14C and 129I in selected samples. In all cases, doses were dominated by 137Cs. One infant was identified who consumed wild food, giving an estimated effective dose of 0.3 microSv a(-1). In the age group 2 to 10 years a mean dose of 0.51 microSv a(-1), and a maximum of 2.8 microSv a(-1), were estimated. Intakes by adults were higher and resulted in more radiologically significant doses. The extreme individual received a dose of 32 microSv a(-1) largely due to consumption of honey that included contributions from the Chernobyl accident, and hedgerow fruits. This is comparable to doses to the critical group for consumption of conventional agricultural produce close to the Sellafield site. The 97.5th percentile dose, for all age groups of consumers taken together, was 16.6 microSv a(-1), or 6.2 microSv a(-1) if the contributions from Chernobyl are excluded. Considering the contributions from different foods to the whole group of 181 wild food consumers, the rank order is honey, blackberries and venison.

Is the incidence of acute appendicitis really falling?

To determine if there has been a genuine fall in the incidence of acute appendicitis, an epidemiological study using HAA and Korner datasets for the years 1975-1994 was carried out to identify those children and young adults undergoing appendicectomy for acute appendicitis. The overall incidence of acute appendicitis fell from 1.84/1000 to 1.17/1000. This fall was statistically significant (R2 = 0.74, P < 0.01). The decrease was significant in both males (overall reduction, 34%) and females (overall reduction, 40%). No significant reduction was observed in either males or females between 15 and 19 years of age. The overall reduction remains essentially unexplained, but may have implications for health planning and provision of services.

OB-GYN Consultants and Sharp the BirthPlace: an exemplar of nurse-midwife and obstetrician interdependence and integration

The "co-management" model of perinatal care as practiced at OB-GYN Consultants and Sharp The BirthPlace maximizes the practice strengths of both nurse-midwives and obstetricians. The nurse-midwife is the primary provider for 95% of the clients; high-risk women are referred to the physician as appropriate. The model provides extensive health education and an option of a freestanding birth center for low-risk women. In the face of rapid health care changes, which emphasize cost effectiveness, this model has appealing features for managed care systems.

More than motherhood? A feminist exploration of 'women's health' in papers indexed by CINAHL 1993-1995

Holism is claimed to be the signifying feature that sets women's health apart from traditional approaches to health care. As such, articles published in the nursing literature about women's health would, one might expect, reflect the centrality of holism to women's health care nursing. The findings of a study which examined the content and the focus of articles published about women's health in journals indexed by CINAHL in the period 1993-1995 challenge this assumption. It was found that women's health is a taken-for-granted notion and is used interchangeably and synonymously to refer to reproductive health, maternal health, neonatal health, family health and (hetero) sexual health. Confounding the view that holism is foundational to a women's health perspective, the papers forming the study's sample largely depict issues to do with women's health from a narrow and stereotypical perspective and with a bio-medical focus. Women were referred to as fragmented bodies, body parts and diseases, and were depicted as being passive and silent. By contrast, the voice (and the activity) of nurses and nursing's imperative to intervene was clearly discernible.

Mucosal addressin cell adhesion molecule-1 (MAdCAM-1). Its binding motif for alpha 4 beta 7 and role in experimental colitis

The integrin alpha 4 beta 7 and mucosal addressin cell adhesion molecule-1 (MAdCAM-1) are molecules involved in the normal recirculation of lymphocytes between the blood and the gastrointestinal tract. These molecules may play a complementary and significant role in animal models of colitis. We have investigated the structural interaction between alpha 4 beta 7 and MAdCAM-1. Site-directed mutagenesis studies of the MAdCAM-1 molecule has led to the identification of the amino acid residue (LDT) in the loop between beta strands C and D of the Ig-superfamily-like folds being involved in the adhesive and cell activation functions of MAdCAM-1 with alpha 4 beta 7.

A role for fibroblast growth factor signaling in the lobuloalveolar development of the mammary gland

The inappropriate expression of growth factors, or activating mutations of their receptors, have been implicated as causative factors in mouse and human mammary cancer. For example, it has been known for some time that three members of the fibroblast growth factor (FGF) family behave like oncogenes in virally induced mammary cancer of mice. In normal circumstances, signaling via FGF receptors is known to mediate growth, differentiation, and patterning, during embryogenesis and fetal development. A powerful approach to dissecting the roles for these signaling pathways is to determine the developmental consequences of abrogating their function in transgenic mice. In this review, we describe the use of dominant negative FGF receptors to evaluate the contribution of specific FGF signals in normal mammary gland development. These studies have revealed that normal lobuloalveolar development requires FGF signaling to the mammary epithelium, a function that is presumably usurped by MMTV in mouse mammary tumorigenesis.

Retrograde cerebral perfusion provides limited distribution of blood to the brain: a study in pigs

OBJECTIVE

The objective of this study was to investigate flow distribution during retrograde and antegrade cerebral perfusion with India ink as a marker.

METHODS

Ten pigs received cerebral perfusion with a solution containing 50% filtered India ink for 5 minutes either antegradely through both internal carotid arteries at a flow of 180 to 200 ml/min (n = 5) or retrogradely via the superior vena cava at a flow of 300 to 500 ml/min (n = 5). The brains were then fixed for quantitative measurement of the density of ink-filled capillaries (reported as a percentage of the total selected area). The assessment was done with the use of an in-house software program.

RESULTS

In the antegrade cerebral perfusion group, the intracranial arterial and venous systems were completely filled with ink. The gray matter was colored uniformly black, and light coloring was observed in the white matter. During retrograde cerebral perfusion, the majority of ink was returned to the inferior vena cava, and only a small amount of ink was found in the innominate artery draining from the brain. Massive ink filling was observed in the sagittal sinus and other venous sinuses in all the pigs. Vessels on the surface of the brain and large vessels in the brain were also well filled with ink. However, only 10% of capillaries were filled with ink during retrograde cerebral perfusion relative to the number observed with antegrade cerebral perfusion.

CONCLUSIONS

Retrograde cerebral perfusion supplies a limited amount of blood to brain tissue, which flows mainly through superficial and large deep cerebral vessels.

Lactate accumulation in the shell of the turtle Chrysemys picta bellii during anoxia at 3°C and 10°C

Lactate concentrations were measured in the shell and plasma of the turtle Chrysemys picta bellii after 3 months of submergence anoxia at 3&deg;C and during and after 9 days of submergence anoxia at 10&deg;C. Liver and skeletal muscle lactate levels were also measured in control and anoxic animals at each temperature. At 3&deg;C, mean shell lactate concentration (N=4) reached 133mmolkg-1shellmass and plasma lactate levels were 144mmoll-1; at 10&deg;C, shell and plasma lactate concentrations (N=5) rose in parallel during anoxic exposure, to 70.8mmolkg-1shellmass and 78.9mmoll-1, respectively, and returned in parallel to control levels during 9 days of recovery. At the end of the anoxic periods, an estimated 44% of the total body lactate resided in the shell at 3&deg;C and 43% at 10&deg;C, and indirect evidence suggests that the shell buffered these same fractions of the acid load. Because of the high lactate concentration per kilogram of shell water (416mmolkg-1 at 3&deg;C; 221mmolkg-1 at 10&deg;C) and the known formation of calcium lactate complexes, it is postulated that most of the lactate existed in the shell in combined form. I conclude that sequestration of lactate within the shell represents a potentially major adaptation to anoxic acidosis for this animal and, together with the previously described release of shell carbonates, may account for up to two-thirds of the total lactic acid buffering in this animal.

Morphogenesis on the move: cell-to-cell trafficking of plant regulatory proteins

It has been shown recently that some plant transcription factors that regulate cell fate during development can traffic through plasmodesmata-the intercellular channels that connect plant cells. This phenomenon helps explain the non-autonomous effects of many developmental mutations in plants and defines a novel mechanism by which cells signal to each other during development.

Fibroblast growth factor receptor signalling has a role in lobuloalveolar development of the mammary gland

We have used the mouse mammary tumor virus promoter to express two dominant negative (DN) fibroblast growth factor receptor (FGFR) isoforms in the mammary epithelium of transgenic mice. While expression of DN-FGFR1(IIIc) showed no discernible phenotype, a similar kinase negative form of FGFR2(IIIb) caused a marked impairment of lobuloalveolar development. The growth retardation was apparent by mid-pregnancy and persisted in the post-partum glands. Despite the substantial underdevelopment of the mammary gland there was a measurable lactational response, but it was insufficient to properly sustain the new-born pups. These findings demonstrate that fibroblast growth factor signalling is necessary for pregnancy dependent lobuloalveolar development of the mammary gland.

Feminism: a path to clinical knowledge development

Nurses are under increasing pressure to defend the efficacy, value and cost benefits of professional nursing care. Now more than ever, there is a need for nurses to undertake quality clinical research, through which practice may be shaped and guided. Feminist theory can provide a lens through which nurses may explore clinical issues. It also provides a framework by which socially constructed differences, such as gender and culture, may be incorporated into the design of clinical research projects. Because feminism is an openly political and transformative process, feminist concepts are suitable for use where the aim of the research is to catalyse practice change. This paper explores the use of feminism as a theoretical framework for nursing research.

A randomized trial of group outpatient visits for chronically ill older HMO members: the Cooperative Health Care Clinic

OBJECTIVE

To compare the impact of group outpatient visits to traditional "physician-patient dyad" care among older chronically ill HMO members on health services utilization and cost, self-reported health status, and patient and physician satisfaction.

DESIGN

A 1-year randomized trial.

SETTING

A group model HMO in the Denver Metropolitan area.

PARTICIPANTS

Three hundred twenty-one members aged 65 and older, randomized to a group visit intervention (n = 160) or to usual care (n = 161).

INTERVENTION

Patients with high health services utilization and one or more chronic conditions had monthly group visits with their primary care physician and nurse. Visits included health education, prevention measures, opportunities for socialization, mutual support, and for one-to-one consultations with their physician, where necessary.

MEASUREMENTS

Health services utilization and associated cost, health status, and patient and physician satisfaction.

RESULTS

Outcome measures obtained after a 1-year follow-up period showed that group participants had fewer emergency room visits (P = .009), visits to subspecialists (P = .028), and repeat hospital admissions per patient (P = .051). Group participants made more visits (P = .021) and calls (P = .038) to nurses than control group patients and fewer calls to physicians (P = .019). In addition, a greater percentage of group participants received influenza and pneumonia vaccinations (P < .001). Group participants had greater overall satisfaction with care (P = .019), and participating physicians reported higher levels of satisfaction with the groups than with individual care. No differences were observed between groups on self-reported health and functional status. Cost of care per member per month was $14.79 less for the group participants.

CONCLUSIONS

Group visits for chronically ill patients reduce repeat hospital admissions and emergency care use, reduce cost of care, deliver certain preventive services more effectively, and increase patient and physician satisfaction.

Antibody to Haemophilus ducreyi among trucking company workers in Kenya

BACKGROUND AND OBJECTIVES

To determine the prevalence, correlates, and incidence of Haemophilus ducreyi antibodies, a cohort of East African trucking company employees was evaluated.

STUDY DESIGN

Human immunodeficiency virus (HIV)-1-seronegative men working in six trucking companies in Mombasa, Kenya, were evaluated with a questionnaire and serologic testing for antibodies to H. ducreyi and other sexually transmitted pathogens. Men who were initially H. ducreyi seronegative were retested at 1 year of follow-up.

RESULTS

The H. ducreyi seroprevalence among 501 men at enrollment was 26.5%. Seropositivity was significantly associated with older age, married status, years of active sex life, number of sex partners in the past year, history of unprotected sex with a prostitute in the past year, and history of alcohol intake (all P values < 0.01). Occupational travel for more than 14 days per month was also significantly associated with H. ducreyi seropositivity (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.3-3.2). Using multivariate analysis, H. ducreyi seropositivity was independently associated with age, married status, history of sex with a prostitute, and history of alcohol intake. Presence of H. ducreyi antibodies was significantly associated with seropositivity to the other major genital ulcerative pathogens, Treponema pallidum (OR 4.3, 95% CI 2.2-8.3), herpes simplex virus type 2 (OR 4.9, 95% CI 2.0-11.5), and Chlamydia trachomatis (OR 3.2, 95% CI 1.5-6.9). These associations remained significant after adjusting for demographic and exposure variables. The incidence of seroconversion to H. ducreyi antibodies was 3.6 per 100 person years.

CONCLUSIONS

Serologic evidence of H. ducreyi infection was common among male trucking company employees. H. ducreyi seropositivity is an objective marker of high-risk behavior and is associated with serologic evidence of other ulcerative sexually transmitted diseases.

In uncharted waters: confronting the culture of silence in a residential care institution

This paper describes a study grounded in feminism, which explored the experiences of three registered nurses who were employed in a residential care institution in which they believed the standard of care to be unacceptably poor. Ultimately, the nurses became 'whistle blowers'. Data surrounding these events were gathered through serial encounters and analysed using feminist interpretive methods. Three distinct phases were revealed: (i) trepidation and optimizm; (ii) barriers and obstacles; and (iii) disillusionment and defeat. It was in this final phase that the whistle blowing occurred. For these women, whistle blowing was an intervention of last resort; a stressful and negative event that carried personal and professional cost. Issues pertaining to professional autonomy and patient advocacy are raised, together with concerns surrounding the appropriation by business people of the language and images of nursing, and the power of these people to negatively impact upon nursing practice.