CELPI: trial protocol for a randomised controlled trial of a Carer End of Life Planning Intervention in people dying with dementia

Background

Dementia is a leading cause of death in developed nations. Despite an often distressing and symptom laden end of life, there are systematic barriers to accessing palliative care in older people dying of dementia. Evidence exists that 70% of people living with severe dementia attend an emergency department (ED) in their last year of life. The aim of this trial is to test whether a Carer End of Life Planning Intervention (CELPI), co-designed by consumers, clinicians and content specialists, improves access to end of life care for older people with severe dementia, using an ED visit as a catalyst for recognising unmet needs and specialist palliative care referral where indicated.

Methods

A randomised controlled trial (RCT) enrolling at six EDs across three states in Australia will be conducted, enrolling four hundred and forty dyads comprising a person with severe dementia aged ≥ 65 years, and their primary carer.

Participants will be randomly allocated to CELPI or the control group. CELPI incorporates a structured carer needs assessment and referral to specialist palliative care services where indicated by patient symptom burden and needs assessment. The primary outcome measure is death of the person with dementia in the carer-nominated preferred location. Secondary outcomes include carer reported quality of life of the person dying of dementia, hospital bed day occupancy in the last 12 months of life, and carer stress. An economic evaluation from the perspective of a health funder will be conducted.

Discussion

CELPI seeks to support carers and provide optimal end of life care for the person dying of dementia. This trial will provide high level evidence as to the clinical and cost effectiveness of this intervention.

Trial registration

ACTRN12622000611729 registered 22/04/2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03534-1.

Association between pelvic inflammatory disease, infertility, ectopic pregnancy and the development of ovarian serous borderline tumor, mucinous borderline tumor and low-grade serous carcinoma

OBJECTIVE

Risk factors for ovarian borderline tumors and low-grade serous carcinoma (LGSC) are poorly understood. The aim of this study was to examine the association between infertility, pelvic inflammatory disease (PID), endometriosis, ectopic pregnancy, hysterectomy, tubal ligation and parity and the risk of serous borderline tumor (SBT), mucinous borderline tumor (MBT) and LGSC.

METHODS

This was a population-based cohort study using linked administrative and hospital data. Participants were 441,382 women born between 1945 and 1975 who had been admitted to hospital in Western Australia between 1 January 1980 and 30 June 2014. We used Cox regression to estimate hazard ratios (HRs).

RESULTS

We observed an increased rate of SBT associated with infertility, PID and ectopic pregnancy (HRs and 95% CIs were, respectively, 1.98 (1.20-3.26); 1.95 (1.22-3.10) and 2.44 (1.20-4.96)). We did not detect an association between any of the factors under study and the rate of MBT. A diagnosis of PID was associated with an increased rate of LGSC (HR 2.90, 95% CI 1.21-6.94).

CONCLUSIONS

The association with PID supports the hypothesis that inflammatory processes within the upper gynaecological tract and/or peritoneum may predispose to the development of SBT and LGSC.

Risk of persistent or recurrent cervical neoplasia in patients with 'pure' adenocarcinoma-in-situ (AIS) or mixed AIS and high-grade cervical squamous neoplasia (cervical intra-epithelial neoplasia grades 2 and 3 (CIN 2/3)): a population-based study

OBJECTIVE

To compare outcomes of patients with pure adenocarcinoma-in-situ (AIS) and mixed AIS/CIN 2/3 lesions including the incidence of AIS persistence, recurrence and progression to adenocarcinoma.

DESIGN

Retrospective cohort study.

SETTING

Statewide population in Western Australia.

POPULATION

Women diagnosed with AIS between 2001 and 2012.

METHODS

We conducted a retrospective, population-based cohort study.

MAIN OUTCOME MEASURES

De-identified linked data were utilised to ascertain the association between patient age at excisional treatment, margin status, lesion type, lesion size, and risk of persistent AIS (defined as the presence of AIS <12 months from treatment), recurrent AIS (≥12 months post-treatment), and adenocarcinoma.

RESULTS

636 patients were eligible for analysis. The mean age was 32.3 years and median follow-up interval was 2.5 years. Within the study cohort, 266 patients (41.8%) had pure AIS and 370 (58.2%) had mixed AIS/CIN 2/3. Overall, 47 patients (7.4%) had AIS persistence/recurrence and 12 (1.9%) had adenocarcinoma. Factors associated with persistence/recurrence were pure AIS (hazard ratio (HR) 2.3; 95%CI 1.28-3.94; P = 0.005), age >30 years (HR 2.1; 95%CI 1.16-3.81; P = 0.015), positive endocervical margins (HR 5.8; 95%CI 3.05-10.92; P = <0.001) and AIS lesions >8 mm (HR 2.5; 95%CI 1.00-6.20; P = 0.049). A histologically positive AIS ectocervical margin was not associated with persistence/recurrence.

CONCLUSION

In this study, pure AIS was associated with greater risk of persistence/recurrence than was mixed AIS/CIN 2/3. AIS lesions >8 mm and positive endocervical margins were significant predictors for persistent or recurrent disease.

TWEETABLE ABSTRACT

Pure cervical adenocarcinoma-in-situ (AIS) may have greater risk of recurrence than AIS co-existing with CIN 2/3.

Detection of liver injury in IBD using transient elastography

BACKGROUND

Up to 5% of inflammatory bowel disease (IBD) patients are thought to have clinically significant liver disease due to multifactorial causes, however, this figure may be an underestimate due to reliance on abnormal liver tests (LTs) and/or liver biopsies.

AIMS

Our aim was to evaluate the prevalence of clinically significant liver disease in IBD patients as defined by an increased liver stiffness measurement (LS) ≥8kPa using transient elastography (TE).

METHODS

110 IBD patients, and 55 non-IBD control subjects, had their LS recorded using FibroScan® (EchoSense, Paris, France) by a single blinded operator trained in TE.

RESULTS

71 Crohn's disease and 39 ulcerative colitis subjects were included. All demographic variables were similar between the IBD and control groups apart from a significantly higher proportion of IBD patients who smoked (17.3% vs 3.6%, P=0.013). Seven IBD patients (6.4%) had an LS over 8 kPa and 3 had persistently elevated LS 6 months later. One patient had compensated cirrhosis. No significant differences in overall LS were observed between the IBD and control groups. Increased BMI and age, however, were independently associated with a higher LS in the IBD but not in the control group (P<0.001 and 0.010 respectively).

CONCLUSION

Using TE, the prevalence of clinically significant liver disease in IBD patients is low. The association of increased BMI and age with increased LS in IBD suggests fatty liver disease being the prevailing aetiology in these patients.

Long-term survival following laparoscopic and open colectomy for colon cancer: a meta-analysis of randomized controlled trials

AIM

Large randomized clinical trials comparing long-term survival after laparoscopic and open colectomy for large bowel cancer show equivalence, but meaningful analysis of data by stage has not been possible due to the small numbers of patients in individual trials. The aim of this meta-analysis was to improve statistical power by combining data to enable assessment of survival for individual stages.

METHOD

A systematic review and meta-analysis was conducted through a computerized search of all randomized controlled trials comparing open and laparoscopic surgery for large bowel cancer. Overall survival data were analysed and subgroup analysis was performed for cancer of Stages I-III.

RESULTS

Five trials (3152 patients) were included. Overall survival was equivalent (hazard ration 0.93; 95% confidence interval 0.80-1.07). With each of the cancer stages, I-III, there was no difference in 5-year survival. There was, however, a nonsignificant trend in favour of open surgery in the subgroup analysis of Stage II patients.

CONCLUSION

Laparoscopic-assisted surgery for colon cancer is equivalent to open surgery with respect to long-term survival although there may be a difference for Stage II cancer.

Earlier age of dementia onset and shorter survival times in dementia patients with diabetes

Diabetes is a risk factor for dementia, but relatively little is known about the epidemiology of the association. A retrospective population study using Western Australian hospital inpatient, mental health outpatient, and death records was used to compare the age at index dementia record (proxy for onset age) and survival outcomes in dementia patients with and without preexisting diabetes (n = 25,006; diabetes, 17.3%). Inpatient records from 1970 determined diabetes history in this study population with incident dementia in years 1990-2005. Dementia onset and death occurred an average 2.2 years and 2.6 years earlier, respectively, in diabetic compared with nondiabetic patients. Age-specific mortality rates were increased in patients with diabetes. In an adjusted proportional hazard model, the death rate was increased with long-duration diabetes, particularly with early age onset dementia. In dementia diagnosed before age 65 years, those with a ≥15-year history of diabetes died almost twice as fast as those without diabetes (hazard ratio = 1.9, 95% confidence interval: 1.3, 2.9). These results suggest that, in patients with diabetes, dementia onset occurs on average 2 years early and survival outcomes are generally poorer. The effect of diabetes on onset, survival, and mortality is greatest when diabetes develops before middle age and after 15 years' diabetes duration. The impact of diabetes on dementia becomes progressively attenuated in older age groups.

Support matters: a mixed methods scoping study on the use of assistant staff in the delivery of community nursing services in England

Background

Community nursing (and health) services are faced with the growing challenge of caring for increasingly dependent patients with chronic conditions and complex care needs. Over the past decade there have been changes in the composition of the community nursing workforce with increasing numbers of assistants yet there is a lack of published literature on the roles, contribution and impacts of community nursing assistants to the delivery of care and services.

Design

We adopted a three-stage approach for the scoping study using mixed quantitative and qualitative methods. First, we established contact with senior managers in provider organisations where we had research governance approval (n = 76; 75% of total provider organisations) to determine whether or not (a) they employ assistants within community nursing teams and (b) they would be interested in participating in the study. Second, we carried out a short telephone interview with all senior managers who indicated a willingness to participate (census approach). We also analysed secondary data (using the NHS iView data source, from the Electronic Staff Record Data Warehouse) to scope the national use of community nursing assistant roles. Finally, we conducted telephone interviews with a purposive sample of managers from 10 organisations that participated in stage two to gain an in-depth understanding of assistant roles in community nursing teams

Setting

Community nursing provider organisations in England, UK.

Participants

Thirty-seven senior managers were interviewed for stage two (49% of all contacted). Thirty managers (20 service-level managers and 10 senior managers) were interviewed for stage three.

Results

Assistants promote flexibility in the community nursing workforce so as to respond to the changing demands on these services. However, the lack of consensus in defining the role of community nursing assistants has created inconsistency in the national deployment and development of these roles. These roles have tended to develop ad hoc, creating variations in numbers of assistants, the roles that they play and preparation for practice across different provider organisations and nursing teams. There is general enthusiasm among managers about the contribution of assistants. Their employment is regarded as fundamental to the ability of community nursing teams to deliver acceptable and appropriate services. However, the role may not always support career progression and development for those assistants who require this. The maturity and life experience of assistants is greatly valued in the nursing team to support care delivery and to offer stability and support to other members of the nursing team. Line management, responsibility and accountability in managing the work of assistants were highlighted as important for managing risk associated with an unregulated role. These have to be balanced with promoting flexibility in use and innovation.

Conclusions

Our scoping study highlights the opportunities and challenges associated with the use of assistants to deliver care by the community nursing team. Further attention at national and local levels is required to support and mediate the development of these roles in the future so as to promote the delivery of quality, safe and acceptable care. As provider organisations plan for delivering an ambitious community services agenda in the future, the role of the assistant is likely to have increasing importance.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Morbidity outcomes of 78,577 hysterectomies for benign reasons over 23 years

OBJECTIVE

To investigate the association of the method of hysterectomy for benign reasons with morbidity outcomes in Western Australia after taking other demographic, social and health-related factors into account.

DESIGN

Population-based retrospective observational study.

SETTING

All hospitals in Western Australia where hysterectomies were performed from 1981 to 2003.

POPULATION

All women aged 20 years or older who underwent a hysterectomy for benign reasons.

METHOD

Logistic and zero-truncated negative binomial regression analysis of record-linked administrative health data.

MAIN OUTCOME MEASURES

Relative odds of experiencing complications during the hysterectomy admission or readmission and relative length of stay in hospital by type of hysterectomy.

RESULTS

There were 78,577 hysterectomies performed for benign reasons from 1981 to 2003. Procedure-related haemorrhage (2.4%) was the most commonly recorded complication, followed by genitourinary disorders (1.9%), infection (1.6%) and urinary tract infections (1.6%). Vaginal hysterectomy was associated with reduced odds of infection and haemorrhage compared with abdominal procedures during the hysterectomy admission. Readmission rates increased from 5.4% in 1981-84 to 7.2% in 2000-03 as average length of stay decreased by 53% over the same time period. Women who underwent laparoscopically assisted vaginal hysterectomies and vaginal hysterectomies had increased odds of readmission for haemorrhage and genitourinary disorders compared with abdominal hysterectomy. Young age, increasing number of co-morbid conditions and having a complication at hysterectomy admission were also associated with increased odds of readmission.

CONCLUSION

These findings identify women at risk of readmission following hysterectomy and highlight an opportunity to modify early discharge and patient follow-up practices to reduce this risk.

A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers

OBJECTIVES

To review the evidence for different models of community-based respite care for frail older people and their carers, where the participant group included older people with frailty, disability, cancer or dementia. Where data permitted, subgroups of carers and care recipients, for whom respite care is particularly effective or cost-effective, were to be identified.

DATA SOURCES

Major databases were searched from 1980 to March 2005. Ongoing and recently completed research databases were searched in July 2005.

REVIEW METHODS

Data from relevant studies were extracted and quality assessed. The possible effects of study quality on the effectiveness data and review findings were discussed. Where sufficient clinically and statistically similar data were available, data were pooled using appropriate statistical techniques.

RESULTS

Twenty-two primary studies were included. Most of the evidence came from North America, with a minority of effectiveness and economic studies based in the UK. Types of service studied included day care, host family, in-home, institutional and video respite. Effectiveness evidence suggests that the consequences of respite upon carers and care recipients are generally small, with better controlled studies finding modest benefits only for certain subgroups. However, many studies report high levels of carer satisfaction. No reliable evidence was found that respite can delay entry to residential care or that respite adversely affects care recipients. Randomisation validity in the included randomised studies was sometimes unclear. Studies reported many different outcome measures, and all of the quasi-experimental and uncontrolled studies had methodological weaknesses. The descriptions of the studies did not provide sufficient detail of the methods of data collection or analysis, and the studies failed to describe adequately the groups of study participants. In some studies, only evidence to support respite care services was presented, rather than a balanced view of the services. Only five economic evaluations of respite care services were found, all of which compared day care with usual care and only one study was undertaken in the UK. Day care tended to be associated with higher costs and either similar or a slight increase in benefits, relative to usual care. The economic evaluations were based on two randomised and three quasi-experimental studies, all of which were included in the effectiveness analysis. The majority of studies assessed health and social service use and cost, but inadequate reporting limits the potential for exploring applicability to the UK setting. No study included generic health-related quality of life measures, making cost-effectiveness comparisons with other healthcare programmes difficult. One study used sensitivity analysis to explore the robustness of the findings.

CONCLUSIONS

The literature review provides some evidence that respite for carers of frail elderly people may have a small positive effect upon carers in terms of burden and mental or physical health. Carers were generally very satisfied with respite. No reliable evidence was found that respite either benefits or adversely affects care recipients, or that it delays entry to residential care. Economic evidence suggests that day care is at least as costly as usual care. Pilot studies are needed to inform full-scale studies of respite in the UK.

Patient acceptability of larval therapy for leg ulcer treatment: a randomised survey to inform the sample size calculation of a randomised trial

BACKGROUND

A trial was commissioned to evaluate the effectiveness of larval therapy to debride and heal sloughy and necrotic venous leg ulcers. Larval therapy in the trial was to be delivered in either loose or bagged form. Researchers were concerned that resistance to larval therapy may threaten the feasibility of the trial. Additionally there was concern that the use of larval therapy may require a larger effect size in time to healing than originally proposed by the investigators.

METHODS

To formally evaluate patient preferences a survey using two randomly allocated, nurse administered questionnaires was undertaken. Patients were randomised to receive one of the two following questionnaires (i) preferences between loose larvae and standard treatment (hydrogel) or (ii) patient preferences between bagged larvae and standard therapy (hydrogel). The study was undertaken in a Vascular Clinic, in an Outpatients Department of a large teaching hospital in the North of England. The sample consisted of 35 people aged 18 years and above with at least one leg ulcer of venous or mixed (venous and arterial) aetiology.

RESULTS

Approximately 25% of participants would not consider the use of larval therapy as an acceptable treatment option for leg ulcers, regardless of the method of containment. For the patients that would consider the use of larval therapy, different preferences in healing times required to use the therapy were observed depending upon the method of containment. The median response of those participants questioned about bagged larvae found that they would be willing to use this therapy even if they were equally able to achieve healing with the use of hydrogel by 20 weeks. For those participants questioned about the use of loose larvae complete healing would have to have taken place over 17 weeks for them to choose larvae as their preferred option rather than hydrogel. This difference was not significant (p = 0.075).

CONCLUSION

We found no evidence of widespread resistance to the utilisation of larval therapy from patients regardless of the method of larval therapy containment. These methods have the potential to inform sample size calculations where there are concerns of patient acceptability.

Persistent high rates of hysterectomy in Western Australia: a population-based study of 83 000 procedures over 23 years

OBJECTIVE

To investigate incidence trends and demographic, social and health factors associated with the rate of hysterectomy and morbidity outcomes in Western Australia and compare these with international studies.

DESIGN

Population-based retrospective cohort study.

SETTING

All hospitals in Western Australia where hysterectomies were performed from 1981 to 2003.

POPULATION

All women aged 20 years or older who underwent a hysterectomy.

METHODS

Statistical analysis of record-linked administrative health data.

MAIN OUTCOME MEASURES

Rates, rate ratios and odds ratios for incidence measures and length of stay in hospital and odds ratios for morbidity measures.

RESULTS

The age-standardised rate of hysterectomy adjusted for the underlying prevalence of hysterectomy decreased 23% from 6.6 per 1000 woman-years (95% CI 6.4-6.9) in 1981 to 4.8 per 1000 woman-years (95% CI 4.6-4.9) in 2003. Lifetime risk of hysterectomy was estimated as 35%. In 2003, 40% of hysterectomies were abdominal. The rate of hysterectomy to treat menstrual disorders fell from 4 per 1000 woman-years in 1981 to 1 per 1000 woman-years in 1993 and has since stabilised. Low socio-economic status, having only public health insurance, nonindigenous status and living in rural or remote areas were associated with increased risk of having a hysterectomy for menstrual disorders. Indigenous women had higher rates of hysterectomy to treat gynaecological cancers compared with nonindigenous women, particularly in rural areas. The odds of a serious complication were 20% lower for vaginal hysterectomies compared with abdominal procedures.

CONCLUSION

Western Australia has one of the highest hysterectomy rates in the world, although proportionally, significantly fewer abdominal hysterectomies are performed than in most countries.

Pressure relieving support surfaces: a randomised evaluation

OBJECTIVES

To determine differences between alternating pressure overlays and alternating pressure replacement mattresses with respect to the development of new pressure ulcers, healing of existing pressure ulcers, patient acceptability and cost-effectiveness of the different pressure-relieving surfaces. Also to investigate the specific additional impact of pressure ulcers on patients' well-being.

DESIGN

A multicentre, randomised, controlled, open, fixed sample, parallel-group trial with equal randomisation was undertaken. The trial used remote, concealed allocation and intention-to-treat (ITT) analysis. The main trial design was supplemented with a qualitative study involving a purposive sample of 20-30 patients who developed pressure ulcers, to assess the impact of the pressure ulcers on their well-being. In addition, a focus group interview was carried out with clinical research nurses, who participated in the PRESSURE (Pressure RElieving Support SUrfaces: a Randomised Evaluation) Trial, to explore the experiences of their role and observations of pressure area care.

SETTING

The study took place in 11 hospital-based research centres within six NHS trusts in England.

PARTICIPANTS

Acute and elective patients aged 55 years or older and admitted to vascular, orthopaedic, medical or care of the elderly wards in the previous 24 hours were investigated.

INTERVENTIONS

Patients were randomised to either an alternating pressure overlay or an alternating pressure mattress replacement, with mattress specifications clearly defined to enable the inclusion of centres using products from different manufacturers, and to exclude hybrid mattress systems (which either combine foam or constant low pressure with alternating pressure in one mattress, or can be used as either an overlay or a replacement mattress).

MAIN OUTCOME MEASURES

Development of a new pressure ulcer (grade < or =2, i.e. partial-thickness wound involving epidermis/dermis only) on any skin site. Also healing of existing pressures ulcers, patient acceptability and cost-effectiveness.

RESULTS

In total, 6155 patients were assessed for eligibility to the trial and 1972 were randomised: 990 to the alternating pressure overlay (989 after one postrandomisation exclusion) and 982 to the alternating pressure mattress replacement. ITT analysis found no statistically significant difference in the proportions of patients developing a new pressure ulcer of grade 2 or above [10.7% overlay patients, 10.3% mattress replacement patients, a difference of 0.4%, 95% confidence interval (CI) -2.3 to 3.1%, p = 0.75]. When logistic regression analysis was used to adjust for minimisation factors and prespecified baseline covariates, there was no difference between the mattresses with respect to the odds of ulceration (odds ratio 0.94, 95% CI 0.68 to 1.29). There was no evidence of a difference between the mattress groups with respect to time to healing (p = 0.86). The Kaplan-Meier estimate of the median time to healing was 20 days for each intervention. More patients allocated overlays requested mattress changes due to dissatisfaction (23.3%) than mattress replacement patients (18.9%, p = 0.02) and more than one-third of patients reporting difficulties associated with movement in bed and getting into or out of bed. There is a higher probability (64%) that alternating mattress replacements are cost-saving; they were associated with lower overall costs (74.50 pounds sterling per patient on average, mainly due to reduced length of stay) and greater benefits (a delay in time to ulceration of 10.64 days on average). Patients' accounts highlighted that the development of a pressure ulcer could be pivotal in the trajectory from illness to recovery, by preventing full recovery or causing varied impacts on their quality of life.

CONCLUSIONS

There is no difference between alternating pressure mattress replacements and overlays in terms of the proportion of patients developing new pressure ulcers; however, alternating pressure mattress replacements are more likely to be cost-saving. The results suggest that when renewing alternating pressure surfaces or ordering equipment within a rental contract, mattress replacements should be specified; however, overlays are acceptable if no replacement mattress is available. Similarly, patient preferences can be supported, without any great increase in risk, if individual patients request an overlay rather than a replacement mattress. Further research could include a randomised controlled trial comparing alternating pressure mattress replacements and high-specification foam mattresses in patients at moderate to high risk; an accurate costing study to understand better how much pressure ulcers cost health and social services in the UK; and trials in higher risk groups of patients. Also future trials should measure time to ulceration as the primary end-point, since this is more informative economically and possibly also from a patient and clinical perspective.

Economic evaluation of a nursing-led intermediate care unit

OBJECTIVES

The aim of this paper is to examine the costs of introducing a nursing-led ward program together with examining the impact this may have on patients' outcomes.

METHODS

The study had a sample size of 177 patients with a mean age of 77, and randomized to either a treatment group (care on a nursing-led ward, n = 97) or a control group (standard care usually on a consultant-led acute ward, n = 80). Resource use data including length of stay, tests and investigations performed, and multidisciplinary involvement in care were collected.

RESULTS

There were no significant differences in outcome between the two groups. The inpatient costs for the treatment group were significantly higher, due to the longer length of stay in this group. However, the postdischarge costs were significantly lower for the treatment group.

CONCLUSIONS

The provision of nursing-led intermediate care units has been proposed as a solution to inappropriate use of acute medical wards by patients who require additional nursing rather than medical care. Whether the treatment group is ultimately cost-additive is dependent on how long reductions in postdischarge resource use are maintained.

Addition of a c-myc epitope tag within the VEGF protein does not affect in vitro biological activity

The overexpression of vascular endothelial growth factor (VEGF) has been strongly implicated in diseases involving neovascularization. VEGF exists in as many as six different isoforms, each showing a unique pattern of tissue distribution and activity. To investigate the effect of individual VEGF isoform overexpression in neovascular disease models, we inserted c-myc epitope tags into the three VEGF isoforms expressed in retinal pigment epithelial cells, VEGF121, VEGF165, and VEGF189. We found that the 12-amino acid insertion between the receptor binding and heparin binding domains did not affect VEGF transcription, translation, or secretion. In addition, VEGF isoforms containing the c-myc epitope tag were able to stimulate endothelial cell proliferation as efficiently as non-tagged VEGF isoforms and they could be individually identified by Western blotting and immunocytochemistry using the c-myc epitope specific monoclonal antibody 9E10.

Defining the nursing contribution to patient outcome: lessons from a review of the literature examining nursing outcomes, skill mix and changing roles

A review of the evidence to define the nursing contribution to patient outcome is presented. The review relies on work related to nursing sensitive outcomes, skill mix and changing roles. Methodological difficulties associated with these studies are highlighted. Areas requiring further research are discussed. It is suggested that experimental evidence is not always appropriate, when attempting to describe nursing activity. The authors advocate that new methodologies, in particular practitioner-centred research, are needed to unpack the nature of nursing.

Overexpression of vascular endothelial growth factor (VEGF) in the retinal pigment epithelium leads to the development of choroidal neovascularization

Vascular endothelial growth factor (VEGF) has been strongly implicated in the development of choroidal neovascularization found in age-related macular degeneration. Normally expressed in low levels, this study investigates whether the overexpression of VEGF in the retinal pigment epithelium is sufficient to cause choroidal neovascularization in the rat retina. A recombinant adenovirus vector expressing the rat VEGF(164) cDNA (AdCMV.VEGF) was constructed and injected into the subretinal space. The development of neovascularization was followed by fluorescein angiography, which indicates microvascular hyperpermeability of existing and/or newly forming blood vessels, and histology. VEGF mRNA was found to be overexpressed by retinal pigment epithelial cells and resulted in leaky blood vessels at 10 days postinjection, which was maintained for up to 31 days postinjection. By 80 days postinjection, new blood vessels had originated from the choriocapillaris, grown through the Bruch's membrane to the subretinal space, and disrupted the retinal pigment epithelium. This ultimately led to the formation of choroidal neovascular membranes and the death of overlying photoreceptor cells. By controlling the amount of virus delivered to the subretinal space, we were able to influence the severity and extent of the resulting choroidal neovascularization. These results show that even temporary overexpression of VEGF in retinal pigment epithelial cells is sufficient to induce choroidal neovascularization in the rat eye.

The effectiveness of intermediate care in a nursing-led in-patient unit

In order to assess the potential for a nursing-led in-patient unit (NLIU) to substitute for a period of care in the acute hospital environment and promote recovery before discharge, a randomised controlled trial was conducted. The setting was an acute inner London hospital trust, part of the UK's national health service. Of patients referred to a NLIU from acute wards, 80 were randomly assigned to usual care (remain in normal hospital system) and 97 to the NLIU (nursing-led care with no routine medical involvement). Patients were identified as medically stable but in need of additional nursing intervention by referring medical staff prior to full nursing assessment of suitability. Outcomes compared included functional dependence (Barthel Index), discharge destination and length of hospital stay. Inputs from nursing, paramedical and medical staff were measured. There was no significant difference in functional independence at discharge (p0.05). Patients undergoing usual care stayed in hospital for less time (mean difference 18 days, p<0.01) but the same number of patients were in hospital 90 days after recruitment (23% NLIU, 24% usual care p0.05) due to re-admissions. The model of care implemented differed considerably from that described in the literature with the NLIU having significantly fewer qualified nurses (RNs). Although the anticipated benefits of the NLIU were not demonstrated, the study does not conclude that the model should be rejected. Factors driving length of stay need to be further investigated, as does the possibility of post-discharge benefits. The NLIU does offer some potential to substitute for acute care but also appears to substitute for a period of primary care.

Expression of cathepsin S antisense transcripts by adenovirus in retinal pigment epithelial cells

PURPOSE

To show the production of sense or antisense transcripts by recombinant adenoviruses, to investigate whether the transcripts produced were suitable for downregulating the expression of the targeted gene, cathepsin S (CatS), and to examine the effect of antisense transcript production on the biologic function of retinal pigment epithelial (RPE) cells, including the regulation of endogenous aspartic protease expression.

METHODS

Ad.MLP.CatSAS, Ad.RSV.CatSAS, and Ad.MLP.CatSS recombinant viruses were produced by homologous recombination. The recombinant viruses were tested by restriction enzyme digestion to confirm the orientation of the inserts. The expression of antisense transcripts was tested by northern blot analysis. Western blot analysis was used to study the regulation of the endogenous CatS protein in ARPE19 cells. The biologic effect of CatS downregulation in ARPE19 cells was tested by proliferation and phagocytosis assays, de novo cathepsin D (CatD) synthesis, and measurement of aspartic protease activity.

RESULTS

After characterization of the recombinant adenovirus constructs, the production of antisense and sense CatS transcripts was shown in ARPE19 cells. The transcripts appeared at approximately 1.9 kb 48 hours after transduction, and the expression of the antisense transcripts was similar in constructs carrying either the MLP or the RSV promoter. Western blot analysis showed that ARPE19 cells transduced with Ad.MLP.CatSAS and Ad.RSV.CatSAS had no detectable CatS. In contrast, there was a strong signal appearing at 24 kDa in ARPE19 cells transduced with Ad.MLP.CatSS. ARPE19 cells were transduced to a high level. The transduction of ARPE19 cells with the recombinant adenoviruses did not affect the morphologic appearance of the cells, their proliferation, or their phagocytosing ability. However, ARPE19 cells transduced by Ad.MLP.CatSAS recombinant adenovirus showed a significant downregulation of de novo CatD synthesis and a twofold decrease in aspartic protease activity.

CONCLUSIONS

Recombinant adenoviruses were shown to be suitable for producing antisense CatS transcripts to modulate endogenous CatS expression in RPE cells. It is proposed that CatS may play an important role, directly or indirectly, in the lysosomal digestion of outer segments through the regulation of other lysosomal enzyme activity, such as the expression of CatD.

Isolation of a novel macrophage-specific gene by differential cDNA analysis

To analyze myelomonocytic differentiation we have used the approach of differential cDNA analysis to isolate novel genes that are preferentially expressed in mature macrophages. Differential screening of a macrophage cDNA library led to the identification of a novel cDNA that showed macrophage lineage- and differentiation stage-specific expression. Transcripts from the gene, which we have termed Mpg-1, are found at a high level in mature human and murine macrophages and at a moderate level in certain myelomonocytic cell lines. The expression of Mpg-1 was found to increase when murine fetal liver hematopoietic progenitor cells were induced to differentiate into macrophages. An Mpg-1-specific transcript was not detected in a wide variety of other tissues and cell lines. The DNA sequence of Mpg-1 (4,214 bp) was obtained from a series of overlapping cDNA, 3' rapid amplification of cDNA ends (RACE), and genomic clones. Primer extension analysis predicted the existence of multiple transcription start sites, ranging from 26 to 117 bp upstream of the 5' proximal ATG of the open reading frame. The predicted 669-amino acid, Mpg-1-encoded protein has potential glycosylation and phosphorylation sites in addition to a signal sequence. The core protein is predicted to have a molecular weight of 71 to 74 kD. Computer-assisted local similarity searches indicate that Mpg-1 is a novel gene that may share a distant ancestry to perforin, a lytic protein found in cytotoxic T lymphocytes and natural killer cells.

Stage-specific expression of intracisternal A-particle sequences in murine myelomonocytic leukemia cell lines and normal myelomonocytic differentiation

The levels of intracisternal A-particle (IAP) mRNA were analyzed in a variety of myelomonocytic leukemia cell lines, peritoneally derived macrophages, and normal hemopoietic progenitors induced to differentiate. In both normal and leukemic cells, the highest level of IAP message was found in cells at an intermediate stage of myelomonocytic differentiation, namely, the promyelomonocyte. These results indicate that IAP sequence transcription is regulated differentially during myelomonocytic cell development and that in general, the expression pattern is preserved in leukemic cell lines in vitro. In addition, Northern (RNA) analysis detected only type I IAP transcripts as the major IAP message and the expressed IAP subtypes varied in certain cell lines. This is the first comprehensive study of IAP expression in the myelomonocytic lineage and provides a useful system to study the biology of IAPs.