1245 HEALTH CARE WORKERS’ EXPERIENCES ON WORKING AT RESIDENTIAL CARE HOME FOR THE ELDERLY: AN INTEGRATIVE REVIEW

Introduction

The ageing population poses challenges to the health care industry worldwide. The huge demand for residential care home for the elderly (RCHE) services induces pressure on health care workers (HCWs) recruitment and retention. HCWs are personnel who have prominent roles in direct basic care to the older adults, and all kinds of hands-on care. Due to the “unpleasant” work nature, shift work, and physical demands for HCWs, it is essential to unfold how HCWs comprehend their working experiences.

Methods

An integrative review was conducted to synthesize various streams of literature in order to generate new knowledge. Multiple databases such as CINAHL, ERIC, LWW nursing were adopted to search for relevant literature published between 2012 and 2022.

Results

A total of 24 articles were retrieved at the initial stage, and 7 articles were sorted after in-depth review. In general, results supported that HCWs experienced positively on the works at RCHEs though there were job stresses. The HCWs perceived the roles at RCHEs as routinized and task-oriented by providing direct care to older adults. They perceived their roles at RCHEs as care providers who provided direct care to older adults. Also, their responsibilities to maintain the safety and dignity of older adults was expressed as utmost importance. The meaning of works lay on three levels: interpersonal (e.g. self-achievement), interpersonal (e.g. communication with team members), and job performance (e.g. task compliance).

Conclusions

This study reveals the experiences of working at RCHE from the HCWs’ perspective. The HCWs’ experiences reflected in this study as well as the meaning of works discovered can generate insights for policy-makers on HCWs recruitment and retention.

Acknowledgement

The work described in this abstract was fully supported by a grant from the Research Grants Council of HKSAR, China [RGC: UGC/FDS16/M12/20].

Routine antiseptic baths and MRSA decolonization: diverse approaches across Singapore's acute-care hospitals

To determine the variation in practices on meticillin-resistant Staphylococcus aureus (MRSA) surveillance and management of MRSA-colonized patients amongst 17 acute healthcare facilities in Singapore, the Ministry of Health convened a sharing session with Infection Prevention and Control Leads. All hospitals practised close to universal MRSA entry swabbing in keeping with national policy. There were, however, major variations in the response to both positive and negative surveillance swabs across facilities including the role of routine antiseptic bathing and MRSA decolonization. Most undertaking decolonization considered its role to be in 'bioburden reduction' rather than longer-term clearance.

Population-based trend analysis of voiding cystourethrogram ordering practices in a single-payer healthcare system before and after the release of evaluation guidelines

INTRODUCTION

While voiding cystourethrogram (VCUG) is a widely-accepted test, it is invasive and associated with radiation exposure. Most cases of primary vesicoureteral reflux (VUR) are low-grade and unlikely to be associated with acquired renal scarring. To select patients at greatest risk, in 2011 the American Academy of Pediatrics (AAP) published guidelines for evaluation of children ages 2 - 24 months with urinary tract infections (UTIs). Similarly, in 2010 the Society for Fetal Urology (SFU) published guidelines for patients with hydronephrosis. Herein a prospectively-collected database was queried through the Institute of Clinical Evaluative Sciences (ICES), exploring trends in VCUG ordering within the Ontario Health Insurance Program (OHIP), which guarantees universal access to care.

MATERIAL AND METHODS

A dedicated ICES analyst extracted data on all patients younger than 18 years in Ontario, Canada, with billing codes for VCUG and ICD-9 codes for VUR, from 2004-2014. The baseline characteristics included patient age, gender, geographic region, specialty of ordering provider and previous diagnoses of UTI and/or antenatal hydronephrosis to determine the indication for ordering the test. Of these, patients were subsequently incurred OHIP procedure codes for endoscopic injection or ureteral reimplantation. Patients who had a VCUG in the setting of urethral trauma, posterior urethral valves, and neurogenic bladder were excluded.

RESULTS AND DISCUSSION

Trend analysis demonstrated that the total number of VCUGs ordered in the province has decreased over a decade (Figure 1), with a concurrent decrease in VUR diagnosis. On multivariate regression analysis, the decrease in VCUG ordering could not be explained by changes in population demographics or other baseline patient variables. Most VCUGs obtained per year were ordered by pediatricians or family physicians (mean 2,022+523.8), compared with urologists and nephrologists (mean 616+358.3). Interestingly, while the rate of VCUG requests decreased, the annual number of surgeries performed for VUR (endoscopic or open) did not show a significant reduction over time.

CONCLUSIONS

We present a large population-based analysis in a universal access to care system, reporting a decreasing trend in the number of cystograms and differences by primary care versus specialist providers. While it is reassuring to see practice patterns favorably impacted by guidelines, it is also encouraging to note that the number of surgeries has remained stable. This suggests that patients at risk continue to be detected and offered surgical correction. These data confirm previous institution-based assessments and affirm changes in VCUG ordering independent of variables not relevant to the healthcare system, such as the insurance status.

Stent-related complications after hypospadias repair: a prospective trial comparing Silastic tubing and Koyle urethral stents

INTRODUCTION

There is a paucity of data comparing urethral stents after hypospadias repair. The aim of this study is to compare Silastic tubing vs Koyle stents (Cook Medical), addressing outcomes related to stent-related complications, added visits to healthcare providers in the early postoperative period, and postoperative complications at clinic follow-up.

MATERIALS AND METHODS

Following an alternate week allocation, 150 patients were prospectively assigned to have Silastic tubes (n = 76) and Koyle stents (n = 74) after hypospadias repair. Exclusion criteria included fistula repairs, drainage via alternative catheter, or stentless repairs. Silastic tubes were secured with 5-0 Prolene and removed during a planned clinic visit. Koyle stents were secured with 7-0 PDS and left to fall out spontaneously. Questionnaires capturing postoperative outcomes were completed.

RESULTS AND DISCUSSION

Median age was 13 and 11 months in the Silastic and Koyle stent groups, respectively (P = 0.48). There was no statistically significant difference in hypospadias location. Blockage/kinking of stents occurred in 8% (n = 6) of the Silastic and 9% (n = 7) Koyle stent groups, P = 0.78. Although follow-up was short, there was no difference in fistula rate among the Silastic (21%, n = 14) versus Koyle stent group (17%, n = 11), P = 0.66. There was a twofold higher rate of emergency department (ED) visits in the Silastic (32%, n = 24) versus Koyle stent group (16%, n = 12), P = 0.03. Half of ED visits in the Silastic group were related to stents falling out before planned removal. The authors propose that Silastic stents falling out before the removal date may have led to increased parental anxiety and thus a visit to the ED. With improved parental education, the authors propose that many of these visits may have been preventable.

CONCLUSIONS

There were no significant differences in stent-related complications or fistula rate between the Silastic and Koyle stent groups. Although there were a twofold higher number of visits to the ED in the Silastic stent group, the authors propose that this was due to parental education rather than the stent itself.

Equilibrated warping: Finite element image registration with finite strain equilibrium gap regularization

In this paper, we propose a novel continuum finite strain formulation of the equilibrium gap regularization for image registration. The equilibrium gap regularization essentially penalizes any deviation from the solution of a hyperelastic body in equilibrium with arbitrary loads prescribed at the boundary. It thus represents a regularization with strong mechanical basis, especially suited for cardiac image analysis. We describe the consistent linearization and discretization of the regularized image registration problem, in the framework of the finite elements method. The method is implemented using FEniCS & VTK, and distributed as a freely available python library. We show that the equilibrated warping method is effective and robust: regularization strength and image noise have minimal impact on motion tracking, especially when compared to strain-based regularization methods such as hyperelastic warping. We also show that equilibrated warping is able to extract main deformation features on both tagged and untagged cardiac magnetic resonance images.

Solar Open Flux Migration from Pole to Pole: Magnetic Field Reversal

Coronal holes are solar regions with low soft X-ray or low extreme ultraviolet intensities. The magnetic fields from coronal holes extend far away from the Sun, and thus they are identified as regions with open magnetic field lines. Coronal holes are concentrated in the polar regions during the sunspot minimum phase, and spread to lower latitude during the rising phase of solar activity. In this work, we identify coronal holes with outward and inward open magnetic fluxes being in the opposite poles during solar quiet period. We find that during the sunspot rising phase, the outward and inward open fluxes perform pole-to-pole trans-equatorial migrations in opposite directions. The migration of the open fluxes consists of three parts: open flux areas migrating across the equator, new open flux areas generated in the low latitude and migrating poleward, and new open flux areas locally generated in the polar region. All three components contribute to the reversal of magnetic polarity. The percentage of contribution from each component is different for different solar cycle. Our results also show that the sunspot number is positively correlated with the lower-latitude open magnetic flux area, but negatively correlated with the total open flux area.

Mathematical modeling of cardiac growth and remodeling

This review provides an overview of the current state of mathematical models of cardiac growth and remodeling (G&R). We concisely describe the experimental observations associated with cardiac G&R and discuss existing mathematical models that describe this process. To facilitate the discussion, we have organized the G&R models in terms of (1) the physical focus (biochemical vs mechanical) and (2) the process that they describe (myocyte hypertrophy vs extracellular matrix remodeling). The review concludes with a discussion of some possible directions that can advance the existing state of cardiac G&R mathematical modeling. WIREs Syst Biol Med 2016, 8:211-226. doi: 10.1002/wsbm.1330 For further resources related to this article, please visit the WIREs website.

Training-induced Increase in Bone Mineral Density between Growing Male and Female Rats

The purpose of this study was to determine the existence of sex differences in the resistance training-induced elevation in bone mineral density (BMD) and bone strength (Fmax) during the growth period in rats. 16 male (M) and 16 female (F) rats (approx. 8 weeks old) were randomly divided into sedentary control (MC=8, FC=8), and resistance-trained (RT) groups (M-RT=8, F-RT=8). The RT groups were conditioned to climb a vertical ladder 4 consecutive times (per exercise session) with weights attached to their tail 3 days per week for a total of 6 weeks. After 6 weeks, there were no interaction effects (sex×exercise). The main effect of sex indicated no difference in tibial BMD (in g/cm(2)) for males (0.226±0.005) compared to females (0.221±0.004). However, Fmax (in Newtons) was significantly greater for males (131.3±5.3) compared to females (89.9±3.0). The main effect of exercise indicated that tibial BMD and Fmax were significantly greater for RT groups (0.234±0.004 g/cm(2) and 120.9±7.4 Newtons) compared to controls (0.212±0.003 g/cm(2) and 100.3±5.1 Newtons). The results indicate that during growth, there were no sex differences in the training-induced elevation in BMD and bone mechanical properties.

Heterogeneous growth-induced prestrain in the heart

Even when entirely unloaded, biological structures are not stress-free, as shown by Y.C. Fung׳s seminal opening angle experiment on arteries and the left ventricle. As a result of this prestrain, subject-specific geometries extracted from medical imaging do not represent an unloaded reference configuration necessary for mechanical analysis, even if the structure is externally unloaded. Here we propose a new computational method to create physiological residual stress fields in subject-specific left ventricular geometries using the continuum theory of fictitious configurations combined with a fixed-point iteration. We also reproduced the opening angle experiment on four swine models, to characterize the range of normal opening angle values. The proposed method generates residual stress fields which can reliably reproduce the range of opening angles between 8.7±1.8 and 16.6±13.7 as measured experimentally. We demonstrate that including the effects of prestrain reduces the left ventricular stiffness by up to 40%, thus facilitating the ventricular filling, which has a significant impact on cardiac function. This method can improve the fidelity of subject-specific models to improve our understanding of cardiac diseases and to optimize treatment options.

LAMC2 enhances the metastatic potential of lung adenocarcinoma

Lung cancer is the number one cancer killer, and metastasis is the main cause of high mortality in lung cancer patients. However, mechanisms underlying the development of lung cancer metastasis remain unknown. Using genome-wide transcriptional analysis in an experimental metastasis model, we identified laminin γ2 (LAMC2), an epithelial basement membrane protein, to be significantly upregulated in lung adenocarcinoma metastatic cells. Elevated LAMC2 increased traction force, migration, and invasion of lung adenocarcinoma cells accompanied by the induction of epithelial-mesenchymal transition (EMT). LAMC2 knockdown decreased traction force, migration, and invasion accompanied by EMT reduction in vitro, and attenuated metastasis in mice. LAMC2 promoted migration and invasion via EMT that was integrin β1- and ZEB1-dependent. High LAMC2 was significantly correlated with the mesenchymal marker vimentin expression in lung adenocarcinomas, and with higher risk of recurrence or death in patients with lung adenocarcinoma. We suggest that LAMC2 promotes metastasis in lung adenocarcinoma via EMT and may be a potential therapeutic target.

A computational model that predicts reverse growth in response to mechanical unloading

Ventricular growth is widely considered to be an important feature in the adverse progression of heart diseases, whereas reverse ventricular growth (or reverse remodeling) is often considered to be a favorable response to clinical intervention. In recent years, a number of theoretical models have been proposed to model the process of ventricular growth while little has been done to model its reverse. Based on the framework of volumetric strain-driven finite growth with a homeostatic equilibrium range for the elastic myofiber stretch, we propose here a reversible growth model capable of describing both ventricular growth and its reversal. We used this model to construct a semi-analytical solution based on an idealized cylindrical tube model, as well as numerical solutions based on a truncated ellipsoidal model and a human left ventricular model that was reconstructed from magnetic resonance images. We show that our model is able to predict key features in the end-diastolic pressure-volume relationship that were observed experimentally and clinically during ventricular growth and reverse growth. We also show that the residual stress fields generated as a result of differential growth in the cylindrical tube model are similar to those in other nonidentical models utilizing the same geometry.

Elimination of subterranean termite (Isoptera: Rhinotermitidae) colonies using a refined cellulose bait matrix containing noviflumuron when monitored and replenished quarterly

Using a quarterly (3-mo) monitoring and bait-replenishment interval, 122 subterranean termite colonies throughout the United States were baited with a refined cellulose bait matrix containing 0.5% noviflumuron. All colonies were eliminated in less than 1 yr after initiation of baiting as determined by long-term monitoring and genetic markers. Sixty-three percent of the colonies were eliminated during the first quarter after the initiation of baiting and 77% of colonies were eliminated after consuming two bait tubes or less. This suggests that a single baiting cycle and bait installed in response to a single active monitoring device were sufficient to eliminate the majority of colonies. Although termites temporarily abandoned stations after depleting bait, workers resumed feeding when baits were replenished. Colonies that consumed large amounts of bait before elimination foraged into multiple stations, thus allowing adequate amounts of bait to sustain feeding. The time to eliminate termite colonies with bait replenished quarterly was similar to that previously reported for laminated cellulose bait replenished monthly. Our data support the conclusion that extending the bait replenishment interval from monthly to quarterly for bait tubes with refined cellulose containing 0.5% noviflumuron did not adversely impact colony elimination.

Managing ventricular ectopics: are ventricular ectopic beats just an annoyance?

How important are PVCs and what should we do about them? PVCs are not a disease in themselves, but a marker of possible underlying conditions that may increase the risk of cardiac death. They serve as a flag to alert us to exclude structural heart disease, the presence of which is the strongest predictor of adverse events. However, it is important to know that PVCs are common in people with no structural heart disease. In this situation, the prognosis is generally excellent. Suppression of PVCs with antiarrhythmic medication is not indicated routinely, unless the patient is symptomatic or at risk of tachycardia-induced cardiomyopathy owing to the very high frequency of PVCs. Where pharmacological therapy has failed, there is now the option of radiofrequency ablation for elimination of frequent symptomatic PVCs. The ECG is a simple yet useful tool to improve risk assessment, especially in those with known cardiovascular disease.

Nonlinear saturation of cyclotron maser instability associated with energetic ring-beam electrons

We study the cyclotron maser instability (CMI) driven by an energetic ring-beam distribution by a particle simulation to explain possible generation mechanisms of intense radiation phenomena observed in space. The main objective is to understand the nonlinear processes that control saturation of the emission process. Our study reveals new issues that have been overlooked in past literature. It is found that electrostatic wave modes excited by the electron beam instability compete with the electromagnetic waves excited by the CMI. Nonlinear effects of these electrostatic modes tend to redistribute the energy of the energetic electrons and make the physics more complicated. The CMI can be much less effective in a realistic case than it is anticipated theoretically.

Protein-losing enteropathy post-valvular surgery with severe tricuspid regurgitation in Subutex-related endocarditis

We report a 25-year-old Malay man with Subutex-related endocarditis, complicated by protein-losing enteropathy from severe tricuspid regurgitation and congestive heart failure. The intestinal protein loss was reversed with surgical valvular intervention. This case highlights the importance of recognising the rare association between protein-losing enteropathy and congestive heart failure in the setting of endocarditis.

Observation of large-scale density cavities and parametric-decay instabilities in the high-altitude discrete auroral ionosphere under pulsed electromagnetic radiation

A large density cavity that measured 2000 km across and 500 km in height was observed by DEMETER and Formosat/COSMIC satellites in temporal and spatial relation to a new mode of propagation of electromagnetic (em) pulses between discrete magnetic field-aligned auroral plasmas to high altitudes. Recorded positive plasma potential from satellite probes is consistent with the expulsion of electrons in the creation of density cavities. High-frequency decay spectra support the concept of parametric instabilities fed by free energy sources.

Isolated high lateral acute myocardial infarction with superior injury current axis

We report a 70-year-old man with high lateral ST elevation myocardial infarction secondary to occlusion of left circumflex artery. Electrocardiography (ECG) showed ST depression in inferior leads and isolated ST elevation in leads aVR and aVL, demonstrating a superior axis of the injury current vector. Different presentations of ECG pattern from left circumflex artery occlusion were discussed. This case highlights the importance of recognising unusual ECG pattern in accurate diagnosis of acute myocardial infarction.

Quantitative spectroscopic and theoretical study of the optical absorption spectra of H2O, HOD, and D2O in the 125-145 nm region

The room temperature absorption spectra of water and its isotopomers D2O and HOD have been determined in absolute cross section units in the 125 to 145 nm wavelength region using synchrotron radiation. The experimental results for these B band spectra are compared with results from quantum mechanical calculations using accurate diabatic ab initio potentials. A Monte Carlo sampling over the initial rotational states of the molecules is applied in order to calculate the cross sections at a temperature of 300 K. The overall rotation of the water molecule is treated exactly. Both for the experimental and for the theoretical spectrum an analysis is made in terms of a component attributed to rapid direct dissociation processes and a component attributed to longer-lived resonances. The agreement between the results from experiment and theory is excellent for H2O and D2O. In the case of HOD in the results of theory two more resonances are found at low energy. It is demonstrated that the width of the resonances of 0.04 eV is the result of overlapping and somewhat narrower resonances in the spectra of molecules differing in rotational ground state.

Use of three-dimensional ultrasound scan to assess the clinical importance of midurethral placement of the tension-free vaginal tape (TVT) for treatment of incontinence

The aim of the study is to illustrate that the midurethral positioning of the tension-free vaginal tape (TVT) may not be necessary to achieve continence. Our secondary aim is to highlight that a fair number of successfully performed TVT procedures do not result in midurethral position of the tape. A review of 31 women who underwent TVT operations and consecutively returned for their follow-up visits from July 2003 to November 2003 was conducted. Their TVT procedures were performed between March 2000 and August 2003. Transperineal three-dimensional ultrasound was used to identify and obtain objective measurements of the position of the TVT tape relative to the urethra. Any patients with significant coexisting vault or uterovaginal prolapse were surgically corrected at the same time. Their stress urinary incontinence was objectively diagnosed by performing urodynamic studies (dual-channel subtraction cystometry, erect stress test) in the outpatient urogynaecology clinic. Postoperatively, patients were reviewed at 1 month and then at 6 months followed by annual reviews subsequently. All women were reassessed at the 6-month follow-up visit with a filling and voiding cystometry to detect recurrent genuine stress incontinence and detrusor instability. Any woman complaining of stress urinary incontinence after that was reassessed with urodynamic studies as mentioned above. The majority of women (67.7%, 21 women) had the TVT tape located in the middle one-third of the urethra; 9.7% (3 women) and 22.6% (7 women) of women had the TVT tape situated in the proximal and distal one-third of the urethra, respectively. Despite this, all 31 women remained continent at their postoperative follow-up visits. The midurethral position of the TVT tape may not be essential in restoring continence. The TVT tape once inserted may not always rest in the midurethral position as described.

Gigantic jets between a thundercloud and the ionosphere

Transient luminous events in the atmosphere, such as lighting-induced sprites and upwardly discharging blue jets, were discovered recently in the region between thunderclouds and the ionosphere. In the conventional picture, the main components of Earth's global electric circuit include thunderstorms, the conducting ionosphere, the downward fair-weather currents and the conducting Earth. Thunderstorms serve as one of the generators that drive current upward from cloud tops to the ionosphere, where the electric potential is hundreds of kilovolts higher than Earth's surface. It has not been clear, however, whether all the important components of the global circuit have even been identified. Here we report observations of five gigantic jets that establish a direct link between a thundercloud (altitude approximately 16 km) and the ionosphere at 90 km elevation. Extremely-low-frequency radio waves in four events were detected, while no cloud-to-ground lightning was observed to trigger these events. Our result indicates that the extremely-low-frequency waves were generated by negative cloud-to-ionosphere discharges, which would reduce the electrical potential between ionosphere and ground. Therefore, the conventional picture of the global electric circuit needs to be modified to include the contributions of gigantic jets and possibly sprites.

Clinical manifestation of pulmonary embolism

Results of prospective studies have shown that physicians' estimate of clinical likelihoods of PE have predictive value. The ability of clinicians to assess the factors that determine the probability of disease based on clinical manifestations such as history and signs and symptoms at presentation, and to make bedside estimates of that probability, has not been systematically studied. Data suggest that that this would be a fruitful area of future investigation. Susec et al noted that there has been a total of three studies (including their own) which have examined the clinical features such as risk factors, signs, and symptoms associated with PE in ambulatory outpatients. Hence, the data collected thus far might not be generalizable to the ED patient population. As with other illnesses, the ED patients usually present later and more atypically. The prevalence of PE could be lower among this population compared with hospitalized patients, causing a lower positive predictive value, derivable from the clinical features and risk factors at presentation. Finally, the ED patient population is usually healthier and younger than the hospitalized patients, and it is well recognized that PE can be clinically silent in young patients and that 28% have no associated risk factors. Based on their finding, the authors argue that clinical pathways to risk stratify patients in an ambulatory setting could be less useful than anticipated. The validity of these findings needs further investigation, however.

Large pelvic accessory spleen mimicking an adnexal malignancy in a teenage girl

A large pelvic accessory spleen in a teenage female is rare and may be misdiagnosed as an adnexal tumor. A 17-year-old girl, gravida 0, had suffered from intermittent and dull pain in the lower abdomen for 1 month. Laboratory evaluation showed a low platelet count (136,000/microL). Abdominal sonography showed a large solid mass situated at the right pelvis, containing abundant vascular supply with low resistant blood flow. At laparotomy, an accessory spleen fed by a tortuous vascular pedicle from the omentum was found and then excised. Histopathologic examination revealed congestive accessory splenomegaly. Follow-up platelet count returned to normal levels (374,000/microL). The importance of including accessory spleen in the differential diagnosis of a solid adnexal tumor with thrombocytopenia is emphasized.

Holistic outcome measurement for terminally ill cancer patients in medical centers in Taiwan

The purpose of this cross-sectional study was to examine holistic patient outcomes for terminally ill cancer patients, as well as to examine whether different care patterns affect patient outcomes differently. Holistic patient outcomes were measured by the patients' quality of life, satisfaction with care, and cost of care. A purposive sampling of 224 subjects including 123 patients and 101 nurses was drawn from four medical centers in Taiwan. Among these settings, various care patterns were adopted and categorized into 4 groups: hospice inpatients, hospice team consultation, home hospice care services, and a conventional acute care group. Results showed that hospice inpatients had a higher quality of life, a higher level of satisfaction with the care and a lower average inpatient cost, whereas conventional care tended to have the highest length of hospital stay. Home hospice care patients had better psychological well-being than those with other care patterns. In addition, nurses' work satisfaction with the inpatients care unit tended to be significantly higher than with the other groups. The study findings not only provide an instrument for evaluating the quality of care, but also contribute to identifying patterns of care that will influence the dying process, which can only be beneficial for patients. Given the wide variety of healthcare services available now, understanding and selecting the most effective care patterns to enhance patient outcomes is of utmost importance in Taiwan.

[The effectiveness of implementing an unit-based shared governance model]

The purpose of the nonequivalent control group study was to establish a regional unit-based shared governance model. Fifty-three subjects distributing to experimental (n = 29) and control (n = 24) groups-age, working years, and education were matched statistically-were selected by "purposeful sampling" of Index of Professional Nurse Governance pretest mean scores from six units at a nursing department. Based on Martin's "systematic" evaluation model for shared governance, the study collected: (1) manager's and staff's perception of existing governance using open-ended questions, (2) measure of organizational efficiency using the IPNG and the Index of Working Satisfaction, and (3) the research team's assessment of the unit's willingness to continue this model in the future. The reliability and validity of the questionnaires were established. Intervention of the model was approximately four months, including: preparatory and evaluating phase: data was collected; educative phase: empowering managers and staff were educated in the shared governance concepts; implementing phase: shared governance team was built up. Two-tailed t and chi 2 tests were used to detect differences between the two groups. Results showed, after establishing the unit-based model, (1) an increase in the nursing professional governance and work satisfaction among nurses; (2) an enhanced partnership between managers and nurses; (3) staff nurses perceived increased autonomy, authority, and more frequently expressed their opinions to managers; (4) managers perceived their staff to have more potential competence, then task pushed effectively. The findings suggest that managers and nurses need to refine their professional roles based on the organizational mission, as well as to expand nurses' representation and participation in current organization-wide committees by trust and full delegation from their managers.

An evaluative study of the effects of the implementation of UBSG on nurses' perceptions of professional governance

Health care reform has been a major economic and political challenge in Taiwan. Successful implementation of change in hospitals requires managers to learn new skills. Unit-based shared governance (UBSG) is one innovation used to restructure health care organizations to promote the performance of professionals and to achieve goals for organizations. This research, conducted in a 150-bed community hospital, was a quasi-experimental study designed to evaluate the effectiveness of implementing UBSG. This article describes and compares the degree of nurses' perceptions of professional governance between a UBSG group (n = 29) and a control group (n = 24). The findings of this study indicate that the majority of UBSG respondents scored at a high level of participation in decision-making and professional practice (p < .05). Nurses in the UBSG group shared more in professional governance activities (p < .05). It is suggested that decentralized UBSG within a division of nursing can empower nurses. The study provides an empirical basis for implementing UBSG.

Influence of sanitary conditions on the field performance of chlorpyrifos-based baits against American cockroaches, Periplaneta americana (L.) (Dictyoptera: Blattidae)

The role of sanitation in performance of insecticidal bait stations containing 0.5% chlorpyrifos against the American cockroach, Periplaneta americana (L.), was investigated in residential premises. Test sites were chosen from three locations in Penang Island, Malaysia, and clustered according to their sanitary conditions. Results indicated that at 1-week post-treatment, houses with good sanitary conditions showed a significantly faster reduction (P > 0.05) in the number of cockroaches trapped (> 95%) than those with moderate and poor conditions. At 6 weeks post-treatment, all houses treated with insecticidal baits showed no significant difference in terms of reduction rate of cockroach numbers (P > 0.05), irrespective of sanitary condition. However, the bait performance in houses with poor sanitary conditions could not be sustained up to 12-week post-treatment.

Mental disorders and the incidence of migraine headaches in a community sample: results from the Baltimore Epidemiologic Catchment area follow-up study

BACKGROUND

The cross-sectional relation between migraine headaches and affective disorders has been demonstrated in studies of clinical and community populations. Few studies have investigated the prospective relation between psychiatric disorders and migraine headaches.

METHODS

A prospective follow-up of the Baltimore, Md, cohort of the Epidemiologic Catchment Area Study assessed psychopathologic features in 1981 and again between 1993 and 1996. Interviews included a history of headaches at baseline and self-reported assessment of migraine headaches at follow-up. Risk estimates for incident migraine headaches by 1981 demographic variables and psychopathologic features were calculated. The cross-sectional association between prevalent migraine and lifetime psychiatric diagnoses was estimated.

RESULTS

In the at-risk population of 1343, there were 118 incident cases of migraine headaches. The age- and sex-specific incident rates of migraine headaches followed the expected patterns, with younger age and female sex identified as risk factors. In cross-sectional analyses, major depression (odds ratio, 3.14; 95% confidence interval, 2.03-4. 84) and panic disorder (odds ratio, 5.09; 95% confidence interval, 2. 65-9.79) had the strongest associations, and alcohol and other substance abuse were not associated. In logistic regression models including age, sex, and psychiatric illness in 1981, only phobia was predictive of incident migraines (odds ratio, 1.70; 95% confidence interval, 1.11-2.58). Affective disorders were not predictive of incident migraine headaches. Including a history of tricyclic antidepressant use did not change the results.

CONCLUSIONS

There is a strong cross-sectional relation between affective disorders and migraine headaches in this cohort. However, there is no association between antecedent affective disorders and incident migraine headaches in this population-based prospective study.

A quasi-experimental study on a quality circle program in a Taiwanese hospital

OBJECTIVE

To explore the impact of quality circles on job satisfaction, absenteeism, and turnover among hospital nurses in Taiwan.

DESIGN

A quasi-experimental research design.

SETTING

In November 1995, a study was initiated to establish quality circles in a 500-bed community hospital in Taiwan. After the administrative process and a pilot study, three of the experimental units began implementing the quality circle program in January 1997. For the comparison group, three non-quality circle medical-surgical units were selected from another building.

STUDY PARTICIPANTS

All registered nurses on the three selected units who met the criteria of having worked full-time on those units for > or = 6 months were included in the study. There were 53 full-time registered nurses (49 female, four male) who met the criteria and 100% participated. There were no significant differences between the quality circle group and the non-quality circle group in terms of sex, age, and number of years of working experience, education or marital status.

INTERVENTIONS

After obtaining administrative approval and support, the pilot study began with 3-month quality circle courses and 3-month quality circle process training for the experimental group nurses. Each circle has been meeting for 1 hour each week to identify problems, barriers, and solutions for effective implementation since 1997.

MAIN OUTCOME MEASURES

(i) Demographic data questionnaire; (ii) Stamps and Piedmont's Index of Work Satisfaction; (iii) hospital records for absenteeism and turnover data.

RESULTS

The data reveal that nurses of the three quality circle units felt more satisfied (P < 0.01) than did nurses from the three non-participating units. In the non-participating group, 36% had considered leaving the units, compared to 10% of nurses from the quality circle group. The turnover rate was significantly higher for the non-participating group (40%) than for the quality circle group (13%).

CONCLUSION

This quality circle program in a Taiwanese hospital significantly improved satisfaction, reduced absenteeism, and lowered turnover of nurses. The findings support other studies reported in the literature.

Mid-trimester beta-hCG levels incorporated in a multifactorial model for the prediction of severe pre-eclampsia

Pre-eclampsia remains a major cause of perinatal morbidity and mortality worldwide. Proposed predicting tests for early detection of pregnant women destined to develop pre-eclampsia remain unsatisfactory. The aim of this study was to investigate the clinical utility of combining mid-trimester maternal serum beta-human chorionic gonadotrophin (MShCG) levels with selected clinical determining factors as a multifactorial predictive test for pre-eclampsia. Thirty-nine cases with mild pre-eclampsia and 56 with severe pre-eclampsia were recruited as the study groups. Normotensive women (957) were enrolled as controls. Potential determining risk factors for severe pre-eclampsia were selected using a multiple logistic regression to build various combined prediction models. A receiver-operator characteristic curve was employed to assess the performance of each prediction test for pre-eclampsia. The prediction efficacy of each test was examined by the area under the curve (AUC). Our data show that mid-trimester MShCG levels significantly correlated with severity of pre-eclampsia (Spearman rank correlation coefficient=0.195, p<0.001). Women with mild pre-eclampsia had a 2.61-times greater chance, while women with severe pre-eclampsia had a 6.13-times greater chance of having MShCG exceeding 2.0 multiples of the median than did women with a normal pregnancy. A combined prediction model composed of MShCG levels, body mass index (BMI), parity, and age as a predictive test for severe pre-eclampsia was superior to MShCG levels alone (AUC 0.765 versus 0.648). The integrated multifactorial model could identify women at risk early on for developing severe pre-eclampsia, with a sensitivity of 70% and a specificity of 71%. Thus, we demonstrate a potentially effective and convenient method by which women at risk for developing severe pre-eclampsia can be identified early, based on a multifactorial predictive model composed of midtrimester MShCG levels, BMI, parity, and age.

Absolute configuration of (+)-alpha-dihydrotetrabenazine, an active metabolite of tetrabenazine

Chiral column liquid chromatography and enantiospecific enzymatic hydrolysis were utilized to separate the enantiomers of alpha- and beta-dihydrotetrabenazine and alpha-9-O-desmethyldihydrotetrabenazine, three benzo[a]quinolizines derived from the amine-depleting drug tetrabenazine. An X-ray crystal structure analysis of (-)-alpha-9-O-desmethyldihydrotetrabenazine gave an absolute structure of that compound as the 2S, 3S, 11bS isomer. Therefore, (-)-alpha-dihydrotetrabenazine also has the 2S, 3S, 11bS absolute configuration. (+)-alpha-Dihydrotetrabenazine, the single biologically active isomer from the metabolic reduction of tetrabenazine, thus has the absolute configuration of 2R, 3R, 11bR. For further in vitro and in vivo studies of the vesicular monoamine transporter, it is now possible to use the single enantiomer of radiolabeled alpha-dihydrotetrabenazine.

Pregnancy associated with gastric carcinoma

Gastric cancer during pregnancy is very rare. We present the case of a 32-year-old woman, gravida 1 para 0, who suffered from advanced gastric cancer during pregnancy. Although the clinical symptoms of the tumor were evident early in the third trimester, the tumor was not diagnosed until 7 days postpartum, when it was too far advanced for curative resection. Only palliative procedures were carried out. The woman died of the cancer less than 3 months postpartum. Early diagnosis of this disease entity is often difficult and a poor prognosis invariably ensures, unless obstetricians maintain a high level of awareness. In pregnant patients with eccentric symptoms of the gastrointestinal tract that persist beyond the second trimester, further endoscopic evaluation should be considered. Occult blood in stool concomitant with elevated serum carcinoembryonic antigen concentration should be considered as an important indicator for thorough endoscopic investigation.

Diminished vasomotor component of systemic arterial pressure signals and baroreflex in brain death

We compared the cardiovascular autonomic regulatory mechanisms between patients with brain death or under a persistent vegetative state and healthy volunteers, based on auto- and cross-spectral analysis of systolic blood pressure (SBP) and interpulse interval (PPI) signals. Brain-dead patients exhibited a significant reduction in the absolute and relative power of the low-frequency (LF; 0.04-0.15 Hz) component in both SBP and PPI spectra, along with appreciable decrease in the very low frequency (VLF; 0.004-0.04 Hz), LF, and high-frequency (HF; 0.15-0.4 Hz) power of the PPI signals. Patients in a persistent vegetative state exhibited a power of the VLF and LF component in the SBP spectrum that was comparable to that in healthy subjects, although a discernible reduction in the VLF, LF, and HF power of the PPI spectrum was manifested by the former group. Assessments with the magnitude of SBP-PPI transfer function and linear regression analysis of beat-to-beat fluctuations in SBP and PPI revealed a progressive decline in spontaneous baroreflex sensitivity from healthy subjects to patients in a persistent vegetative state or with brain death. We conclude that the vasomotor component of systemic arterial pressure signals and spontaneous baroreflex are highly correlated with the functional integrity of the brain stem.

A simple synthesis of [11C]dihydrotetrabenazine (DTBZ)

[11C]Dihydrotetrabenazine (2-hydroxy-3-isobutyl-9-[11C]methoxy-10 -methoxy-1,2,3,4,6,7,- hexahydro-11bH-bezo[alpha]-quinolizine) ([11C]DTBZ) was synthesized by reacting the 9-hydroxy precursor in DMSO with gas-phase [11C]methyl iodide on a column of alumina impregnated with KOH. The reaction was instantaneous at room temperature. This column was then connected to the inlet of a short column containing basic alumina. Elution with cyclohexane removed radioactive contaminants. The radioactive product was then eluted with a few milliliters ether containing 1% ethanol. The [11C]DTBZ was obtained in isolated yields of > 200 mCi and specific activities > 1600 Ci/mmol.

Spectral analysis of systemic arterial pressure and heart rate signals as a prognostic tool for the prediction of patient outcome in the intensive care unit

OBJECTIVES

To evaluate the applicability of changes in spectra of systemic arterial pressure and heart rate signals in the prediction of patient outcome in an adult intensive care unit (ICU). To compare the prognostic predictability of this method with the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system.

DESIGN

Prospective data collection from 52 ICU patients.

SETTING

Adult ICU at a large, university-affiliated, medical center.

PATIENTS

Consecutive patients who were admitted to the adult ICU due to noncardiac emergencies, and who remained for at least 2 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The demographic data, diagnosis, and survival data were recorded for each patient enrolled in this study. For the period between admission and 24 hrs before discharge, the APACHE II score was tabulated daily. Likewise, continuous, on-line, and real-time spectral analysis of systemic arterial pressure and heart rate signals was carried out every day for at least 30 mins at 2200 to 2400 hrs. The averaged power density values during this 30-min recording period of the high-frequency (0.15 to 0.4 Hz), low-frequency (0.08 to 0.15 Hz), and very low-frequency (0.016 to 0.08 Hz) components of systemic arterial pressure and heart rate signals were subsequently computed. Systemic vascular resistance index and cardiac index were also determined daily. We observed a trend of changes in the spectral components of systemic arterial pressure and heart rate signals in patients who eventually survived (n = 25) or died (n = 27). Progressive increases in the power density values of both the low-frequency and very low-frequency components of systemic arterial pressure and heart rate signals appeared to be related to recovery. Conversely, progressive decreases in the power density values of these spectral components was indicative of deterioration and fatality. The predicted outcome based on the trend of changes in the low-frequency and very low-frequency components of systemic arterial pressure and heart rate signals correlated positively with daily APACHE II scores. No direct correlation, however, was indicated by mean systemic arterial pressure, heart rate, systemic vascular resistance index, and cardiac index. We also confirmed that the differential trend of spectral changes in patients who survived or died was not due to circadian rhythm, nor alterations in the responsiveness of the blood vessels to intravenous infusion of dopamine.

CONCLUSION

Power spectral analysis of systemic arterial pressure and heart rate signals offers a reasonable means of monitoring acute, critically ill patients, and may be used as an alternative prognostic tool for the prediction of patient outcome in the ICU.

Decreased striatal monoaminergic terminals in olivopontocerebellar atrophy and multiple system atrophy demonstrated with positron emission tomography

We used [11C]dihydrotetrabenazine, a new ligand for the type 2 vesicular monoamine transporter (VMAT2), with positron emission tomography to study striatal monoaminergic presynaptic terminals in 4 patients with multiple system atrophy, 8 with sporadic olivopontocerebellar atrophy, and 9 normal control subjects. Specific binding in the striatum was significantly reduced in the multiple system atrophy patients as compared with the normal control group, with average reductions of 61% in the caudate nucleus (p = 0.002) and 58% in the putamen (p = 0.009). Smaller reductions were found in the sporadic olivopontocerebellar atrophy group, averaging 26% in the caudate nucleus (p = 0.05) and 24% in the putamen (p = 0.11). Mean blood-to-brain [11C]dihydrotetrabenazine transport (K1) was significantly different between groups only in the cerebellum, with values for the sporadic olivopontocerebellar atrophy group diminished compared with the normal control group. Cerebellar K1 was not significantly decreased in the multiple system atrophy group. The finding of reduced striatal VMAT2 in sporadic olivopontocerebellar atrophy patients suggests nigrostriatal pathology, indicating that some may later develop symptomatic extrapyramidal disease.

Kinetic evaluation of [11C]dihydrotetrabenazine by dynamic PET: measurement of vesicular monoamine transporter

(+)-alpha-[11C]Dihydrotetrabenazine (DTBZ) binds to the vesicular monoamine transporter (VMAT2) located in presynaptic vesicles. The purpose of this work was to evaluate various model configurations for analysis of [11C]DTBZ with the aim of providing the optimal measure of monoamine vesicular transporter density obtainable from a single dynamic PET study. PET studies on seven young normal volunteer subjects, ages 20-35, were performed following i.v. injection of 666 +/- 37 MBq (18 +/- 1 mCi) of (+)-alpha-[11C]DTBZ. Dynamic acquisition consisted of a 15-frame sequence over 1 h. Analysis methods included both creation of pixel-by-pixel functional images of transport (K1) and binding (DVtot) and nonlinear least-squares analysis of volume-of-interest data. Pixel-by-pixel calculations were performed for both two-compartment weighted integral calculations and slope-intercept estimations from Logan plots. Nonlinear least-squares analysis was performed applying model configurations with both two-compartments, estimating K1 and DVtot and three compartments, estimating K1-k4. For the more complex configuration, we examined the stability of various binding-related parameters including k3 (konBmax'), k3/k4 (Bmax'/Kd), DVsp[(K1/k2)(k3/k4)], and DVtot [K1/k2(1 + k3/k4)]. The three-compartment model provided significantly improved goodness-of-fit compared to the two-compartment model, yet did not increase the uncertainty in the estimate of the DVtot. Without constraining parameters in the three-compartment model fits, DVtot was found to provide a more stable estimate of binding density than either k3, k3/k4, or DVsp. The two-compartment least-squares analysis yielded approximately 10% underestimations of the total distribution. However, this bias was found to be very consistent from region to region as well as across subjects as indicated by the correlation between two- and three-compartment DVtot estimates of 0.997. We conclude that (+)-alpha-[11C]DTBZ and PET can provide excellent measures of VMAT2 density in the human brain.