UK Stroke Supplement: 001 – High Scoring Oral Presentation – Swallowing and Nutrition: SWALLOWING THERAPY FOR DYSPHAGIA IN ACUTE AND SUB-ACUTE STROKE (COCHRANE SYSTEMATIC REVIEW)

Introduction

Swallowing difficulties (oropharyngeal dysphagia (OD)) are common post-stroke but there is no specific guidance on treatment. We have updated the 2018 Cochrane review of dysphagia interventions to explore whether there is evidence of a significant benefit from OD interventions on swallowing impairment.

Methods

RCT’s of patients with a new onset of OD after stroke published before January 2021 were included. Results were screened and analysed by two independent researchers. Trials were divided to specific intervention types and data was analysed against 8 outcomes, the primary outcome being swallowing impairment (SI).

Results

83 additional trials were analysed producing a review to a total of 129 trials. Three interventions were associated with reductions in outcomes: Acupuncture: SI (SMD −0.94 [95% CI−1.25,−0.63], p < 0.0001); dysphagia (OR 0.41 [95% CI 0.33, 0.49], p < 0.0001); and penetration aspiration scale score (PAS) (MD −0.68 [95% CI −1.17, −0.19], p = 0.006). Behavioural therapy: SI (SMD −0.88 95% CI −1.28, −0.48], p < 0.0001); dysphagia (OR 0.41 [95% CI 0.29, 0.59], p < 0.0001); PAS (MD −0.77 [95% CI −1.11, −0.42], p < 0.0001); and chest infection/pneumonia (OR 0.43 [0.25, 0.74], p = 0.002). Neuromuscular electrical stimulation (NMES): SI (SMD −0.96 95% CI −1.38, −0.54], p < 0.0001) and dysphagia (OR 0.39 [95% CI 0.27, 0.56], p < 0.0001). The limited number of trials precluded comment on other interventions included within the review. Heterogeneity of trials ranged from mild-significant.

Conclusions

Low-to-moderate quality evidence from small-moderate sized trials suggest that Acupuncture, Behavioural and NMES interventions reduce swallowing impairment after stroke. Large, high-quality trials are needed to test whether specific interventions are effective.

Studying health informatics from a distance: issues, problems and experiences

Sheffield University has recently introduced a new Health Informatics Masters degree by distance learning. This paper documents the initial experiences of setting up, managing and delivering this course. The three parts of the paper cover motivation and background, design and content, and the issues, observations and problems relating to the course respectively. The latter relate to the logistics of delivery and how best to utilize the features of WebCT, and also how to meet the aspirations of students from a wide range of backgrounds.

Can comprehensive specialised end-of-life care be provided at home? Lessons from a study of an innovative consultant-led community service in the UK

The Midhurst Macmillan Specialist Palliative Care Service (MMSPCS) is a UK, medical consultant-led, multidisciplinary team aiming to provide round-the-clock advice and care, including specialist interventions, in the home, community hospitals and care homes. Of 389 referrals in 2010/11, about 85% were for cancer, from a population of about 155 000. Using a mixed method approach, the evaluation comprised: a retrospective analysis of secondary-care use in the last year of life; financial evaluation of the MMSPCS using an Activity Based Costing approach; qualitative interviews with patients, carers, health and social care staff and MMSPCS staff and volunteers; a postal survey of General Practices; and a postal survey of bereaved caregivers using the MMSPCS. The mean cost is about 3000 GBP (3461 EUR) per patient with mean cost of interventions for cancer patients in the last year of life 1900 GBP (2192 EUR). Post-referral, overall costs to the system are similar for MMSPCS and hospice-led models; however, earlier referral avoided around 20% of total costs in the last year of life. Patients and carers reported positive experiences of support, linked to the flexible way the service worked. Seventy-one per cent of patients died at home. This model may have application elsewhere.

Analytic Hierarchy Process (AHP) for examining healthcare professionals' assessments of risk factors. The relative importance of risk factors for falls in community-dwelling older people

BACKGROUND

A gap exists between evidence-based medicine and clinical-practice. Every day, healthcare professionals (HCPs) combine empirical evidence and subjective experience in order to maximize the effectiveness of interventions. Consequently, it is important to understand how HCPs interpret the research evidence and apply it in everyday practice. We focused on the prevention of falls, a common cause of injury-related morbidity and mortality in later life, for which there is a wide range of known risk factors.

OBJECTIVES

To use the Analytic Hierarchy Process (AHP) to investigate the opinions of HCPs in prioritizing risk factors for preventing falls.

METHODS

We used the AHP to develop a hierarchy of risk factors for falls based on the knowledge and experience of experts. We submitted electronic questionnaires via the web, in order to reach a wider number of respondents. With a web service, we pooled the results and weighted the coherence and the experience of respondents.

RESULTS

Overall, 232 respondents participated in the study: 32 in the technical pilot study, nine in the scientific pilot study and 191 respondents in the main study. We identified a hierarchy of 35 risk factors, organized in two categories and six sub-categories.

CONCLUSIONS

The hierarchy of risk factors provides further insights into clinicians' perceptions of risk factors for falls. This hierarchy helps understand the relative importance that clinicians place on risk factors for falls in older people and why evidence-based guidelines are not always followed. This information may be helpful in improving intervention programs and in understanding how clinicians prioritize multiple risk factors in individual patients. The AHP method allows the opinions of HCPs to be investigated, giving appropriate weight to their coherence, background and experience.

Assessing quality of care from hospital case notes: comparison of reliability of two methods

OBJECTIVES

To determine which of the two methods of case note review provide the most useful and reliable information for reviewing quality of care.

DESIGN

Retrospective, multiple reviews of 692 case notes were undertaken using both holistic (implicit) and criterion-based (explicit) review methods. Quality measures were evidence-based review criteria and a quality of care rating scale.

SETTING

Nine randomly selected acute hospitals in England.

PARTICIPANTS

Sixteen doctors, 11 specialist nurses and three clinically trained audit staff, and eight non-clinical audit staff. ANALYSIS METHODS: Intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs), completeness of criterion data capture and between-staff group comparison.

RESULTS

A total of 1473 holistic reviews and 1389 criterion-based reviews were undertaken. When the three same staff types reviewed the same record, holistic scale score inter-rater reliability was moderate within each group (ICC 0.46 to 0.52). Inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61 to 0.88). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement between the two methods.

CONCLUSIONS

Using a holistic approach to review case notes, same staff groups can achieve reasonable repeatability within their professional groups. When the same clinical record was reviewed twice by the doctors, and by the non-clinical audit staff, using both holistic and criterion-based methods, there are close similarities between the quality of care scores generated by the two methods. When using retrospective review of case notes to examine quality of care, a clear view is required of the purpose and the expected outputs of the project.

Accessibility versus confidentiality of information in the emergency department

INTRODUCTION

In the emergency department (ED), clinicians can benefit greatly from having access to information at the point of care. It has been suggested that using computerised information systems could improve the accessibility of information. However, making information accessible, while maintaining confidentiality, is one of the main challenges of implementing information systems. This article presents the ED staff perspectives about the accessibility and confidentiality of information in the ED.

METHOD

The authors undertook a qualitative study in March-April 2007. Data were collected using in-depth semi-structured interviews with the ED staff of an ED located in Northern England. In total, 34 interviews were conducted and transcribed verbatim. Data were analysed using framework analysis.

RESULTS

The results showed that the ED staff had role-based access to the current information systems, and these systems met only a small part of their information needs. As a result, different sources were used to get access to the needed information. Although the ED staff believed that improving the accessibility of information could be helpful in emergency care services, there were concerns about the confidentiality of information. The confidentiality of information could be threatened--for example, by sharing passwords, misusing patient information or by unauthorised staff having access to patient information.

CONCLUSION

To design a system, the accessibility and confidentiality of information should be addressed in parallel. A balance between these two is needed, as the failure of each of these may negatively influence the use of the system.

Individual Patient Data Meta-Analysis of Randomized Controlled Trials of Community Occupational Therapy for Stroke Patients

BACKGROUND AND PURPOSE

Trials of occupational therapy for stroke patients living in the community have varied in their findings. It is unclear why these discrepancies have occurred.

METHODS

Trials were identified from searches of the Cochrane Library and other sources. The primary outcome measure was the Nottingham Extended Activities of Daily Living (NEADL) score at the end of intervention. Secondary outcome measures included the Barthel Index or the Rivermead ADL (Personal ADL), General Health Questionnaire (GHQ), Nottingham Leisure Questionnaire (NLQ), and death. Data were analyzed using linear or logistic regression with a random effect for trial and adjustment for age, gender, baseline dependency, and method of follow-up. Subgroup analyses compared any occupational therapy intervention with control.

RESULTS

We included 8 single-blind randomized controlled trials incorporating 1143 patients. Occupational therapy was associated with higher NEADL scores at the end of intervention (weighted mean difference [WMD], 1.30 points, 95% confidence intervals [CI], 0.47 to 2.13) and higher leisure scores at the end of intervention (WMD, 1.51 points; 95% CI, 0.24 to 2.79). Occupational therapy emphasizing activities of daily living (ADL) was associated with improved end of intervention NEADL (WMD, 1.61 points; 95% CI, 0.72 to 2.49) and personal activities of daily living (odds ratio [OR], 0.65; 95% CI, 0.46 to 0.91), but not NLQ. Leisure-based occupational therapy improved end of intervention NLQ (WMD, 1.96 points; 95% CI, 0.27 to 3.66) but not NEADL or PADL.

CONCLUSIONS

Community occupational therapy significantly improved personal and extended activities of daily living and leisure activity in patients with stroke. Better outcomes were found with targeted interventions.

Health information needs of visually impaired people: a systematic review of the literature

Access to, and provision of, information is key to reducing health inequalities in health and social care. However, information is not always accessible and does not always meet the needs of specific groups. One such group is people who are visually impaired. The aim of the present study was to identify the health information needs of visually impaired people, and highlight major gaps in the literature. A systematic review of the literature was undertaken following, where possible, the NHS Centre for Reviews and Dissemination framework. Modifications included the sources searched, the critical appraisal checklist used (Critical Skills Training in Appraisal for Librarians) and the method of data synthesis. Out of the 1114 references identified, only 16 met the inclusion criteria. Quality of reporting of the literature was poor, and this must be taken into consideration when interpreting the findings of this review. The majority of studies were concerned with information for healthy living (e.g. health promotion). The focus of the remaining studies was on information about visual impairment or coping with visual impairment, and about accessing health services (e.g. medication labels and appointment letters). The majority of studies conducted to date have concentrated on the format of information. There are surprisingly few empirical studies which have examined the health information needs of this group. A number of gaps in the literature have been identified. These relate to the types of health information, non-format aspects of information (e.g. content and timing), sources of health and social care information, treating visually impaired people as a heterogeneous group, and recognising the value of actively involving visually impaired people in the research process. Although this review has identified a number of implications for practice, the paucity of evidence places a heavier onus on future research. Visually impaired people are likely to have unique health and social care information needs which are worthy of exploration in their own right.

The role of the information specialist in the systematic review process: a health information case study

There is an increasing body of literature on the information specialist's role in supporting evidence-based health care. In particular, the information component in systematic reviews has received considerable attention in recent years. Information professionals have evolved from simply acting as 'evidence locators' and 'resource providers' to being quality literature filterers, critical appraisers, educators, disseminators, and even change managers. This paper describes ten possible roles for information professionals in the systematic review process, using a case study of a review of the health information needs of visually impaired people carried out by the Centre for Health Information Management Research (CHIMR) at the University of Sheffield. This health information review was undertaken entirely by a team of information professionals. The ten roles identified are: project leader, project manager, literature searcher, reference manager, document supplier, critical appraiser, data extractor, data synthesiser, report writer and disseminator. This review has also identified an eleventh possible role for information professionals; that of primary researcher. Finally, the implications for evidence-based health care and evidence-based health informatics are discussed.

Bleeding time, stroke and myocardial infarction: the Caerphilly prospective study

The stressed bleeding time is a simple 'global' test of haemostasis, dependent upon platelet function, rheology, thrombosis and intimal function. It could be of considerable value in clinical practice if it were shown to be predictive of vascular disease events. A stressed bleeding time test was done on 1319 men aged 55-69 years in the Caerphilly Cohort Study of Heart Disease, Stroke and Cognitive Decline. The men were followed-up and during the following 7-10 years 155 men had a myocardial infarction (MI) and 72 an ischaemic stroke. The mean bleeding time was 323 (SD 113)s. This was shorter in men who smoked by an average of 45 s, and lengthened in men who took aspirin daily by 40s. After making statistical adjustments for numerous possible confounding factors, the relative odds (ROs) of an MI within the third of men with the longest bleeding times, compared to the third with the shortest times, was 0.90 (0.40-2.03). For ischaemic stroke, the ROs in the third of men with the longest times were 1.42 (0.39-5.21). The stressed bleeding time does not predict either MI or ischaemic stroke. It has no place in health screening.

The maternity information concerns of Somali women in the United Kingdom

AIMS

The aims of the study were to explore the maternity information concerns of a group of Somali women in a Northern English city and to investigate the relationships of these women with maternity health professionals.

BACKGROUND

The Somali community is one of the most established ethnic minorities in the United Kingdom (UK). The health needs of this group and in particular, the information needs of Somali women with respect to pregnancy, childbirth and post-natal care are poorly understood. To facilitate information provision to birthing mothers and to support maternal decision-making among minority ethnic women, research is required to understand and identify their information needs.

METHODS

A user-centred study utilizing a focus group and semi-structured interviews with English-speaking and non-English speaking Somali women was conducted in a large English city. Discussions were audiotaped, translated, transcribed and then analysed using a variation of the constant comparative

METHOD

Themes and categories were identified across transcripts during data collection and analysis and appropriate quotations are used to illustrate all themes.

FINDINGS

Major findings that emerged from the analysis related to contact with health professionals, language support and information and satisfaction with health professionals. The findings indicate key maternity information concerns of Somali women with regard to maternity issues and have a number of implications for midwifery and nursing practice.

CONCLUSIONS

Poor communication between the non-English speaking Somali women and health workers was perceived as an underlying problem in seeking information. Fears about misinterpretation and confidentiality, limit the usefulness of interpreters. The Somali women perceived that they were denied information due to punitive attitudes and prejudiced views among health professionals.

Altered megakaryocyte-platelet haemostatic axis in hypercholesterolaemia

Hypercholesterolaemia is associated with accentuated platelet function. We assessed in a pilot study whether megakaryocytes (MK), the platelet precursor cell, were altered in subjects with primary hypercholesterolaemia and whether these changes were linked with platelet function. MK and platelet function were assessed in eight untreated patients with primary hypercholesterolaemia (total cholesterol, TC > 7 mmol/l), and 14 control subjects (TC < or = 7 mmol/l): MK ploidy (DNA content), size, granularity, and expression of the adhesion molecule GP IIIa, and platelet expression of GP IIIa, P selectin and CD 63, and RNA content, were each measured using flow cytometry; mean platelet volume, platelet count, plasma thrombopoietin, and cutaneous bleeding time were also assessed. Hypercholesterolaemic patients had increased MK ploidy, mean (SD) 22.9 N (2.3) vs. 20.8 N (1.6) (2P=0.021); platelet size, 10.6 fl (1.2) vs. 9.3 fl (0.7) (2P=0.006); and platelet expression of GP IIIa, 111.3 (18.9) vs. 92.0 (12.3) (2P=0.010), as compared with matched control subjects. Cutaneous bleeding time tended to be reduced in the hypercholesterolaemic patients, 364 s (136) vs. 483 s (165) (2P=0.11). No differences in MK size, granularity or GP IIIa expression, or platelet count, mass, RNA content, P selectin or CD 63 expression, or plasma thrombopoietin were seen. The data suggest that aspects of megakaryocytes and platelets are altered in hypercholesterolaemia, as has also been seen in other vascular risk factors states, including hypertension and diabetes mellitus. Furthermore, changes in megakaryocytes may have contributed to the altered platelet function seen here. Further study is now required to assess whether lipid lowering therapy "normalises" these changes in the megakaryocyte-platelet haemostatic axis.

Information-seeking behaviors of women with breast cancer

PURPOSE/OBJECTIVES

To explore the information-seeking behaviors of women with breast cancer.

DESIGN

Sequential, between-methods triangulation.

SETTING

Community-based.

SAMPLE

156 women with breast cancer took part in a mailed survey, and 30 women with breast cancer participated in three focus group discussions (n = 11, 12, and 7).

METHODS

Women with breast cancer completed the Miller Behavioral Style Scale (MBSS). Other women with breast cancer participated in one of three age-stratified focus group discussions.

MAIN RESEARCH VARIABLE

Information-seeking behaviors of women with breast cancer.

FINDINGS

The information-seeking behaviors of women with breast cancer, as measured by the monitoring subscale of MBSS, were not significantly associated with their demographic (e.g., age, socioeconomic class) and illness-related characteristics (e.g., months since diagnosis, surgery, therapeutic regimens). The focus group discussions suggested that the information-seeking behaviors of women with breast cancer were highly individualistic. Although some women actively sought information, others avoided information. In addition, women sometimes fluctuated between seeking and avoiding information. Women sought information to cope with breast cancer, regain a sense of control, increase their feelings of confidence, and help facilitate the decision-making process. Women avoided information to escape from worry, fear, and feelings of negativity and depression.

CONCLUSIONS

The information-seeking behaviors of women with breast cancer are highly individualistic and are not related to demographic or disease-related characteristics.

IMPLICATIONS FOR NURSING PRACTICE

Breast-care nurses need to be sensitive to the information-seeking behaviors of women with breast cancer. Information seekers should be given maximum information, and information avoiders should be given minimum information. In addition, more research needs to be conducted into the information-seeking behaviors of women with the disease.

Geriatric assessment in primary care: formulating best practice

Comprehensive geriatric assessment (CGA) is a structured approach to measuring physical, mental and social functioning of older people to identify needs and to plan care. Meta-analysis of trials of CGA suggest that it is cost-effective, but there is no agreed approach to its implementation in primary care. Our aim was to develop a best-practice model for geriatric assessment in primary care. We took an iterative approach to development, combining expert and local stakeholder opinion, and using semi-structured interviews to assess patient and practitioner experience in nine general practices in Sheffield. Patients were aged 75 and over, living at home. The best-practice model was the use of a standardized instrument (EASY-Care) to unselected patients aged 75 years and over living at home or in residential care, administered by a practice nurse in the context of an over-75s health check. There was high patient and practitioner acceptability, and significant cost savings were noted. Key beneficial features were the assessment of mental health and sources of support; goal-setting; generation of a disability score; and high patient satisfaction from contact with nursing staff. We conclude that geriatric assessment in primary care is feasible, economical and beneficial to patients and practitioners. Nursing staff are central to successful implementation of geriatric assessment in primary care.

The use of between-methods triangulation in cancer nursing research: a case study examining information sources for partners of women with breast cancer

This article describes between-methods triangulation-the combination of research strategies using different methods--and illustrates its use in cancer nursing research by outlining a case study, which identified the information sources for partners of women with breast cancer. By combining both qualitative and quantitative data, the study was found to possess good convergent validity. Between-methods triangulation also provided a more complete picture of the topic of inquiry than that supplied by either method alone. It is a useful strategy for identifying the information sources for partners of women with breast cancer and its use is encouraged in cancer nursing research.

Exploring the information flow: partners of women with breast cancer, patients, and healthcare professionals

PURPOSE/OBJECTIVES

To explore the information flow between partners of women with breast cancer and patients and between partners and healthcare professionals (HCPs).

DESIGN

Descriptive.

SETTING

Community-based.

SAMPLE

109 partners of women with breast cancer.

METHODS

Subjects completed a 30-item, self-administered questionnaire that was designed to identify the informational flow between them and their information providers. Subjects also completed the Miller Behavioral Style Scale to determine the informational coping styles of individuals under threat.

MAIN RESEARCH VARIABLE

Informational flow between partners and patients and partners and HCPs.

FINDINGS

The majority of partners received information from patients and were satisfied with the amount of time they spent discussing breast cancer topics. Few partners thought that patients avoided giving them information. A significant association existed between the informational coping styles of partners and the communication flow between partners and patients. The majority of partners sought information from other sources. In addition, the majority of partners accompanied patients to their medical consultations and received information from HCPs. The communication flow among partners, patients, and HCPs largely depended on the amount of communication desired by the woman with breast cancer.

CONCLUSIONS

This study provides new evidence on the information flow and communication patterns between partners and patients and between partners and HCPs.

IMPLICATIONS FOR NURSING PRACTICE

Partners may have informational needs that are not met by patients. Therefore, nurses need to provide them with information to help satisfy their needs. In addition, nurses can help satisfy the informational needs of partners by encouraging good two-way communication and informational exchange between partners and patients.

The psychometric properties of the Miller Behavioural Style Scale with adult daughters of women with early breast cancer: a literature review and empirical study

Several researchers have suggested that the information-seeking behaviours of patients need to be taken into consideration when assessing their information needs. This study reviews published evidence of the psychometric properties of the Miller Behavioural Style Scale, a tool commonly used to identify the information-seeking behaviours of individuals under threat, and examines its reliability and validity with adult daughters of women with early breast cancer. Ninety-seven adult daughters completed the MBSS and a 30-item, self-administered questionnaire, a tool designed to explore the information needs of adult daughters of women with breast cancer. The internal consistency of the monitoring and blunting sub-scales of the MBSS was alpha = 0.65 and 0.41 respectively. The blunting sub-scale fell substantially below acceptable limits and was discarded from subsequent analyses. The monitoring sub-scale possessed good test-retest reliability (n = 17) with a 5-week time interval (r= 0.71, P < 0.005), as measured using a Pearson's correlation coefficient. Furthermore, the majority (73.4%) of monitoring items possessed moderate or substantial test-retest reliability, as indicated by kappa coefficients. Finally, the monitoring sub-scale possessed good construct validity, both discriminant and convergent validity, as measured by the univariate associations between monitoring behaviour and selected items from the information questionnaire and a demographic questionnaire. In conclusion, adequate support exists for the psychometric properties of the monitoring sub-scale of the MBSS and its use with adult daughters of women with early breast cancer in future research. These findings have a number of implications for nursing research and these are discussed in this paper.

Getting the questions right: an example of loss of validity during transfer of a brief screening approach for depression in the elderly

Screening for depression in the elderly has been advocated to improve detection and management. This article summarises the trend towards briefer screening instruments, and the integration of mental health screening with other assessments. The study aimed to validate a single question depression screen which has previously shown adequate sensitivity and specificity in a new context: a multi-faceted assessment instrument used by nurse practitioners within a community sample of over 75 year olds. The GMS-AGECAT computerised interview assessment was used as a 'gold standard' to determine the accuracy of the depression question in this new setting. Three hundred and twenty-eight patients were screened by their own nurse practitioners, of whom 100 consenting patients underwent a further interview with a research assistant using the GMS-AGECAT. The prevalence of depression was 30%, the sensitivity of the question was 67%, and its specificity 60% (compared with 88% and 71% previously). Responses indicating disability and loneliness were more closely correlated with depression than the depression screen itself. Relevant factors may include: the derivation of the question, the effect of a different sample, altered reliability when used by multiple interviewers, differing patient expectations, and the wording and context of the question within the multi-faceted screening instrument. Depression screening questions need repeated validation when used in different contexts. Patient and staff expectations may influence how screening instruments are used in practice in a way that may also alter reliability. Further studies are needed to establish the causes of loss of validity when screening approaches are used in new settings.

The information needs and source preferences of women with breast cancer and their family members: a review of the literature published between 1988 and 1998

A comprehensive and critical literature review was conducted to examine the information needs and source preferences of women with breast cancer and their family members. Relevant papers published between 1988 and 1998 were reviewed and despite their having several methodological weaknesses, a number of conclusions can still be drawn. First, women with breast cancer have distinct needs for information throughout their breast cancer journeys, indicating that information needs change with time since diagnosis and with treatment-related events. Second, family members of women with breast cancer also have substantial needs for information. Third, women with breast cancer and their family members often prefer verbal forms of information from health care professionals (HCPs), particularly around the time of diagnosis. Women with breast cancer, however, are often dissatisfied with the information they receive from HCPs. Further, the family members of women with breast cancer often perceive their information needs to be ignored by HCPs. Finally, few studies have focused specifically on the information needs and source preferences of family members of women with breast cancer. These findings have a number of implications for nursing, both for clinical practice and nursing research, and these are discussed in the review.

Meeting the information needs of adult daughters of women with early breast cancer. Patients and health care professionals as information providers

This study explored the information needs of adult daughters whose mothers had early breast cancer and illustrated the information flows between the daughters and two information providers: patients and health care professionals (HCPs). Participants were 97 daughters, who completed a 30-time self-administered questionnaire, a tool designed to identify the information needs of daughters and their communication channels. Daughters also completed the Miller Behavioral Style Scale, a scale used to determine the information-seeking behavior of individuals under threat. Descriptive statistics revealed that the information flows between women with breast cancer and daughters participating in this study were good. Most of the daughters received information from their mothers and asked their mothers questions. Few daughters thought their mothers avoided giving them information. The vast majority of the daughters, however, sought information from sources other than their mothers, indicating that the mothers alone did not satisfy their information needs. More than half of the daughters participating in this study accompanied their mothers to their medical consultations and received information from HCPs. Logistic regression indicated that the communication flows between patients, HCPs, and adult daughters of women with breast cancer depended on a number of factors, in particular, on the amount of communication desired by women with breast cancer.

New approach to risk determination: development of risk profile for new falls among community-dwelling older people by use of a Genetic Algorithm Neural Network (GANN)

BACKGROUND

Falls risk in older people is multifactorial and complex. There is uncertainty about the importance of specific risk factors. Genetic algorithm neural networks (GANNs) can examine all available data and select the best nonlinear combination of variables for predicting falls. The aim of this work was to develop a risk profile for operationally defined new falls in a random sample of older people by use of a GANN approach.

METHODS

A random sample of 1042 community-dwelling people aged 65 and older, living in Nottingham, England, were interviewed at baseline (1985) and survivors reinterviewed at a 4-year follow-up (n = 690). The at-risk group (n = 435) was defined as those survivors who had not fallen in the year before the baseline interview. A GANN was used to examine all available attributes and, from these, to select the best nonlinear combination of variables that predicted those people who fell 4 years later.

RESULTS

The GANN selected a combination of 16 from a potential 253 variables and correctly predicted 35/114 new fallers (sensitivity = 31%; positive predictive value = 57%) and 295/321 nonfallers (specificity = 92%; negative predictive value = 79%); total correct = 76%. The variables selected by the GANN related to personal health, opportunity, and personal circumstances.

CONCLUSIONS

This study demonstrates the capacity of GANNs to examine all available data and then to identify the best 16 variables for predicting falls. The risk profile complements risk factors in the current literature identified by use of standard and conventional statistical methods. Additional data about environmental factors might enhance the sensitivity of the GANN approach and help identify those older people who are at risk of falling.

Self-rated health as a risk factor for prescribed drug use and future health and social service use in older people

BACKGROUND

Self-rated health is an independent predictor of mortality in older people. Recently, the need to explore other health outcomes that may be predicted by global self-ratings of health has been identified. The aim of this work was to explore the use of self-rated health as a predictor for future health and social service use and for use of prescribed medication.

METHODS

1042 community-dwelling people aged 65 and over living in Nottingham, United Kingdom, were interviewed in 1985, and survivors were reinterviewed in 1989 and 1993. Cox regression and logistic regression models were developed to see whether a self-rating of health was a predictor of 12-year mortality and of baseline, 4-year, and 8-year health and social service use and use of prescribed medication.

RESULTS

Baseline self-rating of health was an independent risk factor for 12-year mortality, and for having seen the general practitioner, community nurse, home help support in the month before the interview, and for increased medication use. Baseline self-rating of health was also a risk factor for 4-year and 8-year use of these services and increased medication use, although it was not significant when baseline service/medication use was included in regression models.

CONCLUSIONS

Self-rating of health not only predicts mortality, but is also useful for predicting long-term service and medication use among older people who live for a number of years.

Differential risk factor profiles for indoor and outdoor falls in older people living at home in Nottingham, UK

The objectives of this work were: to estimate the incidence of falls within an at-risk group of community-dwelling elderly people; to assess the risk factors associated with incident falls; to examine the effects of incident falls on survival. A random sample of 1042 community-dwelling older people in Nottingham (UK) were interviewed in 1985 and survivors re-interviewed at 4-year follow-up. The at-risk group was defined as survivors who had not fallen in the year prior to the baseline interview (n = 444). One-year fall recall was assessed using a questionnaire and included physical health, mobility, prescribed drugs and time spent walking. Body-weight and handgrip strength were measured. Eight-year post-fall mortality was recorded. In 1989 117 new fallers were identified. These people fell a total of 233 times in the year prior to re-interview (incidence rate: 524.8 per 1000 person-years at risk; 95% confidence intervals (CI): 473.3-576.3). People aged less than 75 were more likely to fall outdoors than people aged 75 and over (chi2 = 5.715, df = 1, p = 0.017). Risk factors associated with falling were: being less healthy (odds ratio (OR): 0.55; p = 0.052); having a walking speed in the range stroll/very slow/nonambulant compared with normal/brisk/fast (OR: 1.99; p<0.01); and number of prescribed drugs (OR: 1.30; p = 0.01). When analysed separately, indoor and outdoor falls presented differential risk profiles, with evidence that indoor falls were associated with frailty, while outdoor falls were associated with compromised health status in more active people. In 8-year post-fall monitoring, multiple (3+) fallers and indoor fallers showed a significant excess mortality. The differences in risk factors for, and prognoses following, indoor and outdoor falls, emphasise the complex interactions between intrinsic and extrinsic factors associated with falling among older people.

The information concerns of spouses of women with breast cancer: patients' and spouses' perspectives

A user-centred study employing focus group methodology was conducted in the United Kingdom in order to establish the key information concerns of spouses of women with breast cancer from both patients' and spouses' perspectives. Four unstructured focus group discussions were convened, three with women with breast cancer (n=11, n=7 and n=12) and one with spouses (n=9). The discussions were audio-taped and transcribed in full. All transcripts were analysed manually using theme analysis and considered patterns common to the data. Themes were established and corresponding quotations used to support all themes. Emergent themes were grouped into the following categories: information needs of spouses; sources of information for spouses; and family information. Several important points emerged within each of these categories and these are discussed. Validity was established by participant evaluation of the findings. Findings clearly indicate the key information concerns of spouses from patients' and spouses' perspectives. These findings are of value to health care professionals and have a number of nursing implications. The study also highlights particular areas where further research and development are needed.

Customary physical activity and physical health outcomes in later life

OBJECTIVES

to explore associations between customary physical activity and three longitudinal outcomes: 12-year all-cause mortality, 12-year disease-specific mortality and 8-year change in general practitioner and personal social service use.

DESIGN

longitudinal study.

SUBJECTS

1042 people originally aged 65 and over randomly sampled from general practitioner lists in Nottingham, UK.

METHODS

Cox regression survival and logistic regression analyses.

MAIN OUTCOME MEASURES

questionnaire-assessed levels of physical activity; 12-year mortality; reported health and personal social service contacts in month prior to interview.

RESULTS

on the basis of factor scores derived from the interview questionnaire, activity levels were graded as high, intermediate or low, with respondents grouped accordingly. Relative to the high activity group, 12-year mortality was significantly increased in both the intermediate [adjusted hazard ratio (HR) = 1.53; 95% confidence interval (CI) = 1.10-2.14; P < 0.05] and low (HR = 1.75; 95% CI = 1.24-2.48; P < 0.005) activity groups for men, and in the low activity group (HR= 1.73; 95% CI = 1.28-2.33; P < 0.001) for women. Lower levels of activity were also associated with an increased likelihood of using health and personal social services 8 years after the initial interview, and an increased risk among men of having respiratory disease recorded as the primary cause of death. All models were adjusted for age, health and smoking status and weight category as measured at baseline.

CONCLUSIONS

the results are consistent with the conclusion that, among elderly people, health gain resulting from higher customary physical activity levels can promote a longer and more independent later life.

Customary physical activity and psychological wellbeing: a longitudinal study

OBJECTIVES

to assess longitudinal relationships between habitual levels of physical activity and indices of psychological wellbeing in older people.

DESIGN

baseline assessment with 4- and 8-year follow-ups.

SUBJECTS

1042 people originally aged 65 and over randomly sampled from general practitioner lists in Nottingham, UK.

METHODS

logistic regression analysis of selected T1 (1985) and T2 (1989) variables, with depression at T2 as dependent; multiple regression analyses of selected T1, T2 and T3 (1993) variables, with life satisfaction at T2 (model 1) or T3 (model 2) as dependent.

MAIN OUTCOME MEASURES

questionnaire-assessed levels of physical activity; 14-item Symptoms of Anxiety and Depression scale; 13-item Life Satisfaction Index; health, demographic and social activity variables.

RESULTS

in the logistic regression model, depression at T2 was most strongly associated with depression [odds ratio (OR) = 7.13; 95% confidence interval (CI) = 3.25-15.64; P < 0.001] and lower physical health status (OR = 1.26 per unit change in score; 95% CI = 1.17-1.42; P < 0.001) at T1. Lower levels of outdoor/leisure activities at T1 were also associated with some increased risk of depression 4 years later (OR = 0.92 per hour of activity; 95% CI = 0.85-0.99; P < 0.05). Similar predictive patterns emerged from the multiple regression analyses where, in both models, earlier levels of life satisfaction, social engagement and health accounted for most of the explained variance in life satisfaction (R2 = 0.42 for model 1; R2 = 0.35 for model 2). Again, however, earlier levels of physical activity (as walking and housework) did contribute significantly, although modestly, to longitudinal changes in morale.

CONCLUSIONS

while the results provide some support for the conclusion that physical activity contributes independently to the promotion and maintenance of psychological wellbeing in later life, this contribution is, at best, extremely modest.

The King's College Hospital Acute Stroke Unit

The King's College Hospital (KCH) Acute Stroke Unit (ASU) was set up in January 1994 in order to provide acute management for patients admitted with stroke and to undertake biomedical research. Of 206 patients admitted to KCH with a stroke or suffering an in-hospital stroke, 141 (68%) patients were admitted to the ASU over its first 6 months of operation: 120 (85%) were from the Accident and Emergency Department and 21 (15%) from other wards. Management included resuscitation and medical stabilisation, investigation, prevention of stroke complications (including aspiration, venous thrombosis, and pressure sores), rehabilitation (physiotherapy, occupational therapy, speech and language therapy), nutrition (dietetics) and initiation of secondary prevention measures (aspirin or anticoagulation, blood pressure and lipid lowering, and carotid endarterectomy). All aspects of management are driven by agreed guidelines. Patients remain under the care of the admitting physician but specific stroke management and guidance is provided by two research doctors and the unit's nurses, therapists and dietician. The unit also facilitates research into stroke pathophysiology and acute therapeutic interventions. Our experience suggests that an ASU is relatively easy to set up and may contribute to improved care. Whether ASUs improve patient survival and functional outcome, and are cost-effective, requires further study.

L-arginine infusion has no effect on systemic haemodynamics in normal volunteers, or systemic and pulmonary haemodynamics in patients with elevated pulmonary vascular resistance

1. The evidence that the infusion of L-arginine, the precursor of endothelium-derived relaxing factor (EDRF)/nitric oxide (NO), may reduce systemic blood pressure, via the generation of intracellular cyclic guanosine-3,5-monophosphate(cGMP), in normotensive volunteers is controversial. In the first part of the study we investigated the effect of an L-arginine infusion on systemic blood pressure and plasma cGMP in healthy volunteers. 2. Patients with systemic sclerosis have widespread endothelial damage which, by reducing the release of NO, could contribute to the raised pulmonary vascular resistance (PVR) often found in this condition. We hypothesised that if there were a failure of NO synthesis this might be overcome by infusing L-arginine into the pulmonary artery, thereby lowering PVR. In the second part of the study we investigated the effect of L-arginine infusion on systemic and pulmonary haemodynamics, and on plasma cGMP levels in patients with pulmonary hypertension and systemic sclerosis. 3. L-arginine (500 mg kg-1) was infused over 30 min into five normotensive volunteers and five patients with systemic sclerosis and pulmonary hypertension. Blood pressure, heart rate and skin temperature were measured non-invasively in the volunteers and systemic and pulmonary haemodynamics recorded via radial artery cannulae and balloon-tipped, flow directed, pulmonary artery catheters in the patients with systemic sclerosis. 4. L-arginine had no significant effect on blood pressure, heart rate or skin temperature in the normotensive volunteers nor on systemic or pulmonary haemodynamics in the systemic sclerotic group. Cyclic-GMP levels did not significantly change in either group.(ABSTRACT TRUNCATED AT 250 WORDS)

Similarity searching in databases of three-dimensional molecules and macromolecules

This paper discusses algorithmic techniques for measuring the degree of similarity between pairs of three-dimensional (3-D) chemical molecules represented by interatomic distance matrices. A comparison of four methods for the calculation of 3-D structural similarity suggests that the most effective one is a procedure that identifies pairs of atoms, one from each of the molecules that are being compared, that lie at the center of geometrically-related volumes of 3-D space. This atom mapping method enables the calculation of a wide range of types of intermolecular similarity coefficient, including measures that are based on physicochemical data. Massively-parallel implementations of the method are discussed, using the AMT Distributed Array Processor, that achieve a substantial increase in performance when compared with a sequential implementation on a UNIX workstation. Current work involves the use of angular information and the extension of the method to field-based similarity searching. Similarity searching in 3-D macromolecules is effected by the use of a maximal common subgraph (MCS) isomorphism algorithm with a novel, graph-based representation of the tertiary structures of proteins. This algorithm is being used to identify similarities between the 3-D structures of proteins in the Brookhaven Protein Data Bank; its use is exemplified by searches involving the NAD-binding fold motif.

Corneal wound healing after excimer laser keratotomy in a human eye

A pulsed excimer argon-fluorine laser was used to produce corneal incisions in vivo in a human cornea. Fourteen days after the laser surgery, the incisions were examined by light and transmission electron microscopy. There was good initial healing, with no inflammatory or immune reactions in the incisions.