Cost-utility analysis of levodopa carbidopa intestinal gel (Duodopa) in the treatment of advanced Parkinson's disease in patients in Scotland and Wales

AIMS

To carry out a cost-utility analysis comparing the cost-effectiveness of levodopa carbidopa intestinal gel (LCIG) with standard of care (SOC) in patients with advanced Parkinson's Disease (aPD) unsuitable for apomorphine or deep brain stimulation (DBS). LCIG is the only treatment option in this small, but clinically important, population.

METHODS

A Markov model with 25 disease states based on disease stage and off-time status plus death. Patients enter the model with aPD spending >50% of their waking day in the off-state. Patients progress through the model in 6-monthly cycles for 20 years to approximate lifetime treatment and capture long-term costs and effects of therapy. Inputs are based on LCIG clinical trials for clinical outcomes and health state utilities, the literature for health state transitions and use UK-based input data wherever possible (drug costs, disease/adverse event management costs, discontinuation rates, mortality rates).

LIMITATIONS

Data collection can be challenging in this small, elderly population with advanced disease, therefore some model inputs were estimated, rather than collected directly. It was assumed that a reduction in off-time was the only benefit after the first year of treatment with LCIG; this is a conservative approach, since there may be additional clinical benefits.

RESULTS

There is a considerable incremental gain in quality adjusted life years (QALYs) for patients treated with LCIG of 1.26 QALY with an associated incremental cost-effectiveness ratio (ICER) of £52,110. If the impact on caregivers is included, the ICER reduces to £47,266.

CONCLUSIONS

In cases where there is an orphan population, with no alternative treatment options, HTA assessments have a broader decision-making framework and the ICER is interpreted in this context. In the setting of a very small population, with considerable unmet need, LCIG represents value for money, as reflected by funding approval across the UK.

The functional anatomy of external genitalia in the black tiger prawn (Penaeus monodon) studied by micro-computed tomography and scanning electron microscopy

Although artificial insemination has been used for decades in Penaeus monodon aquaculture, the interaction of male and female external genitalia during spermatophore transfer has not been fully documented. As a result, studying the functional anatomy of this process may help to better refine the insemination technique. The sexual act in penaeoid prawns is virtually impossible to observe directly; as a result, this study aimed to describe the functional anatomy and interaction of external genitalia, such as the petasma, appendices masculinae and genital papillae of the male, with that of the thelycum and genital lobes of the female, using a combination of micro-computed tomography and scanning electron microscopy. We hypothesise that the spermatophores are ejaculated into the ventromedial groove of the petasma and squeezed by abdominal flexure into the spermathecae of female's thelycum. During this process, the 'spike-like' setae observed on the petasma and appendices masculinae are speculated to control the transferring direction of the spermatophores. The approach of three dimensional remodelling and animation reported in this study may prove useful in the examination of further hypotheses related to the functional anatomy of external genitalia and/or appendages for other crustacean species.

New insights into the spermatogenesis of the black tiger prawn, Penaeus monodon

This study reports a comprehensive description of penaeid spermatogenesis (Penaeus monodon) by light and transmission electron microscopy. A conspicuous characteristic of spermatocytogenesis was a ring-like structure with high electron-density adjacent to the nucleus of a primary spermatocyte. During the spermiogenesis from stage I (StI) to stage VI spermatid (StVI), the formation of the acrosome and decondensation of the nucleus were the most notable morphological transformations. StIs were small and compact and they were contained in the syncytia. In the cytoplasm of StII, mitochondrion-like bodies (MLB) participated the extension of perinuclear multi-layered lamellae. The association of MLBs and endoplasmic reticula appeared to contribute to the formation of small cytoplasmic pre-acrosomal vesicles (PV) which coalesced into an acrosomal chamber (AC) at the periphery of StIII. A dense anterior acrosomal body (AB) was formed in the enlarged AC in StIV. The nuclear envelope became disintegrated in StV. At last, an AB-derived spiky acrosome was emerged from AC in StVI. Sperm nuclei became increasingly decondensed during the entire process of spermiogenesis and the nuclear components in the testicular spermatozoa appeared to only contain chains of DNA and nucleosome-contained chromatin.

Short Stay Head Injuries and the Accident and Emergency Department

Objective: To examine the aetiology and outcome of patients admitted to the Accident and Emergency Short Stay ward with a head injury. Method: Prospective, observational, hospital based cohort study with 8 week follow up. This was conducted in the Accident and Emergency Department, Ninewells Hospital, Dundee. The subjects studied were all patients admitted to the Short Stay ward with a head injury. Results: 78 patients returned usable replies at 8 weeks, a response rate of 37.3%. Falls (55.1%) and assaults (20.5%) were the main cause of admission. Alcohol was involved in 58.1% of falls and 75% of assaults. Post Concussion Symptoms were more frequently associated with those under forty years old and those who had been assaulted. Post Head Injury scores were highest in those under forty seven years and associated with assault. Conclusion: The identification of specific groups, who have higher Post Concussion and Post Head Injury scores, allows possible intervention prior to leaving hospital to try and reduce morbidity. A follow up study assessing intervention by a coping strategy is now under way.

Consensus guidelines for the investigation and management of encephalitis in adults and children in Australia and New Zealand

Encephalitis is a complex neurological syndrome caused by inflammation of the brain parenchyma. The management of encephalitis is challenging because: the differential diagnosis of encephalopathy is broad; there is often rapid disease progression; it often requires intensive supportive management; and there are many aetiologic agents for which there is no definitive treatment. Patients with possible meningoencephalitis are often encountered in the emergency care environment where clinicians must consider differential diagnoses, perform appropriate investigations and initiate empiric antimicrobials. For patients who require admission to hospital and in whom encephalitis is likely, a staged approach to investigation and management is preferred with the potential involvement of multiple medical specialties. Key considerations in the investigation and management of patients with encephalitis addressed in this guideline include: Which first-line investigations should be performed?; Which aetiologies should be considered possible based on clinical features, risk factors and radiological features?; What tests should be arranged in order to diagnose the common causes of encephalitis?; When to consider empiric antimicrobials and immune modulatory therapies?; and What is the role of brain biopsy?

The relationship between deprivation and alcohol-related presentation at Accident and Emergency (A&E) over a three-month period

OBJECTIVES

To identify any relationship between deprivation and the level of presentation to Accident and Emergency with alcohol-related conditions in a busy East Coast teaching hospital in Scotland.

METHODS

Over an 87-day-period initial screening to determine whether alcohol played a part in each presentation was conducted at triage. These patients were then streamed according to their Paddington Alcohol Test (Pat) score into Pat +ve and Pat -ve groups. The postcode of each patient was recorded before they were assigned deprivation levels using the DepCat scoring system. This information was then compiled in Microsoft Excel 2003 and a graph showing the differences in the number of presentations across the social spectrum was constructed.

RESULTS

Nine hundred and forty four patients were screened as attending due to alcohol with 43.86% being Pat +ve and 56.14% being Pat -ve. Overall 66.42% of the Pat +ve group and 54.42% of Pat -ve were from deprived or very deprived areas.

CONCLUSIONS

The use of electronic-based screening was effective at highlighting patients presenting to Accident and Emergency with alcohol-related problems, and these presentations highlighted a direct link between the level of deprivation and attendances.

Corrupted cultures in mental health inpatient settings. Is restraint reduction the answer?

The early years of the 21st century have seen successful efforts in a number of countries to reduce the use of restraint in services for people with mental health problems. An underlying emphasis on 'cultural change' is characteristic of such initiatives reflecting, it appears, the re-emergence of interest in the therapeutic milieu. Such efforts have though lacked a comprehensive explanation of how organizational culture plays a role in the development of the excessive use of restraint, which seems to respond to such initiatives. This paper seeks to address that deficit and draws in particular on the concepts of corrupted culture, institutional violence, trauma, parallel processing and contemporary research on restraint and seclusion reduction. In doing so it examines whether restraint reduction initiatives represent part of the solution to the problem of corruption, which is intrinsically associated with the legitimatization of coercion.

Moult cycle specific differential gene expression profiling of the crab Portunus pelagicus

Background

Crustacean moulting is a complex process involving many regulatory pathways. A holistic approach to examine differential gene expression profiles of transcripts relevant to the moulting process, across all moult cycle stages, was used in this study. Custom cDNA microarrays were constructed for Portunus pelagicus. The printed arrays contained 5000 transcripts derived from both the whole organism, and from individual organs such as the brain, eyestalk, mandibular organ and Y-organ from all moult cycle stages.

Results

A total of 556 clones were sequenced from the cDNA libraries used to construct the arrays. These cDNAs represented 175 singletons and 62 contigs, resulting in 237 unique putative genes. The gene sequences were classified into the following biological functions: cuticular proteins associated with arthropod exoskeletons, farnesoic acid O-methyltransferase (FaMeT), proteins belonging to the hemocyanin gene family, lectins, proteins relevant to lipid metabolism, mitochondrial proteins, muscle related proteins, phenoloxidase activators and ribosomal proteins. Moult cycle-related differential expression patterns were observed for many transcripts. Of particular interest were those relating to the formation and hardening of the exoskeleton, and genes associated with cell respiration and energy metabolism.

Conclusions

The expression data presented here provide a chronological depiction of the molecular events associated with the biological changes that occur during the crustacean moult cycle. Tracing the temporal expression patterns of a large variety of transcripts involved in the moult cycle of P. pelagicus can provide a greater understanding of gene function, interaction, and regulation of both known and new genes with respect to the moulting process.

Physical intervention trainers: the case for greater accountability

Physical intervention training courses are commonplace events in psychiatric and mental healthcare settings across the UK. While there is still debate as to what techniques should be taught on such courses, there is good evidence as to the mechanisms whereby pain, injury and even death can be inflicted. There is also a wealth of literature identifying how organizational culture can influence the quality of service delivery and standards of client care. It is well documented that the dignity, well-being and physical integrity of service users can be compromised by staff acts and omissions stemming from corrupted cultures. What has not been explored in detail to date is the role of physical intervention trainer, specifically the values they model and how these may influence the readiness with which staff resort to physical restraint strategies. It is possible that even approved physical techniques can become compromised through poor training technique and expose end recipients to needless humiliation and potential harm. This paper discusses this area of practice, offers insight on how the learning process is compromised by trainers and suggests areas for future research.

Physical intervention: a review of the literature on its use, staff and patient views, and the impact of training

As a principal control measure, physical intervention is intended to be a skilled manual, or hands-on, method of physical restraint implemented by trained individuals, with the intention of controlling the aggressive patient, to restore safety in the clinical environment. Physical intervention is however a contentious practice. There have been reports in the literature of negative psychological views from staff and patients on the procedure. Although formal structured training was introduced in response to concerns around patient safety during restraint, concerns remain that PI is sometimes construed as a stand-alone violence prevention initiative. Its potential for misuse, and overuse, in corrupted cultures of care has emerged as a social policy issue. The following paper critically explores the literature on training in physical intervention in the United Kingdom.

A computer-based radiology simulator as a learning tool to help prepare first-year residents for being on call

RATIONALE AND OBJECTIVES

The start of call is a stressful time for radiology residents. Traditional teaching methods are not ideal for call preparation because they are radically different than the task performed on call. The purpose of this study is to determine if a computer-based radiology simulator would have an effect on resident confidence level or diagnostic abilities.

MATERIALS AND METHODS

A simulator was created to mimic the picture archive and communication system (PACS) at our hospital. Typical call-level cases were selected, anonymized, and entered into the database. The first-year residents were randomly split into a control group and a study group that used the simulator. Each resident took a survey 1 month before and after beginning call to measure his or her subjective feeling of preparedness and nervousness. Objective measures were also obtained through the use of discordance levels from on-call cases.

RESULTS

Seventy-one cases were entered into the simulator. Of the 12 residents in the first-year class, 7 were placed in the study group and 5 in the control group. The residents in both groups claimed they felt more prepared and less nervous 1 month after starting call. The differences at survey were not significant, but the residents in the study group trended toward feeling more prepared and less nervous. There was no statistical difference in the discordance rates for on-call cases between the two groups.

CONCLUSIONS

Although statistical significance was not reached between the users of the radiology simulator and the control group, there was a subjective feeling that the simulator was useful for call preparation and as an interactive learning tool. A larger sample study group size may show statistical significance.

End tidal carbon dioxide monitoring in prehospital and retrieval medicine: a review

End tidal carbon dioxide (ETCO2) monitoring is the non-invasive measurement of exhaled CO2. The Intensive Care Society guidelines include (ETCO2) monitoring as one of the objective standards required for monitoring patients in transport, and the American Heart Association recommends that all intubations must be confirmed by some form of ETCO2 measurement. The physiological principles and technology underlying ETCO2 measurement and the clinical indication for its use in the prehospital environment are reviewed. ETCO2 monitoring has been widely established in the prehospital environment and is of particular use for verification of endotracheal tube placement. It is non-invasive and easy to apply to breathing circuits. The units now available are compact and rugged, with extended battery operating times, which are ideally suited for prehospital use and should be considered as an essential item for advanced airway management.

Introduction of an electronic debrief and governance tool in prehospital care

BACKGROUND

The Tayside Trauma Team is a mobile medical team that is deployed from Ninewells Hospital, Dundee, UK at the request of the ambulance service.

AIM

To describe the implementation of a formal debrief and governance tool to ensure the ongoing provision of a high-quality prehospital service.

METHODS

A questionnaire was devised to examine key issues relating to clinical governance and distributed to all members of staff involved in the provision of prehospital care.

RESULTS

A number of areas of concern were revealed, including a lack of understanding on how to report critical incidents occurring in this field and a low level of opportunity to fully discuss events and vocalise concerns. These areas of concern were used to formulate an electronic debrief tool to be available to staff after each incident attended. Reports were considered and actioned and data collected for audit purposes and to provide a framework for discussion at monthly morbidity and mortality meetings.

CONCLUSION

Any patient requiring the services of a healthcare professional in the prehospital setting has a right to expect the same level of quality of care that they would receive within the hospital. The development of a debrief tool will achieve ongoing quality of care in this specialised area of healthcare.

Provision of mouth-care in long-term care facilities: an educational trial

OBJECTIVES

This randomized clinical trial aimed to assess the effectiveness of a pyramid-based education for improving the oral health of elders in long-term care (LTC) facilities.

METHODS

Fourteen facilities matched for size were assigned randomly to an active or control group. At baseline in each facility, care-aides in the active group participated with a full-time nurse educator in a seminar about oral health care, and had unlimited access to the educator for oral health-related advice throughout the 3-month trial. Care-aides in the control group participated in a similar seminar with a dental hygienist but they received no additional advice. The residents in the facilities at baseline and after 3 months were examined clinically to measure their oral hygiene, gingival health, masticatory potential, Body Mass Index and Malnutrition Indicator Score, and asked to report on chewing difficulties.

RESULTS

Clinical measures after 3 months were not significantly different from baseline in either group, indicating that education neither influenced the oral health nor the dental hygiene of the residents.

CONCLUSIONS

A pyramid-based educational scheme with nurses and care-aides did not improve the oral health of frail elders in this urban sample of LTC facilities.

Isolation and expression analysis of multiple isoforms of putative farnesoic acid O-methyltransferase in several crustacean species

Farnesoic acid O-methyltransferase (FaMeT) is the enzyme responsible for the conversion of farnesoic acid (FA) to methyl farnesoate (MF) in the final step of MF synthesis. Multiple isoforms of putative FaMeT were isolated from six crustacean species belonging to the families Portunidae, Penaeidae, Scyllaridae and Parastacidae. The portunid crabs Portunus pelagicus and Scylla serrata code for three forms: short, intermediate and long. Two isoforms (short and long) were isolated from the penaeid prawns Penaeus monodon and Fenneropenaeus merguiensis. Two isoforms were also identified in the scyllarid Thenus orientalis and parastacid Cherax quadricarinatus. Putative FaMeT sequences were also amplified from the genomic DNA of P. pelagicus and compared to the putative FaMeT transcripts expressed. Each putative FaMeT cDNA isoform was represented in the genomic DNA, indicative of a multi-gene family. Various tissues from P. pelagicus were individually screened for putative FaMeT expression using PCR and fragment analysis. Each tissue type expressed all three isoforms of putative FaMeT irrespective of sex or moult stage. Protein domain analysis revealed the presence of a deduced casein kinase II phosphorylation site present only in the long isoform of putative FaMeT.

Newspaper representations of mental illness and the impact of the reporting of "events" on social policy: the "framing" of Isabel Schwarz and Jonathan Zito

Concerns have been raised internationally about the role of the media in influencing public opinion and by implication, social policy on mental health issues. In particular, anxieties have been expressed that an "excessive" focus by the news media on violence in association with mental illness may reinforce pre-existing stereotypes and by escalating public concerns lead to the adoption of policies which place a high priority on the safety of the public. Such assertions are often contained in the numerous studies that record a seemingly disproportionate number of stories featuring violence in association with mental health. What is, however, almost invariably lacking is a developed theory of agency that explains how or why such depictions of mental illness might exert an influence on social policy. This paper critically examines the potential significance of the way in which responsibility for events is constructed for social policy by means of a discourse analysis, inspired by the genealogical work of Michel Foucault. It uses the device of "frames" originally developed by Goffman to explore the nature of newspaper coverage of two deaths to which causal responsibility for changes in the nature of English social policy in mental health has been attributed. Results presented suggest that attempts to assert a causal influence between media coverage and changes in the nature of social policy must engage with the question of agency.

Constant or special observations of inpatients presenting a risk of aggression or violence: nurses' perceptions of the rules of engagement

In acute psychiatric settings the practice of 'observation' is commonly employed. Increased levels of observation, 'constant' or 'special' are used for those perceived as presenting a 'higher' risk. As an intervention it is used most frequently for those at risk of self-harm or suicide, the practice is also however, used for those thought to present a risk of violent behaviour. In this descriptive study the perceptions of 1st level registered mental nurses (RMNs) gave an account of observation for those perceived to be at risk of violence or aggression and insight into what was considered important and desirable in practice. Unstructured qualitative interviews were conducted with a purposive sample of six RMNs from a psychiatric intensive care unit. Three major categories, Procedure, Role, and Skills emerged which revealed a complex practice far removed from its literal description as merely 'watching'. Six subcategories emerged from the Role. (1) intervening; (2) maintaining the safety of the patient and others; (3) prevention de-escalation and the management of aggression and violence; (4) assessing; (5) communication; and (6) therapy. Skills in these and, experience were thought to IMPACT on the success of the practice. The description of this and the skills involved offer a definition of the 'rules of engagement' which give insight to the practice and the training needs of staff advocated for 'observation'. The acronym IMPACT may be useful in this.

Newspaper coverage of a violent assault by a mentally ill person

The media is an important source of public information on mental ill-health. A man with a serious psychiatric illness attacked a minister with a knife at a Remembrance Sunday service in a remote, rural part of the Highlands, inflicting a severe facial wound. We aimed to identify lessons for the National Health Service (NHS) from the media coverage of the incident and of a subsequent court case and NHS Highland inquiry and in addition to explore how newspaper reporters approached reporting such incidents. We searched local and regional, national Scottish, and the Scottish editions of three UK newspapers for relevant coverage. We also conducted structured telephone interviews with eight reporters who had attended the inquiry press conference. Most of the media coverage was associated with the assault and the court case, rather than the inquiry results. Only three of 10 inquiry recommendations were mentioned in any reports. Coverage largely dealt with identified shortfalls, rather than proposed solutions. The NHS had made little comment in advance of the announcement of the inquiry results. Most of the newspaper coverage had already occurred. The NHS therefore limited its opportunity to influence newspaper coverage. The interpretation of the results is limited by the size of the study, but the coverage of such events forms part of the discourse on mental health in the media episodes and may have some affect on public perception of mental health issues. We conclude that, without providing confidential information, the NHS should take a more active stance in providing information on the nature and treatment of mental illness in such instances, even in advance of court cases.

Deaths associated with restraint use in health and social care in the UK. The results of a preliminary survey

Many aspects of the management of acutely disturbed behaviour have only relatively recently come under systematic scrutiny. Perhaps regrettably one of the last amongst the range of strategies that may be employed to be subjected to rigorous examination has been physical restraint. Considerable debate has recently taken place around what represents good practice in this sensitive and controversial area but the continuing dearth of research in some aspects of this area of practice has meant that this discussion has arguably been over reliant on 'expert' opinion. Questions continue regarding some fundamental issues of restraint, including the relative risks involved in alternative approaches, and anxieties have been expressed about the potential for injuries and death to result from restraint. This article outlines the results of a survey that sought to explore the incidence of deaths associated with restraint in health and social care settings in the UK. The outcome of an initial analysis of the cases identified is then discussed, with reference to the literature on restraint-related deaths, in order to identify the implications for practice.

Efficient or family-centred? Practitioners' goals in decisions regarding parental presence during invasive procedures

Little is currently documented about how health care professionals determine when parental presence is appropriate during an invasive procedure. The research profiled in this article was a qualitative study of the decision-making by 10 nurses and five physicians in PICU regarding when and how to include parents as witnesses to invasive procedures. This article includes one aspect of the research findings: practitioners' goals in such decisions. Specifically, the authors will detail how practitioners' perspectives about the primacy of particular goals of the child's care influenced their decisions to encourage or discourage parents from remaining with their children during invasive procedures. It was found that participants' decisions whether or not to permit parents to remain during invasive procedures were primarily determined by what the practitioner held as the priority goal of his/her practice (i.e., efficiency or family-centred care). The authors conclude by identifying some clinical and research directives that arise from the research findings.

Hypothermia in elderly patients presenting to accident & emergency during the onset of winter

It is well established that the elderly population is vulnerable to hypothermia, leading to increased morbidity. A prospective observational study took place between 1 October 1999 and 31 December 1999 in a large teaching hospital Accident and Emergency department. Core temperature was assessed at presentation using a tympanic probe on patients over 65 years of age. A total of 1543 eligible patients attended during the study period. Complete data was available on 958 patients. Forty-eight patients (5%) were found to be hypothermic (core temperature < 35 degrees Celcius). There were two peaks in hypothermic presentations; these corresponded to periods of cold weather. The incidence of hypothermia was higher in non-ambulant patients and those with co-morbidity; the majority of patients lived in relatively deprived areas by a postcode derived deprivation index. Mortality was 34% in patients hypothermic at presentation. Hypothermia contributes to mortality and morbidity in elderly patients; its incidence may be higher than previously reported.

Myth of empowerment in chronic illness

AIMS

This article presents several findings of a study, conducted between 1996 and 1998, to investigate self-care decision making in diabetes.

RATIONALE

The underlying assumption of many practitioners is that an invitation to people with chronic illness to participate as equal partners is sufficient to guarantee their empowerment.

DESIGN

Using grounded theory, the research examined self-care decision making using a convenience sample of 22 Canadian adults with longstanding type 1 diabetes nominated as expert self-care managers. Participants audiotaped their decision making as it occurred for 3 weeks over the course of one calendar year. These audio-recordings were followed by an interview to clarify participants' decision making and factors that affected their decisions.

FINDINGS

Participants identified several covert and subtle ways that practitioners contradict their stated goal of empowerment in their interactions with diabetics. Participants revealed that despite their intention to foster participatory decision making, practitioners frequently discount the experiential knowledge of diabetes over time and do not provide the resources necessary to make informed decisions.

CONCLUSION

The article concludes with a discussion of the implications of the findings for practice.

Social policy and mental illness in England in the 1990s: violence, moral panic and critical discourse

Violence perpetrated by people experiencing mental illness poses a continuing challenge to practitioners and policy makers in the mental health field. It has been suggested, however, that policy developments in England during the period 1990--2000 became unduly dominated by the perceived need to prevent such violence and in particular that a 'moral panic' occurred following a series of high profile homicides perpetrated by people experiencing mental illness. This paper critically examines the ability of the moral panic theory to offer a cogent explanation of the relationship between media representations, public perceptions and developments in both social policy and legislation during the last decade. Its conclusions, however, suggest that the evidence does not support assertions of a moral panic and that of moral panic theory itself has serious flaws. Ultimately the paper suggests that we must look elsewhere, particularly to Foucault's conceptualization of discourse and to the work of Birkland, an American political theorist, in our search for an understanding of the relationship between events, ideas and social policy.

'They never told us anything': postdischarge instruction for families of persons with brain injuries

This article reports on an analysis of why some families of survivors of traumatic brain injury (TBI) do not perceive that they were prepared for the postdischarge experience, despite discharge planning and teaching by rehabilitation hospital staff and third-party insurance adjusters. Findings are presented of a research study involving single interviews with seven families of survivors of TBI and interviews with four focus groups of healthcare professionals and third-party insurance adjusters who had cared, or were currently caring, for the injured person. Most family members did not recall being taught about what to expect or resources available to them. Healthcare professionals and insurance adjusters, however, stated that extensive discharge planning and multidisciplinary teaching conferences with patients and their families had been held before the patients were discharged. Reasons for such a discrepancy in perceptions are suggested. Implications of these findings for healthcare professionals who conduct discharge teaching in rehabilitation facilities are identified.

Developmental evolution of expertise in diabetes self-management

The following is a description of the findings of a longitudinal exploratory and descriptive research study of 22 persons nominated as expert self-managers of Type 1 diabetes. It entailed an initial interview about previous experiences with self-management, self-recorded taped diaries about self-management decisions for 1 week each, and face-to-face interviews following each weeklong recording of self-management decisions. The study generated a grounded theory about the development of expertise in diabetes self-management. The development of expertise was found to occur as transition through two or more phases, to be individualized, and to involve a complex interplay between social, contextual and personal factors, including the individual's developmental age. The research fIndings challenge the traditional understanding of rebellion in self-management as a manifestation of adolescence, behaviors other than active control as testimony to ineptitude in self-management, metabolic control as the indicator of self-management ability, and the role of others as collaborators in self-management.

Complete cDNA sequence and tissue localization of N-RAP, a novel nebulin-related protein of striated muscle

We have cloned and sequenced the full-length cDNA of N-RAP, a novel nebulin-related protein, from mouse skeletal muscle. The N-RAP message is specifically expressed in skeletal and cardiac muscle, but is not detected by Northern blot in non-muscle tissues. The full-length N-RAP cDNA contains an open reading frame of 3,525 base pairs which is predicted to encode a protein of 133 kDa. A 587 amino acid region near the C-terminus is 45% identical to the actin binding region of human nebulin, containing more than 2 complete 245 residue nebulin super repeats. The N-terminus contains the consensus sequence of a cysteine-rich LIM domain, which may function in mediating protein-protein interactions. These data suggest that the encoded protein may link actin filaments to some other proteins or structure. We expressed full-length N-RAP in Escherichia coli, as well as the nebulin-like super repeat region of N-RAP (N-RAP-SR) and the region between the LIM domain and N-RAP-SR (N-RAP-IB). An anti-N-RAP antibody raised against a 30 amino acid peptide corresponding to sequence from N-RAP-IB detected recombinant N-RAP and N-RAP-IB, but failed to detect N-RAP-SR. This antibody specifically identified a 185 kDa band as N-RAP on immunoblots of mouse skeletal and cardiac muscle proteins. In an assay of actin binding to electrophoresed and blotted proteins, we detected significant actin binding to expressed nebulin super repeats and N-RAP-SR, but only a trace amount of binding to N-RAP-IB. In immunofluorescence experiments, N-RAP was found to be localized at the myotendinous junction in mouse skeletal muscle and at the intercalated disc in cardiac muscle. Based on its domain organization, actin binding properties, and tissue localization, we propose that N-RAP plays a role in anchoring the terminal actin filaments in the myofibril to the membrane and may be important in transmitting tension from the myofibrils to the extracellular matrix.

Expert decision making in relation to unanticipated blood glucose levels

How people (N = 22) with long-standing Type I diabetes make everyday self-care decisions, specifically in regard to unanticipated blood glucose levels (UBGLs) was investigated using grounded theory. Participants differentiated between decisions made in familiar and typical situations and those made in novel situations. Decisions made in familiar situations were straightforward, arising from a confident appraisal of the cause of the UBGL. The primary focus of decision making in response to an UBGL in familiar situations was the decision about the course of action. The focus in unfamiliar situations was the appraisal of the cause of the UBGL. It was characterized by the participants' lack of confidence and by a non-linear progression in which the individual retraced previous phases of the decision-making process or proceeded to tangential steps. Participants matched the features of previously encountered situations to construct a story that explained the events in order to generate some plausible hypotheses. A number of contextual and mediating variables were identified as influencing the decision-making process and the decisions they made. The findings of this research demonstrate that the decision maker's familiarity with the situation influences the nature of the decision-making processes that are used.

Evaluation of patient-administered tampon specimens for Chlamydia trachomatis and Neisseria gonorrhoeae

BACKGROUND

The patient-administered tampon specimen has proven to be an easy and sensitive method for the diagnosis of genital Chlamydia trachomatis and Neisseria gonorrhoeae infections in women by polymerase chain reaction (PCR). This method avoids the need for endocervical sampling and stringent criteria for transport.

GOAL

To evaluate two commercial amplification systems for the detection of C trachomatis and N gonorrhoeae from tampon specimens.

STUDY DESIGN

A group of 400 positive and negative tampon specimens tested by an in-house PCR method were selected from a pool of more than 2,000 previously collected tampons. Overall, 93 C trachomatis-positive and 77 N gonorrhoeae-positive specimens were evaluated. Each specimen was tested by Roche Cobas Amplicor and Abbott LCx (LCR), and results were compared to the in-house PCR method.

RESULTS

Detection of C trachomatis by both assays was not significantly different from the in-house PCR assay. Fewer tampons were positive for N gonorrhoeae by LCR than either the in-house assay (P = 0.0001) or by Roche Amplicor (P = 0.01). However, tampon specimens tested by Roche Amplicor required DNA extraction to achieve comparative sensitivity.

CONCLUSION

Both commercial assays can be applied to tampon-collected specimens for automated detection of sexually transmitted diseases. The detection of C trachomatis was similar to the in-house PCR test for both assays (P = 0.73, 0.68). Detection of N gonorrhoeae resulted in fewer positive tampon specimens when tested by ligase chain reaction than both Roche Amplicor and in-house PCR.

Supporting nursing staff exposed to violence at work

An individual nurses risk of experiencing violence will vary related to his or her area of practice, role and work setting. The available evidence suggests that good practice in environmental design, security management and staff training may reduce but will not eliminate the probability of nurses experiencing assault. If we cannot prevent all violence then we must consider how we best support those who may be exposed to it. This paper thus explores the research on the effects of violence on nurses and critically examines the literature on staff support.

Living with diabetes as a transformational experience

The construct of transformation has been presented in many research studies as the epitome of living with a chronic illness. Because it has been inadequately defined, however, many other concepts (e.g., hope, meaning, control) are used in ways that suggest considerable overlap and correspondence with transformation. This article represents an attempt to explicate the structures and processes of transformation as they were revealed in a qualitative inquiry into the experience of individuals with Type I diabetes. In the accounts constructed with participants in this study, the process of personal transformation was significant in the attainment of healthy outcomes. The authors describe this transformation and examine its relationship to control and to the valued outcomes of intensified sense of self, meaning, and mastery.

Violence at work

In this article, the authors discuss violence in healthcare settings and the health and safety issues that are involved.

Shifting images of chronic illness

PURPOSE

To describe results of a meta-study of client roles in two decades of qualitative research on elements of chronic illness experiences. While a vast body of qualitative health research has uncovered insider perspectives on a range of chronic diseases and their related illness experiences, systematic analysis has not been attempted, and research has not yet contributed to coherent theoretical developments.

ORGANIZING CONSTRUCT

Health care relationships as articulated in the context of insider research into chronic illness experience.

SOURCES

Elements of meta-theory, meta-method, and meta-data-analysis in the available qualitative research reports addressing chronic illness experience published 1980 through June 1996. Of over 400 published reports, 158 met the inclusion criteria and were subjected to systematic analysis on a number of themes, one of which is reported in this article.

METHODS

Data selection, reduction, thematic analysis, and synthesis using constant comparative analysis.

FINDINGS

Early conceptualizations of individuals with chronic illness shift from a focus on loss and burden toward images of health within illness, transformation, and normality. Parallel conceptualizations of health care relationships appropriate to chronic illness shift from client-as-patient to client-as-partner for the 15-year period.

CONCLUSIONS

Meta-study permits critical analysis of the location of current inquiry into the larger context of systematic patterns in knowledge development. Researchers are cautioned against uncritical acceptance of current trends in interpretation.

School screening in remote aboriginal communities--results of an evaluation

As part of ongoing quality assurance, the effectiveness of the school screening program in meeting the health needs of Aboriginal children in a rural district in the Northern Territory Top End was evaluated. The major health problems of Aboriginal children were analysed for their suitability for screening programs. A prospective cross-sectional study used routinely collected field data from the school screening program in 1993. To ascertain follow-up, children who had failed screening tests had their clinic notes reviewed. A total of 774 children from 11 remote communities were screened. The results confirmed high level of disease, with rates for anaemia, malnutrition and trachoma reaching 39%, 22% and 26% respectively. Nearly one-third failed the hearing screening, urinalysis was abnormal in 19%, 3% failed visual acuity and 6% were considered to have abnormal heart auscultation. Many of the major health problems did not meet the recommended criteria for screening programs and others would be better dealt with by ongoing surveillance rather than a single screening. Some abnormalities found on screening were inadequately investigated and/or treated. This evaluation has demonstrated a limited role for school screening in identifying and meeting the health needs of Aboriginal children living in remote areas. In collaboration with the NT Department of Education, a school-age child health policy, including a new school-age child health surveillance program, is being developed. This promotes greater participation by communities, families and schools with the aim of improving the health and learning outcomes for all school-age children in the NT.

De-escalation in the management of aggression and violence

De-escalation has historically been viewed by nurses as an intuitive process. This paper argues that de-escalation can be explained by reference to theory and an exposition of practice skills, and refutes the intuitive position by proposing that de-escalation can be understood as an interactive process with discrete identifiable components.