Trans-radial cerebral angiography for stereotactic radiosurgery treatment of arteriovenous malformations

OBJECTIVES

The popularity of trans-radial access (TRA) for cerebral angiography is growing. Potential benefits of TRA over traditional trans-femoral access (TFA) are multitude. This study aimed to evaluate discharge outcomes and patient opinion of TRA compared to TFA in patients undergoing cerebral angiography prior to stereotactic radiosurgery (SRS) treatment for cerebral arteriovenous malformations.

METHODS

Consecutive patients treated at the National Centre for Stereotactic Radiosurgery (Sheffield, United Kingdom) over a 22-month period were included. All patients underwent cerebral angiography with either TRA or TFA as part of treatment planning prior to SRS. TRA patients who had previously undergone TFA in other centres were surveyed for their experience of cerebral angiography using a questionnaire. SRS staff at our centre was approached for their opinion.

RESULTS

492 patients were included (median age = 43 years, 57.5% male, median lesions treated = 1). More patients underwent angiography with TFA (75.2%) than TRA (24.8%). No difference was found in accumulated dose for angiography between the groups (p>0.05). There was 17.6% reduction in overnight stay between TRA and TRF, the proportion of patients requiring overnight admission was higher for the TFA (35.2%) than TRA (17.6%, p<0.05). 101 patients were surveyed, with a response rate of 47%. Most respondents (79%) indicated preference for TRA over TFA.

CONCLUSIONS

Use of TRA in pre-SRS cerebral angiography is feasible and improves both patient and staff experience. The adoption of TRA could have important implications for department resources and costs by reducing the proportion of overnight admissions.

Personal protective equipment training & lived experience for healthcare staff during COVID-19

Objectives

To describe the lived experience of healthcare staff during the Coronavirus Disease 2019 (COVID-19) pandemic relating to the use of personal protective equipment (PPE) and investigate risks associated with PPE use, error mitigation and acceptability of mindfulness incorporation into PPE practice.

Methods

A qualitative human factors' study at two Irish hospitals occurred in late 2020. Data was collected by semi-structured interview and included role description, pre-COVID-19 PPE experience, the impact of COVID-19 on lived experience, risks associated with PPE use, contributory factors to errors, error mitigation strategies and acceptability of incorporating mindfulness into PPE practice.

Results

Of 45 participants, 23 of whom were nursing staff (51%), 34 (76%) had previously worn PPE and 25 (56%) used a buddy system. COVID-19 lived experience impacted most on social life/home-work interface (n=36, 80%). Nineteen staff (42%) described mental health impacts. The most cited risk concerned 'knowledge of procedures' (n=18, 40%). Contributory factors to PPE errors included time (n=15, 43%) and staffing pressures (n=10, 29%). Mitigation interventions included training/education (n=12, 40%). The majority (n=35, 78%) supported mindfulness integration into PPE practice.

Conclusions

PPE training should address healthcare staff lived experiences and consider incorporation of mindfulness and key organisational factors contributing to safety.

Research and innovation as a catalyst for food system transformation

BACKGROUND

Food systems are associated with severe and persistent problems worldwide. Governance approaches aiming to foster sustainable transformation of food systems face several challenges due to the complex nature of food systems.

SCOPE AND APPROACH

In this commentary we argue that addressing these governance challenges requires the development and adoption of novel research and innovation (R&I) approaches that will provide evidence to inform food system transformation and will serve as catalysts for change. We first elaborate on the complexity of food systems (transformation) and stress the need to move beyond traditional linear R&I approaches to be able to respond to persistent problems that affect food systems. Though integrated transdisciplinary approaches are promising, current R&I systems do not sufficiently support such endeavors. As such, we argue, we need strategies that trigger a double transformation - of food systems and of their R&I systems.

KEY FINDINGS AND CONCLUSIONS

Seizing the opportunities to transform R&I systems has implications for how research is done - pointing to the need for competence development among researchers, policy makers and society in general - and requires specific governance interventions that stimulate a systemic approach. Such interventions should foster transdisciplinary and transformative research agendas that stimulate portfolios of projects that will reinforce one another, and stimulate innovative experiments to shape conditions for systemic change. In short, a thorough rethinking of the role of R&I as well as how it is funded is a crucial step towards the development of the integrative policies that are necessary to engender systemic change - in the food system and beyond.

B-22 Non-Convulsive Seizure and Post-Ictal Psychosis Presenting as Foreign Language in a Monolingual Patient: A Case Report

Objective

This paper seeks to advance the discussion of foreign language automatisms and clinical consequences of Non-Convulsive Status Epilepticus (NCSE) such as post-ictal psychosis. We present the first case of a monolingual English speaker communicating solely in Spanish, a non-native language during an epileptic episode.

Method

A 70-year old man with no history of seizures, epilepsy, or psychiatric illness presented to his primary care provider with episodes of confusion and "speaking Spanish." Prolonged video EEG performed after admission demonstrated a disorganized background with a mixture of generalized theta and delta activity with frequent focal and generalized ictal and epileptiform activity occurring predominantly out of the right hemisphere.

Results

Laboratory evaluation punctures were unrevealing. MRI of the brain with and without contrast were both normal. Keppra and Depakote were continued during the admission. His psychosis and cognitive impairment improved slowly over several days though he did not return back to his neurological baseline. He returned to speaking only English after several days of treatment. He continued to have frontal lobe dysfunction with psychotic features. A diagnosis of rapidly progressive dementia of unclear etiology was given.

Conclusion

Though foreign language automatisms are a rare consequence of NCSE, the combination of psychotic symptoms and confusion presented in this case creates an interesting connection between psychosis, dementia syndromes, and epilepsy, all involving aberrant activity or deficits in similar brain regions. The generation of foreign language automatisms may indicate a form of psychotic symptomology manifesting as a language anomaly as opposed to visual hallucinations, delusions, or formal thought disorder.

Effect of computerised cognitive training on cognitive outcomes in mild cognitive impairment: a systematic review and meta-analysis

OBJECTIVES

To determine the effect of computerised cognitive training (CCT) on improving cognitive function for older adults with mild cognitive impairment (MCI).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, Web of Science and the Cochrane Library were searched through January 2018.

ELIGIBILITY CRITERIA

Randomised controlled trials comparing CCT with control conditions in those with MCI aged 55+ were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed the risk of bias. Effect sizes (Hedges' g and 95% CIs) were calculated and random-effects meta-analyses were performed where three or more studies investigated a comparable intervention and outcome. Heterogeneity was quantified using the I² statistic.

RESULTS

18 studies met the inclusion criteria and were included in the analyses, involving 690 participants. Meta-analysis revealed small to moderate positive treatment effects compared with control interventions in four domains as follows: global cognitive function (g=0.23, 95% CI 0.03 to 0.44), memory (g=0.30, 95% CI 0.11 to 0.50), working memory (g=0.39, 95% CI 0.12 to 0.66) and executive function (g=0.20, 95% CI -0.03 to 0.43). Statistical significance was reached in all domains apart from executive function.

CONCLUSIONS

This meta-analysis provides evidence that CCT improves cognitive function in older people with MCI. However, the long-term transfer of these improvements and the potential to reduce dementia prevalence remains unknown. Various methodological issues such as heterogeneity in outcome measures, interventions and MCI symptoms and lack of intention-to-treat analyses limit the quality of the literature and represent areas for future research.

Genomic and Biochemical Characterization of Acinetobacter Podophage Petty Reveals a Novel Lysis Mechanism and Tail-Associated Depolymerase Activity

The increased prevalence of drug-resistant, nosocomial Acinetobacter infections, particularly from pathogenic members of the Acinetobacter calcoaceticus-baumannii complex, necessitates the exploration of novel treatments such as phage therapy. In the present study, we characterized phage Petty, a novel podophage that infects multidrug-resistant Acinetobacter nosocomialis and Acinetobacter baumannii Genome analysis reveals that phage Petty is a 40,431-bp ϕKMV-like phage, with a coding density of 92.2% and a G+C content of 42.3%. Interestingly, the lysis cassette encodes a class I holin and a single-subunit endolysin, but it lacks canonical spanins to disrupt the outer membrane. Analysis of other ϕKMV-like genomes revealed that spaninless lysis cassettes are a feature of phages infecting Acinetobacter within this subfamily of bacteriophages. The observed halo surrounding Petty's large clear plaques indicated the presence of a phage-encoded depolymerase capable of degrading capsular exopolysaccharides (EPS). The product of gene 39, a putative tail fiber, was hypothesized to possess depolymerase activity based on weak homology to previously reported phage tail fibers. The 101.4-kDa protein gene product 39 (gp39) was cloned and expressed, and its activity against Acinetobacter EPS in solution was determined. The enzyme degraded purified EPS from its host strain A. nosocomialis AU0783, reducing its viscosity, and generated reducing ends in solution, indicative of hydrolase activity. Given that the accessibility to cells within a biofilm is enhanced by degradation of EPS, phages with depolymerases may have enhanced diagnostic and therapeutic potential against drug-resistant Acinetobacter strains.IMPORTANCE Bacteriophage therapy is being revisited as a treatment for difficult-to-treat infections. This is especially true for Acinetobacter infections, which are notorious for being resistant to antimicrobials. Thus, sufficient data need to be generated with regard to phages with therapeutic potential, if they are to be successfully employed clinically. In this report, we describe the isolation and characterization of phage Petty, a novel lytic podophage, and its depolymerase. To our knowledge, it is the first phage reported to be able to infect both A. baumannii and A. nosocomialis The lytic phage has potential as an alternative therapeutic agent, and the depolymerase could be used for modulating EPS both during infections and in biofilms on medical equipment, as well as for capsular typing. We also highlight the lack of predicted canonical spanins in the phage genome and confirm that, unlike the rounding of lambda lysogens lacking functional spanin genes, A. nosocomialis cells infected with phage Petty lyse by bursting. This suggests that phages like Petty employ a different mechanism to disrupt the outer membrane of Acinetobacter hosts during lysis.

What do patients find helpful in psychotherapy? Implications for the therapeutic relationship in mental health nursing

This study examined client perception of the therapeutic impact of two models of therapy delivered by mental health nurses and clinical psychologists respectively - psychodynamic interpersonal therapy (PIT) and cognitive behavioural therapy (CBT). A non-equivalent groups design was used in order to benchmark results against Llewelyn et al.: one group received PIT and the other received CBT. This design was utilized principally because the research was conducted across two practice settings where randomization was not feasible. We used two intact groups in practice research settings that received the therapies as reported in Llewelyn et al. Sixty-one clients receiving CBT or PIT in practice research settings completed a Helpful Aspects of Therapy form after each session in order to measure client perceptions of helpful and hindering events in therapy. Only two out of the 13 impacts were rated as significantly different. PIT clients reported higher levels of 'awareness' than CBT clients, whereas CBT clients reported higher levels of problem solution than PIT clients. The results replicate Llewelyn et al.'s findings in that clients experienced theoretically different models of therapy as broadly similar in their therapeutic impact. We argue that this provides some support for the influence of 'common' rather than 'specific' factors in psychotherapy effectiveness in mental health nursing.

The impact of abdominal aortic aneurysm surgery on intensive care unit resources in an Irish tertiary centre

BACKGROUND

The potential impact of surgical service reconfiguration on intensive care unit (ICU) resources needs to be assessed.

AIMS

To determine the resources required to provide post-operative ICU care to patients undergoing open abdominal aortic aneurysm (AAA) repair or endovascular aneurysm repair (EVAR) at a specialist centre in the HSE South area

METHODS

For 198 patients, we calculated: (1) ICU bed-days; (2) organ support required; and (3) monetary cost of ICU care.

RESULTS

In total, 82.8% (101/122) of patients undergoing open AAA repair required post-operative ICU care (52 emergency and 49 elective). Emergency cases required more ICU bed-days (median 4.2 vs. 1.9, p<0.0005) and were more likely to require ventilation (odds ratio, OR 11.7, p<0.0001), inotropes (OR 3.1, p=0.01) or enteral nutrition (OR 23.3, p<0.0001). Mean cost per patient was €3,956 for elective cases and €16,419 for emergency cases. No patient required ICU admission after EVAR (n=76).

CONCLUSIONS

Open AAA surgery places significant demands on ICU resources. The planned reconfiguration of surgical services in Ireland must provide for parallel investment in ICU facilities and expertise.

Guided entropy mode Rayleigh scattering in optical fibers

Rayleigh scattering in optical fibers has the potential to degrade the performance of low-noise opto-electronic systems. In this Letter, we measure the Rayleigh gain spectrum of optical fibers. Our data show the gain bandwidth and the offset frequency of the Rayleigh gain peak. Both the gain bandwidth and the peak frequency are 3 orders of magnitude lower than the corresponding values for bulk silica. Our data suggest that the narrower gain bandwidth and frequency shift that we observe are due to guided entropy modes in the fiber. This effect is fundamental and will be present in any medium in which light is guided so that transverse intensity gradients exist.

Antimicrobial usage in an intensive care unit: a prospective analysis

Antimicrobial therapies in the Intensive Care Unit (ICU) need to be appropriate in both their antimicrobial cover and duration. We performed a prospective observational study of admissions to our semi-closed ICU over a three-month period and recorded the indications for antimicrobial therapy, agents used, duration of use, changes in therapy and reasons for changes in therapy. A change in therapy was defined as the initiation or discontinuation of an antimicrobial agent. There were 51 patients admitted during the three-month study period and all received antimicrobial therapy. There were 135 changes in antimicrobial therapy. 89 (66%) were made by the ICU team and 32 (24%) were made by the primary team. Changes were made due to a deterioration or lack of clinical response in 41 (30%) cases, due to the completion of prescribed course in 36 (27%) cases, and in response to a sensitivity result in 25 (19%) cases. Prophylactic antibiotic courses (n=24) were of a duration greater than 24 hours in 15 (63%) instances. In conclusion, the majority of changes in antimicrobial therapy were not culture-based and the duration of surgical prophylaxis was in excess of current recommended guidelines.

Qualitative research as evidence: criteria for rigour and relevance

This paper is about the nature and construct of evidence and its relation to qualitative research. Using a post-modern lens, we begin by defining evidence, signifying the importance of context, and use discourse as a vehicle for looking at the ways in which qualitative research evidence struggles to achieve the equivalent standing of its quantitative counterpart. In outlining the role of discourse in the creation of research paradigms, we offer a conceptual map that enables a repositioning of qualitative research in the evidence-based genre. In order to best illustrate our standpoint, we then provide two examples of qualitative, transformational research approaches and relate these to the criteria of rigour and relevance, criteria which we would argue when met are examples of high-quality evidence. Having used the examples of discourse analysis and auto-ethnography, we then conclude by exposing and decentralising the myth that surrounds the discourse of evidence-based practice, which continues, albeit unintentionally, to discredit any evidence that falls outside of its parameters.

The advancement of a new human factors report--'The Unique Report'--facilitating flight crew auditing of performance/operations as part of an airline's safety management system

This paper presents the findings of research relating to the specification of a new human factors report, conducted as part of the work requirements for the Human Integration into the Lifecycle of Aviation Systems project, sponsored by the European Commission. Specifically, it describes the proposed concept for a unique report, which will form the basis for all operational and safety reports completed by flight crew. This includes all mandatory and optional reports. Critically, this form is central to the advancement of improved processes and technology tools, supporting airline performance management, safety management, organisational learning and knowledge integration/information-sharing activities. Specifically, this paper describes the background to the development of this reporting form, the logic and contents of this form and how reporting data will be made use of by airline personnel. This includes a description of the proposed intelligent planning process and the associated intelligent flight plan concept, which makes use of airline operational and safety analyses information. Primarily, this new reporting form has been developed in collaboration with a major Spanish airline. In addition, it has involved research with five other airlines. Overall, this has involved extensive field research, collaborative prototyping and evaluation of new reports/flight plan concepts and a number of evaluation activities. Participants have included both operational and management personnel, across different airline flight operations processes. Statement of Relevance: This paper presents the development of a reporting concept outlined through field research and collaborative prototyping within an airline. The resulting reporting function, embedded in the journey log compiled at the end of each flight, aims at enabling employees to audit the operations of the company they work for.

A review and critical appraisal of measures of therapist-patient interactions in mental health settings

OBJECTIVES

To assemble and to appraise critically the current literature on tests and measures of therapist-patient interactions in order to make recommendations for practice, training and research, and to establish benchmarks for standardisation, acceptability and routine use of such measures.

DATA SOURCES

Major electronic databases (including PsycINFO) were searched from inception to 2002.

REVIEW METHODS

A comprehensive conceptual map of the subject area of therapist-patient interactions was developed through data extraction from, and analysis of, studies selected from the literature searches. The results of these searches were assessed and appraised to produce a set of possible therapist-patient measures. These measures were then evaluated.

RESULTS

The contextual map included the various concepts and domains that had been used in the context of the literature on therapist-patient interactions, and was used to guide the successive stages of the review. Three developmental processes were identified as necessary for the provision of an effective therapeutic relationship: 'establishing a relationship', 'developing a relationship' and 'maintaining a relationship'. Eighty-three therapist-patient measures having basic information on reliability and validity were identified for critical appraisal. The areas of the conceptual map that received most coverage (i.e. over 50% measures associated with them) were framework, therapist and patient engagement, roles, therapeutic techniques and threats to the relationship. These areas relate to the three key developmental processes outlined above. Of the 83 measures matching the content domain, 43 met the minimum standard. A total of 30 measures displayed adequate responsiveness or precision. None of the 43 measures that met the minimum standard was fully addressed in terms of acceptability and feasibility evidence. The majority of these measures had three or fewer components described. Therefore, out of a total of 83 measures matching the content domain, no measure could be said to have met an industry standard.

CONCLUSIONS

The findings indicate that the therapist-patient interaction can be measured using a wide range of instruments of varying value. However, due care should be taken in ensuring that the measure is suitable for the context in which it is to be used. Following on from this work, it is suggested that specific research networks for the development of therapist-patient measures should be established, that research activity should prioritise investment in increasing the evidence base of existing measures rather than attempting to develop new ones, and that research activity should focus on improving these existing measures in terms of acceptability and feasibility issues.

Introduction of a child and adolescent mental health link worker: education and health staff focus group findings

Policy guidance suggests that outcomes for adolescents with mental health problems can be improved by secondary education services (SES) and child and adolescent mental health services (CAMHS) working more closely. This study reports on staff experiences of the introduction of a mental health link worker (MHLW). The findings of two focus groups are presented, conducted with staff from CAMHS and SES. These focus groups formed part of the overall wider evaluation of the MHLW role. The groups explored staff perceptions and experiences following the introduction of the MHLW, and elicited their views on the effectiveness of this innovative role. Qualitative methods were employed, and analysis was conducted using the principles of grounded theory and the constant comparative method. The findings revealed that the MHLW was well received by both groups, despite the identification of potential barriers. A number of key themes emerged, which included the ability of the link worker to improve communication and to encourage mutual understanding between services. The issues raised by these themes are discussed and recommendations are made for future practice and research.

Inhibition of c-Jun N-terminal kinase pathway attenuates cerebral vasospasm after experimental subarachnoid hemorrhage through the suppression of apoptosis

BACKGROUND

Recent studies have demonstrated that apoptosis in cerebral arteries could play an essential role in cerebral vasospasm after subarachnoid hemorrhage (SAH) and that SP600125, an inhibitor of c-Jun N-terminal kinase (JNK) could suppress apoptosis. The present study examined whether SP600125 could reduce cerebral vasospasm through the suppression of apoptosis.

METHOD

Fifteen dogs were assigned to 3 groups: control, SAH, and SAH + SP600125 (30 micromol/l). SAH was induced by the injection of autologous blood into the cisterna magna on day 0 and day 2. Angiograms were evaluated on day 0 and day 7. The activation of the JNK pathway and caspase-3 were also evaluated using Western blot. To determine the distribution, TUNEL staining and immunohistochemistry for phosphorylated c-jun and cleaved caspase-3 were performed.

FINDINGS

Severe vasospasm was observed in the basilar artery of the SAH dogs. SP600125 reduced angiographic and morphological vasospasm and reduced the expression of cleaved caspase-3, thereby suppressing apoptosis.

CONCLUSIONS

These results demonstrate that SP600125 attenuates cerebral vasospasm through the suppression of apoptosis, which may provide a novel therapeutic target for cerebral vasospasm.

Elevated BNP with normal systolic function in asymptomatic individuals at-risk for heart failure: a marker of diastolic dysfunction and clinical risk

BACKGROUND

B-type natriuretic peptide (BNP) is widely accepted in the evaluation of left ventricular systolic dysfunction and heart failure. However, little is known of the implications of elevated BNP levels in individuals with preserved systolic function (PSF).

AIMS

To investigate the drivers and clinical implications of elevated BNP levels in asymptomatic individuals with established PSF.

METHODS

We enrolled 154 individuals who all underwent physical examination, BNP evaluation and Doppler-echocardiographic studies. They were divided into those above and below the median BNP level (50 pg/ml).

RESULTS

Independent predictors of higher BNP were older age, more severe left ventricular hypertrophy (LVH), reduced E/A ratio and ischaemic heart disease. Survival and multivariable analysis demonstrated more death and/or admission in those above the median BNP (HR: 4.79, p=0.007).

CONCLUSIONS

Elevated BNP is the strongest, independent predictor of serious adverse cardiovascular outcomes in this population and requires closer clinical follow-up.

Reporting participation in epidemiologic studies: a survey of practice

Self-selection bias may threaten the internal validity of epidemiologic studies. Studies with a low level of participation are particularly vulnerable to this bias, and commentators note apparent declines in participation in recent years. The authors therefore conducted a retrospective review to survey the practice of reporting participation in epidemiologic studies, to assess changes in participation over time, and to evaluate the impact of increased biologic specimen collection on participation. The authors abstracted selected study characteristics from 355 peer-reviewed, original, analytic-epidemiology research articles published from January 1 to April 30, 2003, in 10 high-impact general epidemiology, public health, and medical journals. At least some information regarding participation was provided in 59% of cross-sectional studies, 44% of case-control studies, and 32% of cohort studies. Participation appears to have declined during 1970-2003 for all study designs. Participation declined most steeply for controls in population-based, case-control studies (-1.86% per year, 95% confidence interval: -3.03, -0.69), with steeper declines after 1990. Proportionately more studies collected biologic specimens over time, particularly for cohort and case-control study designs (p(trend) = 0.06 and 0.03, respectively), yet participation was reported separately for the biologic specimen study component in only 27% of studies. The authors conclude that epidemiologists need to address declining participation and to report participation consistently, including for biologic specimen collection.

Reporting participation in epidemiologic studies: a survey of practice

Self-selection bias may threaten the internal validity of epidemiologic studies. Studies with a low level of participation are particularly vulnerable to this bias, and commentators note apparent declines in participation in recent years. The authors therefore conducted a retrospective review to survey the practice of reporting participation in epidemiologic studies, to assess changes in participation over time, and to evaluate the impact of increased biologic specimen collection on participation. The authors abstracted selected study characteristics from 355 peer-reviewed, original, analytic-epidemiology research articles published from January 1 to April 30, 2003, in 10 high-impact general epidemiology, public health, and medical journals. At least some information regarding participation was provided in 59% of cross-sectional studies, 44% of case-control studies, and 32% of cohort studies. Participation appears to have declined during 1970-2003 for all study designs. Participation declined most steeply for controls in population-based, case-control studies (-1.86% per year, 95% confidence interval: -3.03, -0.69), with steeper declines after 1990. Proportionately more studies collected biologic specimens over time, particularly for cohort and case-control study designs (p(trend) = 0.06 and 0.03, respectively), yet participation was reported separately for the biologic specimen study component in only 27% of studies. The authors conclude that epidemiologists need to address declining participation and to report participation consistently, including for biologic specimen collection.

Dynamics of coherent and incoherent spin polarizations in ensembles of quantum dots

The temperature dependence of spin coherence in InGaAs quantum dots is obtained from quantum beats observed in polarization-resolved pump-probe experiments. Within the same sample we clearly distinguish between coherent spin dynamics leading to quantum beats and incoherent long-lived spin-memory effects. Analysis of the coherent data using a theoretical model reveals approximately 10 times greater stability of the spin coherence at high temperature compared to that found previously for exciton states in four-wave-mixing experiments by Borri et al. [Phys. Rev. Lett. 87, 157401 (2001)]]. The data on incoherent polarization reveal a new form of spin memory based on charged quantum dots.

Gut mucosal response to food antigens in Crohn's disease

BACKGROUND

Food antigens may contribute to gut inflammation in Crohn's disease.

AIM

To assess in vivo sensitization to food antigens, ascertain whether sensitivity is gut specific, assess food sensitization in vitro, and correlate in vivo changes with histological and blood changes.

METHODS

Skin testing and rectal exposure to six food antigens (cereal, cabbage, citrus, milk, yeast and peanut) and control saline were assessed double-blind by immediate and 3.5-h laser Doppler blood flowmetry, and rectal biopsies were taken. Peripheral blood lymphocyte proliferation was measured in response to the same antigens.

RESULTS

Ten patients with Crohn's disease and 10 healthy controls were studied. Blood flow increased in 24 of 60 antigen sites in Crohn's disease patients and six of 60 antigen sites in controls (P < 0.0001) after 3.5 h. The Crohn's disease group demonstrated higher rectal blood flow than controls in response to all food antigens, and this was significantly different for the responses to yeast (P = 0.036) and citrus fruits (P = 0.038). Lymphocyte proliferation occurred in 32 of 60 tests in Crohn's disease patients and eight of 60 tests in controls (P < 0.0001). There were no skin responses. Submucosal oedema corresponded to increased mucosal flow.

CONCLUSIONS

Crohn's disease patients demonstrate in vivo and in vitro sensitization to food antigens, which is gut specific. Mucosal flowmetry allows the identification of sensitization to gut antigens.

Self-rated quality of life measures: effect of change to a low-fat, high-fiber, fruit and vegetable enriched diet

The Polyp Prevention Trial (PPT) was a multicenter, randomized clinical trial to determine the effect of a low-fat (20% of energy from fat), high-fiber (18 g/1,000 kcal/day), high-fruit/vegetable (3.5 servings/1,000 kcal/day) eatingplan on the recurrence of large bowel adenomatous polyps. The PPT provided an opportunity to examine the impact of dietary changes on quality of life. At baseline and annuallyfor 4 years, participants in the Quality of Life Substudy of PPT completed a Quality of Life Factors (QF) Questionnaire, a modified Block-National Cancer Institute Food Frequency Questionnaire, and a Health and Lifestyle Questionnaire. The 51-item QF Questionnaire assessed changes in nine domains: taste, convenience, cost, self-care, social, health assessment, health belief health action, and life satisfaction. The analysis compared annual changes in domain scores for intervention (n = 194) and control (n = 200) participants. At Year 1, 363 (92%) completed a questionnaire, and 325 (82%) participants completed a Year 4 questionnaire. There were no statistically significant differences between treatment groups in the change from baseline to Year 1 for the convenience, cost, taste, health assessment, and life satisfaction domains. At Year 1, intervention participants rated the self-care (p < .001), health belief (p = .021), and health action (p < .001) domains significantly higher and the social domain significantly lower (p <.001) than control participants. These changes were consistent through Years 2, 3, and 4. This study

Client interpersonal and cognitive styles as predictors of response to time-limited cognitive therapy for depression

This study examined the relationship between cognitive and interpersonal styles and outcome among 24 clients who received time-limited cognitive therapy for depression. The authors hypothesized that this relationship would be mediated by therapeutic alliance. They found that clients' interpersonal style, particularly an underinvolved style, was predictive of treatment outcome. As predicted, the impact of this style on outcome was mediated through the therapeutic alliance.

Client interpersonal and cognitive styles as predictors of response to time-limited cognitive therapy for depression

This study examined the relationship between cognitive and interpersonal styles and outcome among 24 clients who received time-limited cognitive therapy for depression. The authors hypothesized that this relationship would be mediated by therapeutic alliance. They found that clients' interpersonal style, particularly an underinvolved style, was predictive of treatment outcome. As predicted, the impact of this style on outcome was mediated through the therapeutic alliance.

Severe intellectual disability and transition to adulthood

Institutional and psychological aspects of transition were explored with parents and staff involved with five young adults with severe intellectual disability whose challenging behaviour diminished after they made the transition, and five whose challenging behaviour remained high. They were selected from a previously surveyed cohort. Grounded theory analysis of interviews suggested little connection between the perspectives of parents and staff. The impact these differences have on communication about challenging behaviour was explored, and recommendations for service changes are made.

Elimination of early rehospitalization in a randomized, controlled trial of multidisciplinary care in a high-risk, elderly heart failure population: the potential contributions of specialist care, clinical stability and optimal angiotensin-converting enzyme inhibitor dose at discharge

BACKGROUND

Despite a growing body of data demonstrating the benefits of multidisciplinary care in heart failure, persistently high rates of readmission, especially within the first month of discharge, continue to be documented.

AIMS

As part of an ongoing randomized study on the value of multidisciplinary care in a high risk (NYHA Class IV), elderly (mean age 69 years) heart failure population, we examined the effects of this intervention on previously high (20%) 1-month readmission rates.

METHODS

Unlike previous studies of this approach, both multidisciplinary (MC) and routine care (RC) populations were cared for by the cardiology service, complied with adherence to clinical stability criteria prior to discharge (100% of patients) and received at least target dose angiotensin-converting enzyme (ACE) inhibition with perindopril prior to discharge (94% of indicated patients). We analysed death and unplanned readmission for heart failure at 1 month.

RESULTS

This early report from the first 70 patients (67% male, 71% systolic dysfunction with a mean ejection fraction of 31.0+/-6.7%) enrolled in this study demonstrates elimination of 1-month hospital readmission in both RC and MC groups. This unexpected result represents a dramatic improvement both for this patient cohort (20% 30-day readmission rate prior to enrollment reduced to 0% following the index admission in both care groups) and in comparison with available data.

CONCLUSIONS

Critical contributors to this improvement appear to be specialist cardiology care, adherence to clinical stability criteria prior to discharge and routine use of target or high-dose ACE inhibitor therapy prior to discharge. Widespread application of this approach may have a dramatic improvement in morbidity of CHF while limiting the escalating costs of this condition.

Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. Polyp Prevention Trial Study Group

BACKGROUND

We tested the hypothesis that dietary intervention can inhibit the development of recurrent colorectal adenomas, which are precursors of most large-bowel cancers.

METHODS

We randomly assigned 2079 men and women who were 35 years of age or older and who had had one or more histologically confirmed colorectal adenomas removed within six months before randomization to one of two groups: an intervention group given intensive counseling and assigned to follow a diet that was low in fat (20 percent of total calories) and high in fiber (18 g of dietary fiber per 1000 kcal) and fruits and vegetables (3.5 servings per 1000 kcal), and a control group given a standard brochure on healthy eating and assigned to follow their usual diet. Subjects entered the study after undergoing complete colonoscopy and removal of adenomatous polyps; they remained in the study for approximately four years, undergoing colonoscopy one and four years after randomization.

RESULTS

A total of 1905 of the randomized subjects (91.6 percent) completed the study. Of the 958 subjects in the intervention group and the 947 in the control group who completed the study, 39.7 percent and 39.5 percent, respectively, had at least one recurrent adenoma; the unadjusted risk ratio was 1.00 (95 percent confidence interval, 0.90 to 1.12). Among subjects with recurrent adenomas, the mean (+/-SE) number of such lesions was 1.85+/-0.08 in the intervention group and 1.84+/-0.07 in the control group. The rate of recurrence of large adenomas (with a maximal diameter of at least 1 cm) and advanced adenomas (defined as lesions that had a maximal diameter of at least 1 cm or at least 25 percent villous elements or evidence of high-grade dysplasia, including carcinoma) did not differ significantly between the two groups.

CONCLUSIONS

Adopting a diet that is low in fat and high in fiber, fruits, and vegetables does not influence the risk of recurrence of colorectal adenomas.

The impact of lean production and related new systems of work organization on worker health

New systems of work organization, such as lean production and total quality management, have been introduced by employers throughout the industrialized world to improve productivity, quality, and profitability. However, few studies have examined the impact of such systems on occupational injuries or illnesses or on job characteristics related to job strain, which has been linked to hypertension and cardiovascular disease. The studies reviewed provide little evidence to support the hypothesis that lean production "empowers" auto workers. In fact, auto industry studies suggest that lean production creates intensified work pace and demands. Increases in decision authority and skill levels are modest or temporary, whereas decision latitude typically remains low. Thus, such work can be considered to have job strain. In jobs with ergonomic stressors, intensification of labor appears to lead to increases in musculoskeletal disorders. The evidence for adverse health effects remains inconclusive for related new work systems in other industries, such as modular manufacturing or patient-focused care.

Quantitation and mapping of aflatoxin B1-induced DNA damage in genomic DNA using aflatoxin B1-8,9-epoxide and microsomal activation systems

Aflatoxin B1 (AFB1) is a mutagenic and carcinogenic mycotoxin which may play a role in the etiology of human liver cancer. In vitro studies have shown that AFB1 adducts form primarily at the N7 position of guanine. Using quantitative PCR (QPCR) and ligation-mediated PCR (LMPCR), we have mapped total AFB1 adducts in genomic DNA treated with AFB1-8,9-epoxide and in hepatocytes exposed to AFB1 activated by rat liver microsomes or human liver and enterocyte microsomal preparations. The p53 gene-specific adduct frequencies in DNA, modified in cells with 40-400 microM AFB1, were 0.07-0.74 adducts per kilobase (kb). In vitro modification with 0. 1-4 ng AFB1-8,9-epoxide per microgram DNA produced 0.03-0.58 lesions per kb. The adduct patterns obtained with the epoxide and the different microsomal systems were virtually identical indicating that adducts form with a similar sequence-specificity in vitro and in vivo. The lesions were detected exclusively at guanines with a preference towards GpG and methylated CpG sequences. The methods utilizing QPCR and LMPCR thus provide means to assess gene-specific and sequence-specific AFB1 damage. The results also prove that microsomally-mediated damage is a suitable method for avoiding manipulations with very unstable DNA-reactive metabolites and that this damage can be detected by QPCR and LMPCR.

The impact of lean production and related new systems of work organization on worker health

New systems of work organization, such as lean production and total quality management, have been introduced by employers throughout the industrialized world to improve productivity, quality, and profitability. However, few studies have examined the impact of such systems on occupational injuries or illnesses or on job characteristics related to job strain, which has been linked to hypertension and cardiovascular disease. The studies reviewed provide little evidence to support the hypothesis that lean production "empowers" auto workers. In fact, auto industry studies suggest that lean production creates intensified work pace and demands. Increases in decision authority and skill levels are modest or temporary, whereas decision latitude typically remains low. Thus, such work can be considered to have job strain. In jobs with ergonomic stressors, intensification of labor appears to lead to increases in musculoskeletal disorders. The evidence for adverse health effects remains inconclusive for related new work systems in other industries, such as modular manufacturing or patient-focused care.

Patient's perceptions of bedside handovers

The bedside handover is a universal phenomenon in nearly every type of care setting. It has become the chief arena for the intershift handover in contemporary nursing practice. Published literature investigating patients' viewpoints on the location of the bedside handover is sparse. The overall aim of this study is to describe and provide an analysis of patients' perceptions of the bedside handover. A grounded theory approach to data collection and data analysis was employed to capture surgical patients' views about the bedside handover. The analysis tentatively suggests the existence of three categories that describe the patients' perceptions of the bedside handover. 'Maintaining a Professional Distance', 'Establishing Professional Sharing' and 'Maintaining Patient Safety.'

Short-term vs long-term dexamethasone treatment: effects on rat diaphragm structure and function

The effects of dexamethasone treatment duration (2.5 vs 10 weeks) on diaphragm myosin heavy chain isoforms, fiber types, and contractile characteristics were studied in male rats. Compared with ad libitum-fed and pair-fed controls, dexamethasone significantly decreased body weight, costal diaphragm weight, and the relative expression of myosin heavy chain isoform MHC-2B. Compared with pair-fed controls, the effect on MHC-2B expression was greater after 10 weeks than after 2.5 weeks. Type I and type II costal diaphragm fiber atrophy occurred, and type II fiber atrophy was greater after 10 weeks. Costal diaphragm-specific forces were not affected significantly by dexamethasone, regardless of the treatment duration or control group comparison. Fatigue resistance indexes were increased significantly after long term treatment compared with pair-fed controls and after both short-term and long-term treatment compared with ad libitum-fed controls. In conclusion, the effects of dexamethasone on MHC isoform phenotype expression, fiber type costal diaphragm atrophy, and fatigue resistance were dependent on treatment duration, with greater effects after long-term (10 weeks) treatment.

Patient participation--a review of the literature

This article presents a critical review of the concept of patient participation. The concept of patient participation has become widely accepted in contemporary nursing practice. It is now part of the vocabulary of professional nurses and has been heralded as a means of enhancing decision making and human dignity and enriching quality of life. Patient participation in care is emerging as a growing movement wherein patients are assuming more responsibility for the prevention, detection and treatment of health problems in a manner that supplements or substitutes for professional services. The review concludes with some recommendations for nursing practice, education and research.