Increased Ion Temperature and Neutron Yield Observed in Magnetized Indirectly Driven D_{2}-Filled Capsule Implosions on the National Ignition Facility

The application of an external 26 Tesla axial magnetic field to a D_{2} gas-filled capsule indirectly driven on the National Ignition Facility is observed to increase the ion temperature by 40% and the neutron yield by a factor of 3.2 in a hot spot with areal density and temperature approaching what is required for fusion ignition [1]. The improvements are determined from energy spectral measurements of the 2.45 MeV neutrons from the D(d,n)^{3}He reaction, and the compressed central core B field is estimated to be ∼4.9  kT using the 14.1 MeV secondary neutrons from the D(T,n)^{4}He reactions. The experiments use a 30 kV pulsed-power system to deliver a ∼3  μs current pulse to a solenoidal coil wrapped around a novel high-electrical-resistivity AuTa_{4} hohlraum. Radiation magnetohydrodynamic simulations are consistent with the experiment.

Aerial baiting for feral cats is unlikely to affect survivorship of northern quolls in the Pilbara region of Western Australia

Abstract ContextFeral cats (Felis catus) are known predators of northern quolls (Dasyurus hallucatus). Management to suppress feral cat densities often uses the poison sodium monofluoroacetate (compound 1080) in baits broadcast aerially. Eradicat® baits have demonstrated efficacy at reducing feral cat densities in some environments. However, these are not registered for use in northern Australia because their risk to non-target northern quolls remains unknown. AimsWe investigated the risks of aerially deployed feral cat Eradicat® baits containing 4.5mg of the poison 1080 on the survival of free-ranging northern quolls. MethodsThe study was conducted over a 20000-ha area in the Pilbara bioregion in Western Australia. Twenty-one wild northern quolls from a baited area and 20 quolls from a nearby reference area were fitted with radio-collars, and their survivorship was compared following the aerial deployment of over 9700 feral cat baits. Survivorship of quolls was assessed before and after the baiting campaign. Key resultsFive radio-collared quolls died at the baited area; four mortalities were due to feral cat predation, and the cause of one death was uncertain. At the reference area, seven radio-collared quolls were confirmed dead; three mortalities were due to feral cat predation, two from wild dog predation, and the cause of death of two could not be determined. Evidence for sublethal poison impacts on quolls, inferred by monitoring reproductive output, was lacking; average litter size was higher in quolls from the baited area than in those from the unbaited area, and within range of litters reported elsewhere, suggesting that acute effects of 1080 (if ingested) on reproductive success were unlikely. ConclusionsRadio-collared northern quolls survived the trial using Eradicat® baits, and females showed no acute effects of sublethal poisoning on the basis of reproductive output. A lack of quoll deaths attributed to 1080 poisoning suggests that the use of Eradicat® poses a low risk to northern quolls in the Pilbara. Importantly, the high level of mortalities associated with predation by feral cats, and to a lesser extent, canids, validates the threats of these introduced predators on quolls, suggesting that their control in areas where quolls are present is likely to be beneficial for the recovery of this species. ImplicationsLand managers aiming to conserve northern quolls in the Pilbara would see conservation benefits if they introduced an operational landscape-scale feral cat baiting program using Eradicat® baits, with appropriate monitoring.

Diabetes care and mental illness: constraining elements to physical activity and social participation in a residential care facility

OBJECTIVE

To explore barriers and constraints to physical activity, as an integral component of diabetes care, in those with serious mental illness who reside in a for-profit group home.

METHODS

Institutional ethnography was the approach used to explore diabetes-related care practices among 26 women in a rural residential care facility in southern Ontario. Semi-structured, in-depth interviews were conducted with residents who had diabetes as well as with care providers, field workers and health professionals. Observations and document analysis were further methods used to reveal the disjuncture between diabetes care guidelines and the actualities of living within imposed constraints of group home care.

RESULTS

The residents in this government-regulated group home were sedentary, obtaining approximately 10 minutes per day of low-intensity exercise. The overarching government interest in cost containment created a context of rationing that resulted in a lack of opportunities to exercise and fully participate in social life. Furthermore, group home policies regulated systems of safety, reporting and financial accountability, but did not promote health.

CONCLUSIONS

The findings indicate an urgent need for government financial support for quality of life initiatives and amendments to group home policies that give primacy to health promotion, illness prevention and medical management of prevalent comorbid conditions such as diabetes.

Factors influencing referral to cardiac rehabilitation and secondary prevention programs: a systematic review

BACKGROUND

Referral to cardiac rehabilitation and secondary prevention programs remains very low, despite evidence suggesting strong clinical efficacy. To develop evidence-based interventions to promote referral, the complex factors and processes influencing referral need to be better understood.

DESIGN

We performed a systematic review using qualitative meta-synthesis.

METHODS

A comprehensive search of 11 databases was conducted. To be included, studies had to contain a qualitative research component wholly or in a mixed method design. Population specific data or themes had to be extractable for referral to programs. Studies had to contain extractable data from adults >18 years and published as full papers or theses during or after 1995.

RESULTS

A total of 2620 articles were retrieved: out of 1687 studies examined, 87 studies contained data pertaining to decisions to participate in programs, 34 of which included data on referral. Healthcare professional, system and patient factors influenced referrals. The main professional barriers were low knowledge or scepticism about benefits, an over-reliance on physicians as gatekeepers and judgments that patients were not likely to participate. Systems factors related to territory, remuneration and insufficient time and workload capacity. Patients had limited knowledge of programs and saw physicians as key elements of referral but found the process of attaining a referral confusing and challenging.

CONCLUSIONS

The greatest increases in patient referral to programs could be achieved by allowing referral from non-physicians or alternatively, automatic referral to a choice of hospital or home-based programs. All referring health professionals should receive educational outreach visits or workshops around the ethical and clinical aspects of programs.

The social context of career choice among millennial nurses: implications for interprofessional practice

Health human resource and workforce planning is a global priority. Given the critical nursing shortage, and the fact that nurses are the largest group of healthcare providers, health workforce planning must focus on strategies to enhance both recruitment and retention of nurses. Understanding early socialization to career choice can provide insight into professional perceptions and expectations that have implications for recruitment, retention and interprofessional collaboration. This interpretive narrative inquiry utilized Polkinghorne's theory of narrative emplotment to understand the career choice experiences of 12 millennial nurses (born between 1980 and 2000) in Eastern Canada. Participants were interviewed twice, face-to-face, 4 to 6 weeks apart prior to commencing their nursing program. The narratives present career choice as a complex consideration of social positioning. The findings provide insight into how nursing is perceived to be positioned in relation to medicine and how the participants struggled to locate themselves within this social hierarchy. Implications of this research highlight the need to ensure that recruitment messaging and organizational policies promote interprofessional collaboration from the onset of choosing a career in the health professions. Early professional socialization strategies during recruitment and education can enhance future collaboration between the health professions.

Access to cancer screening for women with mobility disabilities

Women with mobility disabilities are less likely to access cancer screening, even when they have a primary care provider. The Gateways to Cancer Screening project was initiated to document the challenges for women with disabilities in their access and experiences of screening for breast, cervical and colorectal cancer. The study followed the tenets of participatory action research. Five peer-led focus groups were held with 24 women with mobility disabilities. Study participants identified multiple and interacting institutional barriers to cancer screening. Their discussions highlighted the complex work of (1) arranging and attending health-related appointments, (2) confronting normative assumptions about women's bodies and (3) securing reliable health care and information. These overlapping, mutually reinforcing issues interact to shape how women with disabilities access and experience cancer screening. We explore implications for redesign of cancer screening services and education of health providers, providing specific recommendations suggested by our participants and the findings.

Working Toward a Decision: The Development and First Impressions of a Decision Aid for Older Women with Early-stage Breast Cancer

BACKGROUND

The use of decision aids (DAs) have been advocated in cancer decisions to help patients understand treatment options and to promote patient involvement in the treatment decision. Although the challenges of involving older patients in treatment decision making have been highlighted, decisional support for older early-stage breast cancer patients has not been established yet. This study reports on the development of a DA prototype and the initial assessment of it.

OBJECTIVE

To conduct a preliminary testing of the DA prototype to ensure that the format and information presented is clear and acceptable to patients.

RESEARCH DESIGN

Twelve one-on-one interviews were conducted with women over the age of 70 diagnosed with Stage I breast cancer after radiation therapy from an academic cancer centre.

RESULTS

The overall impression of the DA prototype was favorable with all participants rating the tool as extremely acceptable. All participants felt that this tool would be helpful for older women with early-stage breast cancer making decisions about treatments and would recommend its use in clinical practice.

CONCLUSION

Similar to previous literature, we found that older breast cancer patients experienced difficulties expressing their concerns and found it challenging to participate in treatment decisions. These findings led to the next steps in the development of a DA for older early-stage breast cancer patients.

P5-15-03: Development of a Patient Decision Aid for Women 70 Years and Older with Stage I, Hormonally Sensitive, Breast Cancer Considering Adjuvant Treatment Post-Lumpectomy

Background: Decision Aids (DA) are developed with the intent to support people in making specific and deliberate choices by improving information transfer about different outcomes. Previous research has shown that DAs can increase patient knowledge regarding treatment options, reduce decisional conflict, and increase patient satisfaction with the decision-making process. However, no DAs have been developed to help older breast cancer patients decide whether or not to undergo adjuvant RT. We developed and tested a DA for older women with stage I,ER/PR positive breast cancer considering adjuvant treatment post-lumpectomy and we examined its impact on treatment decision-making process.

Methods and Materials: A DA was developed and evaluated in three steps following the Ottawa Decision Aid Framework: 1) Needs assessment (N=16); 2) Pilot I, to examine the DA's acceptability (N=12); and 3) Pilot II, a pre-test post-test (N=38) with older women with ER/PR responsive breast cancer post-lumpectomy who were receiving adjuvant RT. Measures included questionnaires to assess patient's satisfaction with the DA, patients’ self-reported decisional conflict (DC), level of distress, treatment-related knowledge, and choice predisposition

Results: The DA is a booklet that details each adjuvant treatment option's benefits, risks and side-effects tailored to their clinical profile; includes a value clarification exercise; and steps to guide them towards their own treatment decision. All women felt the DA was helpful and informative. Compared with baseline scores, patients had a statistically significant (p < .05) reduction in DC (adjusted mean difference [AMD], −7.18; 95% confidence interval [CI], −13.50 to 12.59); increased clarity of the treatment benefits and risks (AMD, −10.86, CI, −20.33 to 21.49; and improved general treatment knowledge (AMD, 8.99, CI, 2.88 to 10.28) after using the DA. General trends were also reported in patient's choice predisposition scores suggesting potential differences in treatment decision after DA use. Discussion: This study provides evidence that this DA may be a helpful educational tool for this group of women. The quality of care for older breast cancer patients may be enhanced by using a tailored DA to help the patient be informed of their treatment options and to prepare for decision-making.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-15-03.

What do older patients with early breast cancer want to know while undergoing adjuvant radiotherapy?

The study aims to investigate the information needs and unique illness experiences of older women with early stage breast cancer. Breast cancer patients have expressed a high need for information to help them cope with their disease and treatment decision making. Satisfying information needs can also improve patient outcomes including perceptions of control, levels of distress, and psychological well-being. Focus groups and one patient interview were conducted investigating the informational needs of patients 70 years or older who were diagnosed with stage I breast cancer. Women identified their experiences and information needs related to diagnosis, participation in treatment decision making, treatment onset, and unexpected life changes. They provided several suggestions to healthcare professionals related to breast cancer treatment. The study's findings increase our understanding of older breast cancer patients' needs and provide a foundation for the development of a decision aid to help patients better understand their treatment options.

Therapeutic benefit of preventive telehealth counseling in the Community Outreach Heart Health and Risk Reduction Trial

We evaluated whether telehealth counseling augments lifestyle change and risk factor decrease in subjects at high risk for primary or secondary cardiovascular events compared to a recommended guideline for brief preventive counseling. Subjects at high risk or with coronary heart disease (35 to 74 years of age, n = 680) were randomized to active control (risk factor feedback, brief advice, handouts) or telehealth lifestyle counseling (active control plus 6 weekly 1-hour teleconferenced sessions to groups of 4 to 8 subjects). Primary outcome was questionnaire assessment of adherence to daily exercise/physical activity and diet (daily vegetable and fruit intake and restriction of fat and salt) after treatment and at 6-month follow-up. Secondary outcomes were systolic and diastolic blood pressures, ratio of total to high-density lipoprotein cholesterol, and 10-year absolute risk for coronary disease. After treatment and at 6-month follow-up, adherence increased for telehealth versus control in exercise (29.3% and 18.4% vs 2.5% and 9.3%, respectively, odds ratio 1.60, 95% confidence interval 1.2 to 2.1) and diet (37.1% and 38.1% vs 16.7% and 33.3%, respectively, odds ratio 1.41, 95% confidence interval 1.1 to 1.9). Telehealth versus control had greater 6-month decreases in blood pressure (mean ± SE, systolic -4.8 ± 0.8 vs -2.8 ± 0.9 mm Hg, p = 0.04; diastolic -2.7 ± 0.5 vs -1.5 ± 0.6 mm Hg, p = 0.04). Decreases in cholesterol ratio and 10-year absolute risk were significant for the 2 groups. In conclusion, telehealth counseling augments therapeutic lifestyle change in subjects at high risk for cardiovascular events compared to a recommended guideline for brief preventive counseling.

Pathways to breast cancer diagnosis and treatment: exploring the social relations of diagnostic delay

In epidemiological studies, inequitable access to breast cancer care aligns with such variables as income, age, education, ethnicity and residential location. These variables correspond to structural patterns of advantage and disadvantage, which in turn may constrain or facilitate timely access to care. The purpose of this study was to understand the complexities of women's pathways to diagnosis. Thirty-five women from diverse backgrounds and who had clinically detectable breast symptoms at time of diagnosis participated in semi-structured interviews. All were receiving or completing treatment when they participated. Data were analyzed using the strategies of induction, comparison and abduction. All of the participants described a variety of activities involved in seeking care for breast cancer. The findings illustrate how the social relations of health care, rather than simply patient or provider delay, may contribute barriers to timely diagnosis. We illustrate how women's widely differing social and material contexts offer opportunities and barriers to access.

Systemic mastocytosis with diffuse cutaneous involvement and haematological disease presenting in utero treated unsuccessfully with vincristine

Mastocytosis is a disorder characterised by abnormal mast cell proliferation. The diverse spectrum of clinical presentations is dependent on the tissues and organs involved. We report a rare case of aggressive systemic mastocytosis presenting in utero with diffuse cutaneous involvement, and haematological abnormalities. There is little published evidence to guide treatment.

Habitus, stress, and the body: the everyday production of health and cardiovascular risk

The incidence of coronary heart disease (CHD) and the distribution of contributory risk factors are closely linked with social patterns of advantage and disadvantage. The authors conducted eight focus groups in urban, northern, and rural sites in Ontario, Canada. Participants were all at high absolute risk for or had been diagnosed with CHD. Analysis centered on habitus, which forms the pivotal link between the person and "place." The authors focused on participants' dialogue about stress because it dealt with the impingements of the social world and resultant constraints on health-related activities in everyday places. Participants described four types of places or social positions in their "stress talk": work-places, transitional spaces, gendered situations, and exclusions. Places can support or constrain health related activities in many ways. Habits and practices linked with stress by participants were enduringly associated with these contexts, suggesting that place, body, and health are inseparable and coconstituted.

The many faces of secondary syphilis: a re-emergence of an old disease

There has been a recent dramatic re-emergence of syphilis in the UK. This article describes the varied clinical manifestations of secondary syphilis and describes the diagnosis and current guidelines for treatment, especially in association with human immunodeficiency virus infection.

Studying delays in breast cancer diagnosis and treatment: critical realism as a new foundation for inquiry

PURPOSE/OBJECTIVES

To examine how delays in breast cancer care currently are conceptualized and to introduce philosophical and theoretical tenets of critical realism as an alternative approach.

DATA SOURCES

Health and social sciences literature.

DATA SYNTHESIS

Diagnostic and treatment delays in breast cancer most frequently are conceptualized as patient, provider, or system related. The approach has limited utility in guiding explanatory analysis because it does not acknowledge the social context in which the delays occur. The philosophical tenets of critical realism and two related theoretical approaches are an alternative. They illustrate how an individual's biologic, social, and material resources may undermine or support structural inequities in access to breast cancer care.

CONCLUSIONS

Critical realism provides a useful framework for analysis of links between social inequalities and delays in breast cancer diagnosis and treatment.

IMPLICATIONS FOR NURSING

Access to breast cancer care could be better understood and conceptualized by basing future research and theoretical endeavors on a critical realist perspective.

The home as a site for long-term care: meanings and management of bodies and spaces

This paper is concerned with the constitution of the home as a landscape of care in a climate of extensive cost-cutting measures to community provided health care. It draws on data from a multi-disciplinary investigation of various dimensions of the home as a site of long-term care; this paper is concerned specifically with long-term health and associated home-care services provided by paid workers. Through analysis of interviews with adult care recipients and field observations, it examines the micro-scale processes through which the home is reconstructed as caregiving space, highlighting the negotiation of meanings of bodies and homes as fields of knowledge. It argues that the possibilities for the effective negotiation of body knowledge and homespace boundaries that are integral to the production of 'caring' space are embedded in and constrained by policies and practices constructed at a scale beyond home.

“Sneaky disease”: the body and health knowledge for people at risk for coronary heart disease in Ontario, Canada

The contribution of modifiable risk factors to the prevalence of coronary heart disease (CHD) has been well documented in the literature. A focus group component of a cardiovascular risk reduction project, The Community Outreach in Heart Health and Risk Reduction Trial was designed to explore issues that facilitate or constrain individual efforts to implement changes to health behaviours. Eight focus groups were conducted in urban, northern and rural sites in Ontario, Canada. In this article, we elaborate on the difficulties all group members experienced as they attempted to interpret their personal candidacy for CHD. For many participants, CHD was an undetectable or "sneaky disease" in its earlier stages, thus coronary risk was to them an abstract concept that could not ordinarily be detected through sensory perception. Participants drew on three possible strategies to determine their candidacy for CHD: they cognitively engaged in weighing risks, they relied on the interpretive powers of medical hermeneutics, or they waited for "the big event". The findings suggest that lay understandings of the body and health differ from those of health professionals and educators, and that lay understandings differ according to SES and gender. This has implications for health literacy and must be considered in devising strategies for health education.

The personal significance of home: habitus and the experience of receiving long-term home care

The physical, symbolic and experiential aspects of receiving long-term care are examined in this paper using Bourdieu's concepts of habitus and field. We draw on data from an ethnographic study of home care in 16 homes in urban, rural and remote locations in Ontario, Canada. Across all cases, data about domestic and caregiving routines were gathered through observation, interviews with clients and/or the primary family caregiver, interviews with service providers and videotaped tours of the home. Based on the analysis of these data, we argue that a transposition of logics and practices occurred when the domestic and health care fields were superimposed within the spaces of the home. Although all of the care recipients and their family caregivers indicated a strong preference for home care over institutional care, their experiences and practices within their homes were disrupted and reconfigured by the insertion of logics emanating from the healthcare field. These changes were manifested in three main themes: the politics of aesthetics; the maintenance of order and cleanliness; and transcending the limitations of the home. In each of these dimensions, it became apparent that care recipients engaged in improvisatory social practices that reflected their ambiguous and changing habitus or social location. The material spaces of their homes signified, or prompted, altered or changing social placement.

Implementing evidence-based nursing practice: a tale of two intrapartum nursing units

Despite concerns that the rise of evidence-based practice threatens to transform nursing practice into a performative exercise disciplined by scientific knowledge, others have found that scientific knowledge is by no means the preeminent source of knowledge within the dynamic settings of health-care. We argue that the contexts within which evidence-based innovations are implemented are as influential in the outcomes as the individual practitioners who attempt these changes. A focused ethnography was done in follow-up to an earlier trial that evaluated the effectiveness of a marketing strategy to encourage the adoption of evidence-based intrapartum nursing practice. Bourdieu's (1990, 1991) concepts of habitus, capital and social field were used in our refinement of the analysis of the ethnographic findings. Nursing leadership, interprofessional struggle with physicians, the characteristics of the community and the physical environment were prominent issues at all of the sites. Detailed descriptions of the sociohistorical context and of the experiences at two sites are presented to illustrate the complexities encountered when implementing innovations.

Media portrayal of nurses' perspectives and concerns in the SARS crisis in Toronto

Purpose: To describe nursing work life issues as portrayed in the media during the SARS crisis in Toronto.

Methods: Content analysis of local and national news media documents in Canada. Media articles were sorted and classified by topic, and themes were identified.

Findings: Themes were: (a) changing schemas of nursing practice: the new normal; (b) barriers to relational nursing work; (c) work life concerns: retention and recruitment; (d) nursing virtue: nurses as heroes and professionals; (e) paradoxical responses to nurses from the community; and (f) leadership in nursing during the SARS crisis.

Conclusions: This analysis enhanced understanding of how nurses are portrayed in the media, but it indicated the significance of quality of work life and issues about work‐home life. Some descriptions of the care and caring of nurses have made nursing seem like an important and influential profession to potential applicants who might previously have dismissed nursing as a career.

Emergency nurse practitioners: a three part study in clinical and cost effectiveness

AIMS

To compare the clinical effectiveness and costs of minor injury services provided by nurse practitioners with minor injury care provided by an accident and emergency (A&E) department.

METHODS

A three part prospective study in a city where an A&E department was closing and being replaced by a nurse led minor injury unit (MIU). The first part of the study took a sample of patients attending the A&E department. The second part of the study was a sample of patients from a nurse led MIU that had replaced the A&E department. In each of these samples the clinical effectiveness was judged by comparing the "gold standard" of a research assessment with the clinical assessment. Primary outcome measures were the number of errors in clinical assessment, treatment, and disposal. The third part of the study used routine data whose collection had been prospectively configured to assess the costs and cost consequences of both models of care.

RESULTS

The minor injury unit produced a safe service where the total package of care was equal to or in some cases better than the A&E care. Significant process errors were made in 191 of 1447 (13.2%) patients treated by medical staff in the A&E department and 126 of 1313 (9.6%) of patients treated by nurse practitioners in the MIU. Very significant errors were rare (one error). Waiting times were much better at the MIU (mean MIU 19 minutes, A&E department 56.4 minutes). The revenue costs were greater in the MIU (MIU pound 41.1, A&E department pound 40.01) and there was a great difference in the rates of follow up and with the nurses referring 47% of patients for follow up and the A&E department referring only 27%. Thus the costs and cost consequences were greater for MIU care compared with A&E care (MIU pound 12.7 per minor injury case, A&E department pound 9.66 per minor injury case).

CONCLUSION

A nurse practitioner minor injury service can provide a safe and effective service for the treatment of minor injury. However, the costs of such a service are greater and there seems to be an increased use of outpatient services.

Home is where their wheels are: experiences of women wheelchair users

This paper examines the experiences of mothers who are wheelchair users in their roles of homemaking and parenting. A qualitative study using in-depth, focused interviews was conducted with a purposeful sample of 11 women with various physical disabilities. Three major themes were uncovered in the data: (a) lived space restricting personal autonomy, (b) advocacy strategies to secure appropriate housing, and (c) my wheelchair, my liberator, my sense of comfort. Findings from this study showed that women did not have the freedom or economic resources to seek out new living arrangements or make modifications to existing environments. Lack of space, stairs, difficult-to-reach spaces, poor transportation, and limited community access were barriers that women experienced. The study also points to the importance of recognizing that the women used many strategies to regain control over aspects of their environment to enable greater autonomy and participation for themselves. Sensitivity to the meaning of home and the relationship between the body and the environmental features that surround it may be a significant contribution of the clinician as he or she seeks to assist women wheelchair users.

The material and social predicaments of home: women's experiences after aortocoronary bypass surgery

Several authors argue that women's lives are conditioned by social locations such as class, race, ethnicity, age, and chronic illness or (dis)ability. Patterns of advantage and disadvantage, domination and oppression are formed which constitute the groundwork of women's health. An institutional ethnography was designed to follow the experiences of 18 women on their return home following aortocoronary bypass surgery. Using the narratives of 3 women as examples, the author highlights the everyday activities pursued by the women in the first month after their return home. The author describes the circumstances under which the activities occurred and discusses the social relations reflected in the descriptions. From this analysis it is argued that research and substantive work would benefit from a more critical understanding of women's different experiences of the home and of home care.

Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial

BACKGROUND

We aimed to assess the care and outcome of patients with minor injuries who were managed by a nurse practitioner or a junior doctor in our accident and emergency department.

METHODS

1453 eligible patients, over age 16 years, who presented at our department with minor injuries were randomly assigned care by a nurse practitioner (n=704) or by a junior doctor (n=749). Each patient was first assessed by the nurse practitioner or junior doctor who did a clinical assessment; the assessments were transcribed afterwards to maintain masked conditions. Patients were then assessed by an experienced accident and emergency physician (research registrar) who completed a research assessment, but took no part in the clinical management of the patient. A standard form was used to compare the clinical assessment of the nurse practitioner or junior doctor with the assessment of the research registrar. The primary outcome measure was the adequacy of care (history taking, examination of patient, interpretation of radiographs, treatment decision, advice, and follow-up).

FINDINGS

Compared with the rigorous standard of the experienced accident and emergency research registrar, nurse practitioners and junior doctors made clinically important errors in 65 (9.2%) of 704 patients and in 80 (10.7%) of 749 patients, respectively. This difference was not significant. The nurse practitioners were better than junior doctors at recording medical history and fewer patients seen by a nurse practitioner had to seek unplanned follow-up advice about their injury. There were no significant differences between nurse practitioners and junior doctors in the accuracy of examination, adequacy of treatment, planned follow-up, or requests for radiography. Interpretation of radiographs was similar in the two groups.

INTERPRETATION

Properly trained accident and emergency nurse practitioners, who work within agreed guidelines can provide care for patients with minor injuries that is equal or in some ways better than that provided by junior doctors.

Suspected myocardial infarction and left bundle branch block: electrocardiographic indicators of acute ischaemia

OBJECTIVES

To examine the use of thrombolytic treatment in patients with suspected acute myocardial infarction (AMI) and left bundle branch block (LBBB). To evaluate electrocardiographic criteria for the identification of AMI in the presence of LBBB, and examine the implications of using these criteria in the clinical setting.

METHODS

A retrospective study over two years, based in two Sheffield teaching hospitals. Patients presenting with LBBB and suspected AMI were studied by analysis of an AMI database. The proportion of patients with LBBB and AMI receiving thrombolysis, and the in-hospital delay before the start of treatment, were used as indicators of current performance. Three predictive criteria were applied to the electrocardiograms (ECGs) retrospectively, and their ability to identify acute ischaemic change assessed. The implications of using the predictive criteria in the clinical setting were explored.

RESULT

Twenty three per cent (5/22) of patients with LBBB and AMI did not receive thrombolysis, in the absence of documented contraindications. The mean in-hospital treatment delay for thrombolysed patients was 154 minutes. Forty eight per cent (16/33) of those thrombolysed did not have a final clinical diagnosis of AMI. In the majority of cases (8/12), the decision not to administer thrombolysis was based on a single ECG recording. The presence of any of the predictive electrocardiographic criteria was associated with a diagnosis of AMI, with a sensitivity of 0.79 (95% confidence interval 0.63 to 0.95), specificity 1, positive predictive value 1, and negative predictive value 0.79. The kappa scores between four independent observers showed either substantial or near perfect agreement.

CONCLUSION

Currently, thrombolytic treatment is under-utilised in patients with LBBB and AMI, and those who are thrombolysed endure lengthy delays before treatment. Patients with any of the predictive criteria should be thrombolysed immediately. When the diagnosis is in doubt, serial ECGs may demonstrate evolving ischaemic change.

Women and recovery from myocardial infarction and coronary artery bypass surgery, Part I: The everyday activities of Canadian women

As the first of two articles dealing with women's recovery from cardiac events, this paper describes the everyday lives and activities of Canadian women. The concept of women's work is expanded to include only the instrumental tasks of household chores, but also the functions of emotional support and caregiving that are central to many aspects of women's family centered activities. The challenges faced by the increasing numbers of women who combined paid employment with family responsibilities are also discussed. It is argued that following cardiac events such as myocardial infarction and coronary artery bypass surgery, many women face the challenge of recognizing their health behaviours in a social context that does not facilitate optimal recovery. A subsequent article builds on this description to analyze issues in the cardiovascular literature.

Women and recovery from myocardial infarction and coronary artery bypass surgery, Part II: A review of the cardiovascular literature

As the second of two articles dealing with women's recovery from myocardial infarction and coronary artery bypass surgery, this paper builds on a description of the everyday activities of Canadian women. The challenges faced by women as they recover are highlighted in the analysis of the existing cardiovascular research literature. Several issues are identified in this knowledge base and suggestions for future research and practice are discussed.

Reactivity of endothelin-1 on human and canine large veins compared with large arteries in vitro

In comparison with snake venom sarafotoxins S6, the novel, 21-amino acid peptide, endothelin may have selective coronary artery vasoconstrictor actions. We examined endothelin-1 (ET-1) in vitro in five pairs of large arteries and veins from the greyhound dog; (coronary, internal mammary, mesenteric, renal and femoral) as well as the human forearm vein and internal mammary artery and vein. ET-1 caused concentration-dependent, tonic contractions in each pair of vessels, with EC50s significantly lower (5-10 times more sensitive) in each vein compared with the corresponding artery. The coronary artery did not show selective sensitivity to ET-1. For all veins the maximal contraction to ET-1 was approximately 100% that of the maximal contraction (Fmax) achieved with K+ depolarization. In the arteries, however, the Fmax for ET-1 ranged from only 25 to 80% of K+. The contraction responses to ET-1 in all arteries and veins were well maintained after repeated washing with ET-1-free medium. In the dog coronary artery the contraction curve to ET-1 (0.1-30 nM) was endothelium-independent. At the higher concentrations (10-100 nM), however, the peptide often induced transient, endothelium-dependent relaxations prior to the development of the tonic contractions. These results demonstrate that ET-1 is a more potent and efficacious constrictor of large veins than arteries and at high concentrations can release endothelium-derived relaxing factor-like activity from large arteries.

Butter-enriched diets reduce arterial prostacyclin production in rats

Rats were fed diets containing 10%, 30% or 50% energy as fat derived predominantly from butter or lard. The protein content of the diets was maintained at 20%. After three weeks on the diets, the rats were killed and the following parameters measured: prostacyclin production in vitro from abdominal aorta and mesenteric artery; platelet aggregation to ADP and thrombin; fatty acid composition of the phospholipids in plasma, thoracic aorta and liver; smooth muscle reactivity and release of endothelial derived relaxing factor (EDRF) from aortic endothelium stimulated by acetylcholine. There was no significant effect of increasing fat content of the diets (neither lard nor butter) on platelet aggregation. In contrast, prostacyclin production in both the mesenteric artery and the abdominal aorta fell in a concentration-dependent manner in the butter-supplemented rats. However, no effect on prostacyclin production was detected in arteries from the lard-supplemented animals. The effects of the diets on prostacyclin (PGI2) production correlated very well with the changes in plasma, aortic and liver phospholipid arachidonic acid (AA) and eicosapentaenoic acid (EPA) contents. AA decreased in a concentration-dependent manner in the rats fed the butter-enriched diets but did not change in those fed the lard-enriched diets, whereas EPA rose in a concentration-dependent manner in the butter-fed rats and was unchanged in the lard-fed animals. The clear-cut effects of the butter-enriched diets on aortic phospholipid fatty acid composition and aortic PGI2 production were accompanied by a significant reduction in smooth muscle relaxation to EDRF.(ABSTRACT TRUNCATED AT 250 WORDS)