Unpacking the nudge muddle

Libertarian paternalism initially focused on policy domains in which the state was prohibited from interfering coercively in decision making out of respect for individual autonomy. Because adjustment of the s-frame was not an option, achieving better outcomes through manipulation of the i-frame seemed attractive. This original motivation was unfortunately lost in the transition from libertarian paternalism to the nudge framework.

The impact of flash glucose monitoring on adults with type 1 Diabetes' eating habits and relationship with food

AIM

To gain a better understanding of how the FreeStyle Libre (FSL) flash glucose monitor influences the eating habits and relationship with food of adults with type 1 diabetes (T1D).

METHODS

Reflexive thematic analysis was conducted on fifteen semi-structured interviews conducted with adults with T1D, exploring their experiences of at least one year of FSL use.

RESULTS

Four themes were constructed from the qualitative data: (1) Personal Food Story (what food represented before and after diabetes diagnosis), (2) New Opportunities (the FSL offered novel discoveries and increased self-confidence regarding food choices), (3) Body as a Machine (participants viewed their bodies as a collection of complex processes requiring continuous maintenance), and (4) re-evaluating Diabetes (participants expressed a shift in their expectations of themselves and their diabetes management). Although the FSL offered participants more freedom and flexibility with their eating, this was constrained by feeling forever under scrutiny from the data.

CONCLUSIONS

Findings suggest the FSL influences users' eating habits, including when, why, what and how much they eat. Participants described both the positive and negative impact of these changes on their emotional wellbeing and relationship with diabetes, arguing for a need to address patients' relationship with food in routine clinic care.

Ethical Issues in Physician Billing Under Fee-For-Service Plans

Medical ethics has become an important and recognized component of physician training. There is one area, however, in which medical students receive little guidance. There is practically no discussion of the financial aspects of medical practice. My objective in this paper is to initiate a discussion about the moral dimension of physician billing practices. I argue that physicians should expand their conception of professional responsibility in order to recognize that their moral obligations toward patients include a commitment to honest and forthright billing practices. I argue that physicians should aspire to a standard of clinical accuracy-not legal adequacy-in describing their activities. More generally, physicians should strive to promote an integrity-based professional culture, first and foremost by stigmatizing rather than celebrating creative billing practices, as well as condemning the misguided sense of solidarity that currently makes it taboo for physicians to criticize each other on this score.

An ethical framework for global vaccine allocation

The Fair Priority Model offers a practical way to fulfill pledges to distribute vaccines fairly and equitably

Falling through the gap: Dental treatment experiences of patients affected by cleft lip and/or palate

Introduction

In the UK, one in 600–700 infants is born with a cleft lip and/or palate (CL/P). Previous research has identified patients with CL/P to be at high risk of long-term oral health issues. Yet, few of these patients are currently accessing community dental care.

Aims

To assess patients' dental treatment experiences and their suggestions for improving services.

Materials and methods

Five focus groups were conducted with 24 adults with CL/P. Thematic analysis was performed on the data.

Results

Participants perceived local dental practitioners to lack knowledge about CL/P and its treatment. Consequently, some participants had stopped visiting a dental practice altogether. Participants were also largely unaware of the specialist CL/P services they are entitled to.

Discussion

Suggestions are made for the integration of improved training and resources for local dental practitioners. Closer communication between specialist cleft teams and local dental practitioners could also help to bridge the gap in knowledge and improve patients' engagement with dental services. The tertiary sector has a crucial role to play in empowering patients to take more control of their oral health and dental treatment.

On the Scope of Egalitarian Justice

It is not clear whether the social contract is supposed to merely supplement the unequal gains that individuals are able to make through the exercise of their natural endowments with a set of equal gains secured through social cooperation, or whether the social contract must also compensate individuals for the effects of these natural inequalities, so that they literally become all equal. The issue concerns, in effect, whether natural inequality falls within the scope of egalitarian justice. I think it is fair to say that the majority of egalitarians assume that the principle of equality imposes an obligation to redress natural inequality. Yet there is no consensus on this issue. David Gauthier has made the rejection of the principle of redress a central component of his project. It has often escaped notice that John Rawls also rejects the principle of redress. Thus it is not just anti-egalitarians who reject the principle of redress. There is a current of egalitarian thought – which we might call, for lack of a better term, narrow-scope egalitarianism – which also rejects this principle. In this paper, I would like to show that there is considerable wisdom in the narrow-scope egalitarian position. Many of the problems that lead theorists to reject egalitarianism in its entirety are a consequence, not of the principle of equality per se, but rather of the commitment to redress natural inequality. The narrow-scope view avoids all of these difficulties.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Seasonal Influenza Vaccination amongst Medical Students: A Social Network Analysis Based on a Cross-Sectional Study

Introduction

The Chief Medical Officer for England recommends that healthcare workers have a seasonal influenza vaccination in an attempt to protect both patients and NHS staff. Despite this, many healthcare workers do not have a seasonal influenza vaccination. Social network analysis is a well-established research approach that looks at individuals in the context of their social connections. We examine the effects of social networks on influenza vaccination decision and disease dynamics.

Methods

We used a social network analysis approach to look at vaccination distribution within the network of the Lancaster Medical School students and combined these data with the students’ beliefs about vaccination behaviours. We then developed a model which simulated influenza outbreaks to study the effects of preferentially vaccinating individuals within this network.

Results

Of the 253 eligible students, 217 (86%) provided relational data, and 65% of responders had received a seasonal influenza vaccination. Students who were vaccinated were more likely to think other medical students were vaccinated. However, there was no clustering of vaccinated individuals within the medical student social network. The influenza simulation model demonstrated that vaccination of well-connected individuals may have a disproportional effect on disease dynamics.

Conclusions

This medical student population exhibited vaccination coverage levels similar to those seen in other healthcare groups but below recommendations. However, in this population, a lack of vaccination clustering might provide natural protection from influenza outbreaks. An individual student’s perception of the vaccination coverage amongst their peers appears to correlate with their own decision to vaccinate, but the directionality of this relationship is not clear. When looking at the spread of disease within a population it is important to include social structures alongside vaccination data. Social networks influence disease epidemiology and vaccination campaigns designed with information from social networks could be a future target for policy makers.

An inpatient observation and comparison of the bennett's I.p.p.R. And aerosol methods of administering salbutamol

Compared with aerosol administration the Bennett's Intermittent Positive Pressure Respirator (I.P.P.R.) has been the most favoured method of Salbutamol administration in hospitals for the treatment of asthma or Chronic Obstructive Airways Disease (C.O.A.D.).

The effects of short wave diathermy, microwave and ultra sonics on demand pacemakers and ventrical inhibited pacemakers

In 1971 tests were performed by Mrs. D. Bieri, Mrs. J. Heath of the School of Physio-therapy, New South Wales, and Dr. S. Hunyor of the Pacemaker Clinic, Royal Prince Alfred Hospital. Until this time there was no theory regarding diathermy on patients with implanted pacemakers.

An exploratory randomized controlled trial comparing telephone and hospital follow-up after treatment for colorectal cancer

AIM

Following treatment for colorectal cancer it is common practice for patients to attend hospital clinics at regular intervals for routine monitoring, although debate persists on the benefits of this approach. Nurse-led telephone follow-up is effective in meeting information and psycho-social needs in other patient groups. We explored the potential benefits of nurse-led telephone follow-up for colorectal cancer patients.

METHOD

Sixty-five patients were randomized to either telephone or hospital follow-up in an exploratory randomized trial.

RESULTS

The telephone intervention was deliverable in clinical practice and acceptable to patients and health professionals. Seventy-five per cent of eligible patients agreed to randomization. High levels of satisfaction were evident in both study groups. Appointments in the hospital group were shorter (median 14.0 min, range 2.3-58.0) than appointments in the telephone group (median 28.9 min, range 6.1-48.3). Patients in the telephone arm were more likely to raise concerns during consultations.

CONCLUSION

Historical approaches to follow-up unsupported by evidence of effectiveness and efficiency are not sustainable. Telephone follow-up by specialist nurses may be a feasible option. A main trial comparing hospital and telephone follow-up is justified, although consideration needs to be given to trial design and practical issues related to the availability of specialist nurses at study locations.

Eosinophilic infiltration of the esophagus following endoscopic ablation of Barrett's neoplasia

To assess the incidence of esophageal intra-epithelial eosinophilic infiltration following endoscopic ablation of Barrett's esophagus (BE), a retrospective study of consecutive cases of endoscopic ablation of BE with dysplasia or cancer using radiofrequency ablation (RFA) and spray cryotherapy at two centers in the United States was performed. Post-ablation eosinophilia was defined as ≥ 5 eosinophils per high power field during post-treatment surveillance. Twenty of 122 patients (16%) undergoing ablation developed esophageal eosinophilia after ablation, including 8/77 (10%) treated with RFA and 12/44 (27%) treated with cryotherapy. No patient had clinical or endoscopic findings of or risk factors for eosinophilic esophagitis. Esophageal eosinophilia persisted in 30% over a median of 20.2 months. On multivariate analysis, post-ablation eosinophilia was independently associated with increasing BE segment length (adjusted odds ratio 1.46 for every 2-cm increase, 95% confidence interval 1.24-1.71) and cryotherapy as the ablation modality (adjusted odds ratio 5.23, 95% confidence interval 1.67-16.39). Esophageal eosinophilic infiltration after endoscopic ablation with RFA and cryotherapy is common and is associated with the BE segment length and treatment modality. The clinical significance of post-ablation eosinophilia is unclear.

Vision screening in children by Plusoptix Vision Screener compared with gold-standard orthoptic assessment

BACKGROUND/AIMS

To evaluate a new autorefractor, the Plusoptix Vision Screener (PVS), as a screening tool to detect risk factors for amblyopia by comparing it with gold-standard orthoptic vision screening in children.

METHODS

Community-based screening study including 288 children age 4-7 years who were screened with the PVS and by orthoptic assessment (distance acuity, cover test, extraocular movements, 20 PD prism test, Lang stereotest). Follow-up comprehensive eye examination of screening-positive children included manual cycloplegic retinoscopy.

RESULTS

Testability was high for both methods. Orthoptic screening identified 36 children with reduced vision and/or factors associated with amblyopia (referral rate 12.5%). The PVS identified 16 children with potential vision problems (referral rate 5.6%), indicating only moderate sensitivity (44%; 95% CI 27.9 to 61.9%), but high specificity (100%; 95% CI 98.5 to 100%) to detect factors associated with amblyopia. The PVS underestimated visually significant refractive errors.

CONCLUSIONS

Use of the PVS as single screening test in young children may miss a significant number of children with amblyopia or amblyogenic risk factors.

Plusoptix Vision Screener: the accuracy and repeatability of refractive measurements using a new autorefractor

BACKGROUND

The Plusoptix Vision Screener (PVS) is a new non-cycloplegic videoretinoscopy autorefractor. Refractive accuracy may affect its performance as a screening tool.

AIMS

Study 1: To determine the intra- and interobserver variability of PVS measurements. Study 2: To compare PVS measurements with gold-standard manual cycloplegic retinoscopy (MCR).

METHODS

Study 1: PVS refraction of 103 children with mean (SD) age 5.5 (0.6) years by two observers. Study 2: PVS and MCR refraction of 126 children with mean (SD) age 5.5 (1.5) years, including 43 children with manifest strabismus >/=5 PD, comparing mean spherical equivalent (MSE) and Jackson cross cylinders J(0) and J(45).

RESULTS

Study 1: Repeatability coefficients (observer 1): MSE: 0.63 D, J(0): 0.24 D, J(45): 0.18 D; those of observer 2 were nearly identical. The mean difference (95% limits of agreement) between the two observers for MSE, J(0) and J(45) were, respectively, 0.03 (-0.62 to 0.68 D), -0.008 (-0.25 to 0.23 D) and 0.013 (-0.18 to 0.20) D. Study 2: MSE tended to be lower on PVS than MCR, with differences of up to 8.00 D. Less than 20% of values were within +/-0.50 D of each other. Agreement was better for J(0) and J(45). Strabismus was associated with an odds ratio of 3.7 (95% CI 1.3 to 10.5) of the PVS failing to obtain a reading.

CONCLUSIONS

The PVS may underestimate children's refractive error.

Pre-operative DTI and probabilisitic tractography in four patients with deep brain stimulation for chronic pain

This study aimed to examine, using diffusion tensor imaging (DTI), differences in electrode placement in four patients undergoing deep brain stimulation for chronic neuropathic pain of varying aetiology. A pre-operative DTI was obtained for each patient, who was then implanted with deep brain stimulation electrodes in the periventricular/periaqueductal grey area with good pain relief. Using seeds from the postoperative MRI scan, probabilistic tractography was performed from the pre-operative DTI.

Preoperative DTI and probabilistic tractography in an amputee with deep brain stimulation for lower limb stump pain

This study aimed to find out whether preoperative diffusion tensor imaging (DTI) and probabilistic tractography could help with surgical planning for deep brain stimulation in the periaqueductal/periventricular grey area (PAG/PVG) in a patient with lower leg stump pain. A preoperative DTI was obtained from the patient, who then received DBS surgery in the PAG/PVG area with good pain relief. The postoperative MRI scan showing electrode placement was used to calculate four seed areas to represent the contacts on the Medtronic 3387 electrode. Probabilistic tractography was then performed from the pre-operative DTI image. Tracts were seen to connect to many areas within the pain network from the four different contacts. These initial findings suggest that preoperative DTI scanning and probabilistic tractography may be able to assist surgical planning in the future.

Providing a community-based cancer risk assessment service for a socially and ethnically diverse population

BACKGROUND

Patients from ethnic minorities are under-represented in referrals to cancer genetics services. In a regional genetics centre that serves two London boroughs, the existing service attracts 3% of its referrals from Black and Minority Ethnic (BME) and other ethnic groups, despite the fact that these groups make up 34% of the population.

OBJECTIVES

To improve access to familial cancer risk assessment in a socially and ethnically diverse population.

SETTING

The London boroughs of Lambeth and Southwark.

DESIGN

Community-based, nurse-led clinics were established for people who were concerned about their familial cancer risk. Patients were asked to triage themselves by answering three questions. Self-referral was encouraged.

MAIN OUTCOME MEASURES

Data were gathered on ethnicity of clients, cancer risk, source of referral and patient and health professional satisfaction with the service.

RESULTS

Of the 415 people who have accessed the service, 46% were from not White British groups and 67% referred themselves to the service, demonstrating the success of this model in reaching 'hard to reach' groups. Thirty-seven percent of patients were assessed as being at population risk and 63% were assessed as being at moderate risk or higher, showing that the clinics were meeting an unmet need in the community.

Nicotine improves memory for delayed intentions

RATIONALE

The present paper asked first whether the cholinergic agonist nicotine improves memory for delayed intentions (prospective memory, ProM) and second whether pharmacological dissociation would support the psychological distinction that is made between strategic (effortful) and automatic (non-effortful) intention activation in prospective memory.

OBJECTIVES

To use nicotine as a pharmacological tool with which to examine the neurochemical bases of prospective memory and to dissociate strategic from automatic components of ProM retrieval.

METHODS

In three experiments, minimally deprived (2 h) smokers either smoked or abstained prior to completing a standard prospective memory study. This involved participants in the simultaneous processing of a ProM task and a cover task (ongoing between the setting and the recall of the intention). Here, the ongoing task involved lexical decision (LDT), while the ProM task required a response to pre-specified target items occurring within the LDT stimuli. Variations in task instructions were used to manipulate the processing requirements of the ProM task, the attention allocated to the ProM task and the balance of importance assigned to the ongoing and ProM tasks.

RESULTS

In experiment 1, where the ProM processing was automatic, nicotine did not improve ProM accuracy. In experiment 2, where the ProM task involved strategic processing, positive effects of nicotine were observed. In experiment 3, we covaried ProM task instructions, assigned task importance and nicotine conditions. We observed a main effect of nicotine on ProM accuracy, a main effect of task on ProM accuracy and a main effect of assigned task importance on ProM accuracy. There were no interactions between the factors.

CONCLUSIONS

Employing both direct and indirect manipulations of strategic engagement, we demonstrated nicotine-induced enhancement of performance on the ProM task. The results are consistent with the view that relatively small changes in instruction and in task variables engage strategic processing in a ProM task and that when these conditions stretch cognitive resources, nicotine may significantly improve performance.

Women and the global tobacco epidemic: nurses call to action

BACKGROUND

Tobacco consumption is increasing among women across the globe at alarming rates. Without effective intervention, the smoking prevalence among women will nearly triple over the next generation. These trends are potentially more threatening when considering how tobacco intersects women's lives, regardless if they use tobacco products or not.

AIM

A review and analysis of the literature is conducted to examine the scope of tobacco's global effect on the multiple dimensions of women's health.

METHOD

Medline (1990-2003), Cumulative Index to Nursing and Allied Health Literature (1990-2003) and World Health Organization databases were searched for related topics. Keywords for searches included global health, tobacco, women and nursing.

FINDINGS

The epidemiology and prevalence of tobacco use among women are presented and its impact on women globally. Using an ecological perspective, the consequences of tobacco are analysed within the contexts of health, social, environment, economic and policy as it relates to women, their families and their communities.

IMPLICATIONS

Nurses are in prime positions to empower individuals, families, communities and nations in the prevention and treatment of tobacco use. Health for all women continues to be a call for equity and social justice. Recommendations are provided for nursing practice, education, theory, research and policy to address this global health concern.

Analysis of CO2 leakage through ‘low-permeability’ faults from natural reservoirs in the Colorado Plateau, east-central Utah

The numerous CO2 reservoirs in the Colorado Plateau region of the United States are natural analogues for potential geological CO2 sequestration repositories. To understand better the risk of leakage from reservoirs used for long-term underground CO2 storage, we examine evidence for CO2 migration along two normal faults that cut a reservoir in east-central Utah. CO2-charged springs, geysers, and a hydrocarbon seep are localized along these faults. These include natural springs that have been active for long periods of time, and springs that were induced by recent drilling. The CO2-charged spring waters have deposited travertine mounds and carbonate veins. The faults cut siltstones, shales, and sandstones and the fault rocks are fine-grained, clay-rich gouge, generally thought to be barriers to fluid flow. The geological and geochemical data are consistent with these faults being conduits for CO2 moving to the surface. Consequently, the injection of CO2 into faulted geological reservoirs, including faults with clay gouge, must be carefully designed and monitored to avoid slow seepage or fast rupture to the biosphere.

Activation of human matrix metalloproteinase 2 by gingival crevicular fluid and Porphyromonas gingivalis

AIM

To assess the potential of gingival crevicular fluid (GCF) from adult periodontitis patients and Porphyromonas gingivalis proteases to activate matrix metalloproteinase 2 (MMP-2) in vitro.

MATERIAL AND METHODS

GCF samples were collected from each of 15 adult periodontitis patients, from a clinically healthy site, a deep (>6 mm) bleeding site, and a deep nonbleeding site. The GCF samples were examined for general proteolytic activity, gelatinolytic activity and ability to activate pro-MMP-2 by zymography. Ultrasonic extracts of a range of clinical isolates of P. gingivalis cells and purified arg- and lys-gingipains were also assessed for their ability to activate pro-MMP-2.

RESULTS

GCF from deep nonbleeding sites showed higher general proteolytic activity than samples from deep bleeding and healthy sites but this did not reach statistical significance. Pefabloc, a general serine protease inhibitor, inhibited the majority (92%) of the proteolytic activity. GCF samples contained neutrophil MMP-9 in its latent form in 93% of the samples, and in its activated form in 40% of the samples. In contrast, MMP-2 was present in only trace amounts in 9% of the samples. When latent MMP-2 was added to these GCF samples, it was converted to the activated form (59 kDa) in 68% of the samples. Lower molecular weight (55 and 45 kDa) activated forms also appeared in 53% of the samples, particularly those from deep sites. Activation to the 55 and 45 kDa forms was inhibited by MSAAPket (a neutrophil elastase inhibitor), whereas Pefabloc completely inhibited the activation of latent MMP-2. All ultrasonic extracts of P. gingivalis activated latent MMP-2 in a concentration- and time-dependent manner. Also, latent MMP-2 was activated by purified arg-gingipain but less efficiently by lys-gingipain.

CONCLUSION

These findings suggest that P. gingivalis arg-gingipain and neutrophil elastase present in GCF can activate latent MMP-2, which may contribute in vivo to local periodontal tissue destruction.

Building capacity of the Baltic States to meet the EU Water Framework Directive through watershed demonstration projects

The Ohio River Valley Water Sanitation Commission (ORSANCO), in cooperation with the United States EPA, is completing it role in assisting the Baltic Countries of Estonia, Latvia, Lithuania and Kaliningrad Oblast, Russia with watershed management capacity building demonstration projects under the Great Lakes/Baltic Sea Partnership Program. The Countries of Estonia, Latvia and Lithuania view the skills gained through this program as important to their objective of complying with the European Union's Water Framework Directive and thus facilitating accession into the European Union. The program also addressed Kaliningrad's desire to work cooperatively with their neighboring countries concerning shared waters. Three watershed demonstration projects were designed and implemented, two of which involved joint country efforts: Parnu River (Estonia) modeling for nutrients and bacteria survey; river basin assessment and management planning for the Lielupe Basin (Latvia and Lithuania); and data base development and cooperative water quality survey and analysis for the Sesupe River (Lithuania and Kaliningrad). The benefits of the projects include enhancing the country's technical skills and the forging of relationships, without which achieving effective watershed management will be difficult to achieve.

Evaluation of an early two-dose measles vaccination schedule

Vaccination at 6 months of age followed by routine revaccination is recommended when exposure of infants to measles is likely. Dade County, Florida, began this early two-dose schedule during a large epidemic in 1986-1987 (i.e., 22% of cases occurred in infants aged 6-11 months). This schedule was continued routinely in high-risk areas. The effect of an early two-dose schedule on measles prevention in the county was examined by comparing measles vaccination coverage and epidemiology before (1985-1987) and after (1988-1996) the schedule became routine. To assess serologic response, seroprevalence of measles antibody among children aged 4-6 years in 1995 was examined. To evaluate vaccine effectiveness, a case-control study was conducted among preschool-aged children. Among those aged 2 years, vaccination coverage with > or =1 dose increased from 75% to 94% in 1996. The number of annual cases declined, and endemic measles transmission reportedly ended after 1993. Seroprevalence of plaque reduction neutralization antibody (titer > 1:120) among those receiving vaccination according to an early two-dose schedule and a single dose at age > or =12 months was 94% (95% confidence interval: 89, 98) and 98% (95% confidence interval: 95, 100). In these groups, vaccine effectiveness was comparably high. Early two-dose measles vaccination is associated with improved coverage and a comparably high level of humoral immunity and clinical protection as a single dose at age > or =12 months. This strategy can be useful in areas at high risk for measles among infants.

Discovery of potent and selective peptide agonists at the GRP-preferring bombesin receptor (BB2)

Analogues of the nonselective bombesin receptor synthetic agonist H-D-Phe-Gln-Trp-Ala-Val-betaAla-His-Phe-Nle-NH2 were prepared and their biological activity assessed at the NMB-preferring/bombesin receptor (NMB-R: BB1), the GRP-preferring/bombesin receptor (GRP-R: BB2) and the orphan receptor bombesin receptor subtype-3 (BRS-3; BB3). Progressive N-terminal deletions identified the minimum C-terminal sequences required for maintaining a significant agonist effect, whilst an alanine scan, targeted changes in stereochemistry and other pertinent substitutions identified key side-chain and stereochemical requirements for activation. Key structural elements required for functional potency at BB1 BB2 and BB3, and for selectivity between these receptor subtypes were established. Synthetic peptides were discovered. which were highly potent agonists at BB2 and extremely selective over both BB1 and BB3.

Spirocyclic nonpeptide glycoprotein IIb-IIIa antagonists. Part 1: design of potent and specific 3,9-diazaspiro[5.5]undecanes

The synthesis and biological activity of novel glycoprotein IIb-IIla antagonists containing the 3,9-diazaspiro[5.5]undecane nucleus are described. The potent activity of these compounds as platelet aggregation inhibitors demonstrates the utility of the spirocyclic structures as a central template for nonpeptide RGD mimics.

Spirocyclic nonpeptide glycoprotein IIb-IIIa antagonists. Part 2: design of potent antagonists containing the 3-azaspiro[5.5]undecanes

The synthesis and biological activity of novel glycoprotein IIb-IlIa anatagonists containing 3-azaspiro[5.5]undec-9-yl nucleus are described. The potent activity of these compounds as platelet aggregation inhibitors demonstrates the utility of the monoazaspirocyclic structure as central template for nonpeptide RGD mimics.

Utilization of an elastomeric continuous infusion device to maintain catheter patency

The frequency of vascular access device (VAD) complications increases with the complexity of therapy or poor catheter maintenance. Catheter occlusions are most frequently caused by inadequate catheter flushing or technique. The study group of 25 patients was placed on an elastomeric continuous infusion device with patient costs and occlusion rates compared with historic data. The use of the elastomeric continuous infusion device saved an average of $123 per week when compared with traditional flushing devices, which cost from $216 to $248 per week. The incidence of catheter patency loss was reduced by 50%. The nurses also reported considerable timesaving in catheter maintenance and patient education and an overwhelmingly positive response from staff and patients.

Hyaluronidase induction of a WW domain-containing oxidoreductase that enhances tumor necrosis factor cytotoxicity

To determine how hyaluronidase increases certain cancer cell sensitivity to tumor necrosis factor (TNF) cytotoxicity, we report here the isolation and characterization of a hyaluronidase-induced murine WW domain-containing oxidoreductase (WOX1). WOX1 is composed of two N-terminal WW domains, a nuclear localization sequence, and a C-terminal alcohol dehydrogenase (ADH) domain. WOX1 is mainly located in the mitochondria, and the mitochondrial targeting sequence was mapped within the ADH domain. Induction of mitochondrial permeability transition by TNF, staurosporine, and atractyloside resulted in WOX1 release from mitochondria and subsequent nuclear translocation. TNF-mediated WOX1 nuclear translocation occurred shortly after that of nuclear factor-kappaB nuclear translocation, whereas both were independent events. WOX1 enhanced TNF cytotoxicity in L929 cells via its WW and ADH domains as determined using stable cell transfectants. In parallel with this observation, WOX1 also enhanced TRADD (TNF receptor-associated death domain protein)-mediated cell death in transient expression experiments. Antisense expression of WOX1 raised TNF resistance in L929 cells. Enhancement of TNF cytotoxicity by WOX1 is due, in part, to its significant down-regulation of the apoptosis inhibitors Bcl-2 and Bcl-x(L) (>85%), but up-regulation of pro-apoptotic p53 ( approximately 200%) by the ADH domain. When overexpressed, the ADH domain mediated apoptosis, probably due to modulation of expression of these proteins. The WW domains failed to modulate the expression of these proteins, but sensitized COS-7 cells to TNF killing and mediated apoptosis in various cancer cells independently of caspases. Transient cotransfection of cells with both p53 and WOX1 induced apoptosis in a synergistic manner. WOX1 colocalizes with p53 in the cytosol and binds to the proline-rich region of p53 via its WW domains. Blocking of WOX1 expression by antisense mRNA abolished p53 apoptosis. Thus, WOX1 is a mitochondrial apoptogenic protein and an essential partner of p53 in cell death.

A new method for generating point mutations in bacterial artificial chromosomes by homologous recombination in Escherichia coli

Bacterial artificial chromosomes (BACs) and P1 artificial chromosomes (PACs), which contain large fragments of genomic DNA, have been successfully used as transgenes to create mouse models of dose-dependent diseases. They are also potentially valuable as transgenes for dominant diseases given that point mutations and/or small rearrangements can be accurately introduced. Here, we describe a new method to introduce small alterations in BACs, which results in the generation of point mutations with high frequency. The method involves homologous recombination between the original BAC and a shuttle vector providing the mutation. Each recombination step is monitored using positive and negative selection markers, which are the Kanamycin-resistance gene, the sacB gene and temperature-sensitive replication, all conferred by the shuttle plasmid. We have used this method to introduce four different point mutations and the insertion of the ss-galactosidase gene in a BAC, which has subsequently been used for transgenic animal production.

Assessment of professional development of critical care nurses: a descriptive study

BACKGROUND: With much attention focused on nurses and the nursing profession, self-evaluation of nurses' contributions to their personal growth and the profession as a whole is needed. OBJECTIVE: To describe professional development characteristics of critical care nurses. METHODS: A descriptive, exploratory approach was used to assess the professional development characteristics of a select population of critical care nurses. A 20-item self-administered questionnaire was given to 169 participants at a regional conference of the American Association of Critical-Care Nurses. The survey was designed to determine the level of involvement in professional opportunities and the perception of factors that influence professional development. RESULTS: Mean age of the respondents was 39 years; 72% had at least a bachelor's degree, and 82% were certified in at least one specialty area. Seventy-three percent were members of at least one professional nursing organization; but only 31% reported active participation with meetings and activities. Fifty-two percent considered themselves mentors, yet only 14% participated in scholarly activities at a high level, and 58% had not recognized a peer for nursing contributions. Seventy-six percent reported a high level of "passion about nursing and promoting the profession." Self-motivation was the leading influential factor (72%) for fostering individual professional development. CONCLUSIONS: Critical care nurses have high levels of motivation for professional development in the areas of education, certification, and membership in professional nursing organizations. However, the level of involvement with professional nursing organizations, promotion of nursing peers, and participation in scholarly activities is less than expected.

Assessment of professional development of critical care nurses: a descriptive study

BACKGROUND

With much attention focused on nurses and the nursing profession, self-evaluation of nurses' contributions to their personal growth and the profession as a whole is needed.

OBJECTIVE

To describe professional development characteristics of critical care nurses.

METHODS

A descriptive, exploratory approach was used to assess the professional development characteristics of a select population of critical care nurses. A 20-item self-administered questionnaire was given to 169 participants at a regional conference of the American Association of Critical-Care Nurses. The survey was designed to determine the level of involvement in professional opportunities and the perception of factors that influence professional development.

RESULTS

Mean age of the respondents was 39 years; 72% had at least a bachelor's degree, and 82% were certified in at least one specialty area. Seventy-three percent were members of at least one professional nursing organization; but only 31% reported active participation with meetings and activities. Fifty-two percent considered themselves mentors, yet only 14% participated in scholarly activities at a high level, and 58% had not recognized a peer for nursing contributions. Seventy-six percent reported a high level of "passion about nursing and promoting the profession." Self-motivation was the leading influential factor (72%) for fostering individual professional development.

CONCLUSIONS

Critical care nurses have high levels of motivation for professional development in the areas of education, certification, and membership in professional nursing organizations. However, the level of involvement with professional nursing organizations, promotion of nursing peers, and participation in scholarly activities is less than expected.

Meeting national tobacco challenges: recommendations for smoking cessation groups

PURPOSE

To review the literature on model smoking cessation programs and provide an overview of the practice guidelines for intensive smoking cessation groups.

DATA SOURCES

Selected evidence-based literature and AHCPR/AHRQ clinical practice guidelines.

CONCLUSIONS

Smoking is the leading cause of preventable death in our global society and is expected to kill more people than any other disease within 20 years. Data support that most smokers want to quit and are more likely to succeed with a combination of behavioral and pharmacological support.

IMPLICATIONS FOR PRACTICE

Smoking cessation must be a priority in the delivery of patient care. Intensive interventions are more effective than brief interventions and should be available for all smokers.