Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

The Experience of the Management of Eating Disorders in a Pop-up Eating Disorder Unit

Anorexia nervosa affects 0.5% of the population (90% female) with the highest mortality of any psychiatric illness, usually suicide, or cardiovascular or neurological sequelae of either malnutrition or refeeding syndrome. The latter two conditions occur in the inpatient setting, carry a high mortality and are thoroughly avoidable with careful informed clinical management. This paper provides an overview of the service and care of these patients in a general hospital setting in Ireland. In response to a number of acute presentations a cross discipline Pop-up Eating Disorder Unit (psychiatrist, physician, dietician, nurse) was established in Sligo University Hospital in 2014 and has experience of 20 people treated according to the MARSIPAN guideline (Management of Really Sick Inpatients with Anorexia Nervosa). They are nursed in a designated ward with continuous cardiac monitoring (in addition 2 required ICU admission), with one-to-one continuous supervision, complete bed rest, careful calorie titration (usually nasogastric) with twice daily phosphate, magnesium, calcium and potassium concentrations measured and replaced. Sabotaging behaviour witnessed includes micro-exercising, requests for windows to be opened (in order to shiver/micro exercise), food concealment, faecal/urinary loading on weighing days, heavy hair accessories, vigorous page turning/toothbrushing/use of computer keypads and animated conversations. A cross disciplinary coordinated approach to this cohort, who often inventive in their resistance to treatment, allows safe management in a general hospital setting.

Using Participatory Learning & Action (PLA) research techniques for inter-stakeholder dialogue in primary healthcare: an analysis of stakeholders' experiences

PLAIN ENGLISH SUMMARY

It is important for health care workers to know the needs and expectations of their patients. Therefore, service users have to be involved in research. To achieve a meaningful dialogue between service users, healthcare workers and researchers, participatory methods are needed. This paper describes how the application of a specific participatory methodology, Participatory Learning and Action (PLA) can lead to such a meaningful dialogue. In PLA all stakeholders are regarded as equal partners and collaborators in research.During 2011-2015, a European project called RESTORE used PLA in Austria, Greece, Ireland, The Netherlands and the UK to investigate how communication between primary health care workers and their migrant patients could be improved.Seventy eight migrants, interpreters, doctors, nurses and other key stakeholders (see Table 2) participated in 62 PLA sessions. These dialogues (involving discussions, activities, PLA techniques and evaluations) were generally 2-3 h long and were recorded and analysed by the researchers.Participants reported many positive experiences about their dialogues with other stakeholders. There was a positive, trusting atmosphere in which all stakeholders could express their views despite differences in social power. This made for better understanding within and across stakeholder groups. For instance a doctor changed her view on the use of interpreters after a migrant explained why this was important. Negative experiences were rare: some doctors and healthcare workers thought the PLA sessions took a lot of time; and despite the good dialogue, there was disappointment that very few migrants used the new interpreting service.

ABSTRACT

Background In order to be effective, primary healthcare must understand the health needs, values and expectations of the population it serves. Recent research has shown that the involvement of service users and other stakeholders and gathering information on their perspectives can contribute positively to many aspects of primary healthcare. Participatory methodologies have the potential to support engagement and dialogue between stakeholders from academic, migrant community and health service settings. This paper focuses on a specific participatory research methodology, Participatory Learning and Action (PLA) in which all stakeholders are regarded as equal partners and collaborators in research.Our research question for this paper was: "Does the application of PLA lead to meaningful engagement of all stakeholders, and if so, what elements contribute to a positive and productive inter-stakeholder dialogue?". Methods We explored the use of PLA in RESTORE, a European FP7-funded project, during 2011-2015 in 5 countries: Austria, Greece, Ireland, the Netherlands and the UK. The objective of RESTORE was to investigate and support the implementation of guidelines and training initiatives (G/TIs) to enhance communication in cross-cultural primary care consultations with migrants.Seventy eight stakeholders (migrants, interpreters, doctors, nurses and others - see Table 2) participated in a total of 62 PLA sessions (discussions, activities, evaluations) of approximately 2-3 h' duration across the five sites. During the fieldwork, qualitative data were generated about stakeholders' experiences of engagement in this dialogue, by means of various methods including participatory evaluations, researchers' fieldwork reports and researcher interviews. These were analysed following the principles of thematic analysis. Results Stakeholders involved in PLA inter-stakeholder dialogues reported a wide range of positive experiences of engagement, and very few negative experiences. A positive atmosphere during early research sessions helped to create a sense of safety and trust. This enabled stakeholders from very different backgrounds, with different social status and power, to offer their perspectives in a way that led to enhanced learning in the group - they learned with and from each other. This fostered shifts in understanding - for example, a doctor changed her view on interpreted consultations because of the input of the migrant service-users. Conclusion PLA successfully promoted stakeholder involvement in meaningful and productive inter-stakeholder dialogues. This makes it an attractive approach to enhance the further development of health research partnerships to advance primary healthcare.

Implementing guidelines and training initiatives to improve cross-cultural communication in primary care consultations: a qualitative participatory European study

Background

Cross-cultural communication in primary care is often difficult, leading to unsatisfactory, substandard care. Supportive evidence-based guidelines and training initiatives (G/TIs) exist to enhance cross cultural communication but their use in practice is sporadic. The objective of this paper is to elucidate how migrants and other stakeholders can adapt, introduce and evaluate such G/TIs in daily clinical practice.

Methods

We undertook linked qualitative case studies to implement G/TIs focused on enhancing cross cultural communication in primary care, in five European countries. We combined Normalisation Process Theory (NPT) as an analytical framework, with Participatory Learning and Action (PLA) as the research method to engage migrants, primary healthcare providers and other stakeholders. Across all five sites, 66 stakeholders participated in 62 PLA-style focus groups over a 19 month period, and took part in activities to adapt, introduce, and evaluate the G/TIs. Data, including transcripts of group meetings and researchers’ fieldwork reports, were coded and thematically analysed by each team using NPT.

Results

In all settings, engaging migrants and other stakeholders was challenging but feasible. Stakeholders made significant adaptations to the G/TIs to fit their local context, for example, changing the focus of a G/TI from palliative care to mental health; or altering the target audience from General Practitioners (GPs) to the wider multidisciplinary team. They also progressed plans to deliver them in routine practice, for example liaising with GP practices regarding timing and location of training sessions and to evaluate their impact. All stakeholders reported benefits of the implemented G/TIs in daily practice. Training primary care teams (clinicians and administrators) resulted in a more tolerant attitude and more effective communication, with better focus on migrants’ needs. Implementation of interpreter services was difficult mainly because of financial and other resource constraints. However, when used, migrants were more likely to trust the GP’s diagnoses and GPs reported a clearer understanding of migrants’ symptoms.

Conclusions

Migrants, primary care providers and other key stakeholders can work effectively together to adapt and implement G/TIs to improve communication in cross-cultural consultations, and enhance understanding and trust between GPs and migrant patients.

Postnatal depression mediates the relationship between infant and maternal sleep disruption and family dysfunction

BACKGROUND

Previous research has linked family sleep disruption and dysfunction in children; however, the mechanism is unknown.

AIMS

This study examined whether maternal sleep and postnatal depression (PND) mediate the relationship between infant sleep disruption and family dysfunction.

STUDY DESIGN AND PARTICIPANTS

Mothers of infants aged 12 months old (N=111; 48% male) completed infant and parent sleep surveys, the Edinburgh Postnatal Depression Scale and the Family Assessment Device.

RESULTS

Poor infant sleep was related to poor maternal sleep, which was associated with higher PND and higher level of family dysfunction.

CONCLUSIONS

Results are consistent with the proposition that identification of both infant and maternal sleep problems during infancy can be relevant to reduction of PND and improved family functioning.

Sequential drug verification errors resulting in wrong drug administration during caesarean section

An intravenous bolus of phentolamine was inadvertently given to a parturient during an emergency caesarean section following delivery of her infant when the intention had been to give an intravenous bolus of 5 IU Syntocinon. Root cause analysis identified a series of errors originating in the hospital pharmacy when one drug package was mistakenly issued in place of another. Subsequent checks failed to detect the original mistake. The final and most important check immediately before intravenous administration was also at fault. This case highlights a systems failure that permitted issue, transportation and administration of the wrong drug to a parturient. Robust measures to ensure avoidance of drug administration errors should be evaluated and introduced where possible.

An investigation of the effects of saccharides on the memory performance of middle-aged adults

OBJECTIVES

To investigate the effects of glucose, or a combination of saccharides, or a placebo on the memory performance of middle-aged adults.

DESIGN

A double-blind, placebo controlled design was used. A population-based sample of 45 men and women (aged 40-63 years) completed a series of memory tasks following administration of a single dose of either glucose, a combination of saccharides or placebo. Memory tasks included immediate and delayed recall, recognition, short-term memory, working memory, and a test of general cognitive ability.

RESULTS

There were no statistically significant effects of treatments on any of the outcome measures.

CONCLUSION

The pattern of means in the combination of saccharides group suggests potential enhancement effects of memory performance in middle-aged adults that deserves further investigation.

Elevated blood pressure in overweight and obese Irish children

BACKGROUND

The Irish childhood obesity epidemic, one of the highest ranking internationally, represents a major threat to public health. We sought to perform a retrospective observational study of a clinic based cohort of obese Irish children.

METHODS

Clinical data relating to gender, age, height, weight, body mass index and blood pressure were analysed, from 206 children referred to a paediatric endocrine referral centre over a 15-year period for assessment of obesity.

RESULTS

Younger patients tended to have a higher standardised body mass index at initial presentation; 92% of boys and 96% of girls referred were obese (age-related BMI >/= 95th percentile). Boys (51%) and girls (49%) had initial blood pressure measurements in the hypertensive range. There was a correlation between the degree of obesity and systolic blood pressure, particularly in boys.

CONCLUSIONS

Obese Irish children present with significant long-term health risks, including hypertension at baseline.

Underwater digital holography for studies of marine plankton

Conventional and digital holographies are proving to be increasingly important for studies of marine zooplankton and other underwater biological applications. This paper reports on the use of a subsea digital holographic camera (eHoloCam) for the analysis and identification of marine organisms and other subsea particles. Unlike recording on a photographic film, a digital hologram (e-hologram) is recorded on an electronic sensor and reconstructed numerically in a computer by simulating the propagation of the optical field in space. By comparison with other imaging techniques, an e-hologram has several advantages such as three-dimensional spatial reconstruction, non-intrusive and non-destructive interrogation of the recording sampling volume and the ability to record holographic videos. The basis of much work in optics lies in Maxwell's electromagnetic theory and holography is no exception: we report here on two of the numerical reconstruction algorithms we have used to reconstruct holograms obtained using eHoloCam and how their starting point lies in Maxwell's equations. Derivation of the angular spectrum algorithm for plane waves is provided as an exact method for the in-line numerical reconstruction of digital holograms. The Fresnel numerical reconstruction algorithm is derived from the angular spectrum method. In-line holograms are numerically processed before and after reconstruction to remove periodic noise from captured images and to increase image contrast. The ability of the Fresnel integration reconstruction algorithm to extend the reconstructed volume beyond the recording sensor dimensions is also shown with a 50% extension of the reconstruction area. Finally, we present some images obtained from recent deployments of eHoloCam in the North Sea and Faeroes Channel.

Early-onset type 2 diabetes in obese white subjects is characterised by a marked defect in beta cell insulin secretion, severe insulin resistance and a lack of response to aerobic exercise training

AIMS/HYPOTHESIS

Early-onset type 2 diabetes is associated with marked visceral obesity and extreme insulin resistance, but its pathogenesis and response to treatment are not completely understood. We studied physical fitness, whole-body and hepatic glucose turnover, and insulin secretion in young obese Irish subjects before and after 3 months of aerobic exercise training. We hypothesised that exercise alone, with stable diet, should improve insulin sensitivity.

MATERIALS AND METHODS

Anthropometric parameters and maximum volume of oxygen utilisation (VO(2max)) were measured in 13 subjects with type 2 diabetes and 18 non-diabetic control subjects, matched for age and BMI. Insulin sensitivity and hepatic glucose turnover were measured using the hyperinsulinaemic-euglycaemic clamp. Insulin secretion was assessed from an OGTT and a modified intravenous glucose tolerance test. Some subjects (seven type 2 diabetic, 14 non-diabetic control subjects) then completed a 12-week supervised aerobic exercise programme. All measurements were repeated on completion of the exercise programme.

RESULTS

Type 2 diabetic subjects had higher WHR, systolic blood pressure and triacylglycerols than non-diabetic control subjects. They were significantly more insulin-resistant as measured both by the clamp and oral glucose insulin sensitivity. They also displayed marked defects in insulin secretion in response to oral and intravenous glucose challenges. Exercise intervention had no significant effect on whole-body or hepatic insulin sensitivity or insulin secretion. VO(2max) increased significantly in the non-diabetic control subjects, but not in the type 2 diabetic subjects after exercise training.

CONCLUSIONS/INTERPRETATION

Young obese subjects with type 2 diabetes are severely insulin-resistant with marked loss of beta cell function compared with control subjects matched for age and obesity. Neither group responded metabolically to aerobic exercise intervention.

Development of the Rural-Urban Demand Indicator (RUDI)

In this article we describe development of RUDI (Rural-Urban Demand Indicator), a multivariate interval level measure of demand for health services. RUDI ranks counties by population and purchasing power and was developed for use in a wide variety of health-related research and for policy analyses. RUDI is based on microeconomic theory and Grossman's (1972) extension of the theory, that the family produces health and that the family's demand for health services is derived from the demand for health. Two factors define RUDI: DEMOS (demographics) and EWB (economic well-being). These two factors accounted for 66.2% of the variance observed in 1990 census data. A variety of other analyses offer evidence of known- groups, convergent, factorial, and predictive validity.

Electrostatic and Hydrophobic Effects of Oligopeptide Insertions on Protein Adsorption

The effects of oligopeptide insertions on the adsorption of the protein ZZ, where Z is the IgG binding domain of staphylococcal Protein A, was investigated by in situ ellipsometry. In particular, the interplay between hydrophobic and electrostatic interactions as driving force for adsorption was investigated by studying the effects of oligopeptide insertions of the type Tn((AlaTrpTrpPro)n), Nn((AlaTrpTrpAspPro)n), and Pn((AlaTrpTrpLysPro)n) on the adsorption at silica, methylated silica, and diaminocyclohexane (DACH) plasma polymer surfaces. For comparison, the adsorption of the inserted peptide stretches was also investigated. It was found that the adsorption of all the peptides increases with the molecular weight at methylated silica. At silica, only the Pn peptides were found to adsorb. The net negatively charged proteins modified through peptide insertions did not adsorb at the hydrophilic and negatively charged silica, irrespective of the peptide insertion, whereas an extensive adsorption was found for the positively charged DACH surface for all the proteins investigated. For hydrophobic and negatively charged methylated silica, on the other hand, the peptide insertions were found to have a major influence on the protein interfacial behavior, and the adsorption followed the peptide stretch charge, thus increasing in the order ZZNn < ZZTn < ZZPn. These effects are discussed in terms of the relative importance of hydrophobic and electrostatic interactions as driving force for the adsorption. Copyright 1998 Academic Press.

Effects of ecstasy on aldosterone secretion in the rat in vivo and in vitro

This study investigated the effects of Methylenedioxymethamphetamine (MDMA) on aldosterone and renin secretion via, (1) acute administration of MDMA to conscious Wistar rats, and (2) superfusion of whole rat adrenal capsules with 1 microM and 10 microM MDMA, in the presence of 5-HT. In study 1 basal aldosterone levels increased significantly from 3.490 +/- 1.1 nmol/l to 12.099 +/- 2 nmol/l after administration of MDMA (P < 0.05). Control rats showed no significant increase in aldosterone secretion. Basal plasma renin activity (PRA) was 6.86 +/- 1.65 ng/ml/hr in the MDMA treated animals increasing to 228.56 +/- 34.1 ng/ml/hr after administration (P < 0.05). In study 2 the aldosterone response to 5-HT was potentiated by 1 microM and 10 microM MDMA. No consistent stimulation of aldosterone was observed by MDMA alone. In conclusion, acute administration of MDMA to conscious rats causes activation of the renin-angiotensin-aldosterone system. In addition, MDMA can potentiate the direct action of 5-HT on aldosterone secretion in vitro by a mechanism which could be associated with the 5-HT transporter.

The role of L-aromatic amino acid decarboxylase in serotonin-stimulated aldosterone secretion in response to salt intake

In this study we tested a new hypothesis namely that serotonin (5-hydroxytryptamine, 5-HT) could be synthesised within the zona glomerulosa of the rat adrenal gland from exogenous 5-hydroxytryptophan (5-HTP) by the enzyme L-aromatic amino acid decarboxylase (L-AAAD). A specific monoclonal antibody against L-AAAD showed that the enzyme was present predominantly in the adrenal medulla but also in the zona glomerulosa and zona fasciculata. Wistar rats, maintained on a normal (NS), low (LS) or high (HS) salt diet for one week, were sacrificed by decapitation, blood samples taken and the adrenal glands removed. Plasma aldosterone concentrations were significantly higher in the LS diet group (2.91 +/- 0.35 nM) and significantly lower in the HS diet group (0.261 +/- 0.55 nM) compared with the NS diet group (1.025 +/- 0.133 nM) (p < 0.001). Capsules from the LS diet group synthesised significantly higher maximal levels of 5-HT (2615.463 +/- 480.88 nM/mg protein) than capsules from the NS (1219.117 +/- 150.259 nM/mg protein) and the HS (968.477 +/- 214.485 nM/mg protein) salt diet groups (p < 0.05). Maximal aldosterone secretion in adrenal capsules obtained from rats on the LS diet (73.428 +/- 4.053 nM/mg protein) was significantly higher than in those obtained from rats on the NS diet (41.658 +/- 1.87 nM/mg protein) (p < 0.05). Maximal aldosterone secretion in adrenal capsules from the HS diet group (30.624 +/- 2.114 nM/mg protein) was significantly lower than in the capsules from both the LS and NS groups (p < 0.05). Carbidopa (10(-4) M), a specific inhibitor of L-AAAD, markedly attenuated the secretion of aldosterone when adrenal capsules from all three salt diet groups were incubated with 10(-4) M 5-HTP (p < 0.05), but had no significant effect on basal aldosterone secretion. These results clearly demonstrate that L-AAAD is not only present in the medulla, but also in the zona glomerulosa and zona fasciculata of the rat adrenal gland. In addition, 5-HT can be synthesised in the zona glomerulosa/capsular region of the rat adrenal gland and both its biosynthesis and its ability to stimulate aldosterone secretion is increased by sodium depletion and attenuated by sodium loading. This raises the interesting possibility that L-AAAD could play a role in the regulation of aldosterone secretion during sodium deficiency in the rat by converting circulating 5-HTP (which is present in blood at concentrations exceeding 1 micromolar) into 5-HT within the adrenal cortex.

Structural similarity between the p17 matrix protein of HIV-1 and interferon-gamma

The human immunodeficiency virus (HIV) matrix protein, p17, forms the outer shell of the core of the virus, lining the inner surface of the viral membrane. The protein has several key functions. It orchestrates viral assembly via targeting signals that direct the gag precursor polyprotein, p55, to the host cell membrane and it interacts with the transmembrane protein, gp41, to retain the env-encoded proteins in the virus. In addition, p17 contains a nuclear localization signal that directs the preintegration complex to the nucleus of infected cells. This permits the virus to infect productively non-dividing cells, a distinguishing feature of HIV and other lentiviruses. We have determined the solution structure of p17 by nuclear magnetic resonance (NMR) with a root-mean square deviation for the backbone of the well-defined regions of 0.9 A. It consists of four helices connected by short loops and an irregular, mixed beta-sheet which provides a positively charged surface for interaction with the inner layer of the membrane. The helical topology is unusual; the Brookhaven protein database contains only one similar structure, that of the immune modulator interferon-gamma.

Let the bed take the strain. An ergonomic approach to hospital bed provision

1. The use of an ergonomic approach to risk assessment is advocated by the Manual Handling Operations Regulations. 2. Selection of hospital beds is a key factor in reducing the risk of injury from manual handling. 3. The use of electrically operated beds has eliminated many patient handling episodes. 4. The electrically operated beds have increased patient independence.

Large-scale analysis of gene expression, protein localization, and gene disruption in Saccharomyces cerevisiae

We have developed a large-scale screen to identify genes expressed at different times during the life cycle of Saccharomyces cerevisiae and to determine the subcellular locations of many of the encoded gene products. Diploid yeast strains containing random lacZ insertions throughout the genome have been constructed by transformation with a mutagenized genomic library. Twenty-eight hundred transformants containing fusion genes expressed during vegetative growth and 55 transformants containing meiotically induced fusion genes have been identified. Based on the frequency of transformed strains producing beta-galactosidase, we estimate that 80-86% of the yeast genome (excluding the rDNA) contains open reading frames expressed in vegetative cells and that there are 93-135 meiotically induced genes. Indirect immunofluorescence analysis of 2373 strains carrying fusion genes expressed in vegetative cells has identified 245 fusion proteins that localize to discrete locations in the cell, including the nucleus, mitochondria, endoplasmic reticulum, cytoplasmic dots, spindle pole body, and microtubules. The DNA sequence adjacent to the lacZ gene has been determined for 91 vegetative fusion genes whose products have been localized and for 43 meiotically induced fusions. Although most fusions represent genes unidentified previously, many correspond to known genes, including some whose expression has not been studied previously and whose products have not been localized. For example, Sec21-beta-gal fusion proteins yield a Golgi-like staining pattern, Ty1-beta-gal fusion proteins localize to cytoplasmic dots, and the meiosis-specific Mek1/Mre4-beta-gal and Spo11-beta-gal fusion proteins reside in the nucleus. The phenotypes in haploid cells have been analyzed for 59 strains containing chromosomal fusion genes expressed during vegetative growth; 9 strains fail to form colonies indicating that the disrupted genes are essential. Fifteen additional strains display slow growth or are impaired for growth on specific media or in the presence of inhibitors. Of 39 meiotically induced fusion genes examined, 14 disruptions confer defects in spore formation or spore viability in homozygous diploids. Our results will allow researchers who identify a yeast gene to determine immediately whether that gene is expressed at a specific time during the life cycle and whether its gene product localizes to a specific subcellular location.

Economics of hospice care

As an institution providing care for patients who are dying, hospice has expanded significantly since the opening of the first hospice in the United States in 1974. Many changes have occurred in that time, including the maturation of hospices and the introduction of third-party reimbursement under Medicare. This article examines literature on hospice from an economic perspective; the focus is on the characteristics of the hospice "industry," demand for hospice care, hospice as a supplier of care, and the cost of hospice care. Two major gaps in the research are the failure to categorize hospices by the type of reimbursement received and the emphasis on expenditures for care to the exclusion of consideration of the cost of producing hospice care.

Standards for qualitative research

One of the greatest obstacles to the identification of excellence in qualitative studies is the lack of generally accepted criteria. The criteria developed for quantitative studies are based on a different set of assumptions and are not appropriate. Those who critique qualitative studies need context flexibility, skills in inductive reasoning, skills in theory analysis, and the capacity to transform ideas across levels of abstraction. The following standards are proposed for critique of qualitative studies: (a) descriptive vividness; (b) methodological congruence; (c) analytic preciseness; (d) theoretical connectedness; and (e) heuristic relevance. Methodological congruence has four elements: rigor in documentation; procedural rigor; ethical rigor; and auditability. Heuristic relevance has three elements: intuitive recognition; relationship to existing body of knowledge; and applicability. Threats to each of these standards are identified. Creative strategies for improving the published presentation of qualitative studies must be developed to allow adequate critique.

Hospice: a design for home care for the terminally ill

Hospice may appropriately be understood as a model of holistic care. As a model of holistic care, hospice provides numerous insights suitable for adoption in other health care settings. In addition, hospice provides a preeminent opportunity for nurses to practice within a nursing model; at the present time, nursing goals may be pursued more freely within hospice than in any other setting.

Hospice costs and medicare reimbursement: an application of break-even analysis

The adequacy of Medicare reimbursement to cover hospice costs is examined using break-even analysis. Since hospice costs are high during the first few days after enrollment, a long period of enrollment is required for per diem reimbursement to cover costs. Under a variety of specifications, the length of stay required for the hospice to break even is greater than the median length of stay.

Production and characterization of monoclonal antibodies against avian retrovirus reverse transcriptase

Monoclonal antibodies were prepared against the avian myeloblastosis virus reverse transcriptase. These monoclonal antibodies specifically immunoprecipitated the alpha and beta subunits of the reverse transcriptase molecule, as well as the Pr180gag-pol precursor protein present in virus-infected cells. In addition, these monoclonal antibodies inhibited the DNA polymerase activity associated with the reverse transcriptase molecule but not the RNase H activity. The monoclonal antibody preparations were specific for the amino-terminal portion of the protein, as determined by the immunoprecipitation of a reverse transcriptase-beta-galactosidase fusion protein produced in Escherichia coli by molecular cloning procedures.