Noninvasive cardiac output monitor to quantify hydration status in ischemic stroke patients: A feasibility study

BACKGROUND

Individuals who are dehydrated, volume contracted or both at the time of hospitalization for acute ischemic stroke have worse clinical outcomes than do individuals with optimal volume status. Currently, there is no gold standard method for measuring hydration status, except indirect markers of a volume contracted state (VCS) including elevated blood urea nitrogen (BUN)/creatinine ratio. We sought to test the feasibility and acceptability of a non-invasive cardiac output monitor (NICOM) for the measurement of hydration status in a group of hospitalized ischemic stroke patients, and explore the relationship with a common indirect laboratory-based measure of VCS.

METHODS

We performed a prospective observational feasibility study of hospitalized acute ischemic stroke patients. We collected hemodynamic parameters using the NICOM device before and after fluid auto-bolus via passive leg raise and BUN/creatinine ratio. Successful acquisition of relevant hemodynamic data was the primary objective of this study. We explored agreement between the NICOM results and BUN/creatinine ratio using Cohen's kappa statistic.

RESULTS

Thirty patients hospitalized with acute ischemic stroke were enrolled. We found that 29/30 patients tolerated assessment with NICOM. Hemodynamic data were collected in all 30 patients. Data capture took an average of 10 min(SD ± 112 s). Agreement between NICOM and BUN/creatinine ratio was 70%; (expected agreement 51%; kappa 0.38). Agreement was stronger in the cohort without history of diabetes (81% agreement, kappa 0.61).

CONCLUSIONS

NICOM assessment was feasible in hospitalized stroke patients. The identification of an objective, real-time measure of hydration status would be clinically useful, and could allow precise, goal-directed care.

A randomized controlled trial of motivational interviewing as a tool to enhance secondary prevention strategies in cardiovascular disease (MICIS study)

Physical activity/exercise has consistently been shown to improve objective measures of functional capacity, enhance quality of life, improve coronary risk profile, and reduce mortality for individuals with coronary heart disease. Despite the gains achieved by those who attend cardiac rehabilitation (CR) many individuals fail to maintain lifestyle changes.

The aims of this study were to evaluate the effectiveness of motivational interviewing as a strategy for promoting maintenance of cardiac risk factor modification in patients who had participated in standard, 6-week outpatient CR programs.

In a randomized controlled trail, participants in usual care and intervention group (Motivational interviewing supplemental to a standard 6-week CR program) were followed up at 6-weeks and 12-months. The primary outcome was distance walked on the six-minute walk test (6MWT), used as both an indicator of functional capacity and habitual physical activity. Secondary outcomes included modifiable coronary risk factors (smoking, self-reported physical activity, waist circumference, body mass index and medication adherence), psychological status (depression, anxiety, stress, perceived cardiac control, perceived social support, exercise self-efficacy) and quality of life.

Total 110 patients, usual care (n = 58) and intervention (n = 52), consented to participate in the study. Overall, demographic and clinical characteristics did not differ between groups at baseline. Motivational interviewing was no more likely to promote maintenance of cardiac risk factor modification (both primary and secondary outcomes) than a standard CR program alone. Both intervention and control groups maintained the gains achieved during CR at the 12-month follow-up except for weight loss.

Although both groups maintained the gains achieved during CR for physical activity, there was no effect of the intervention on maintenance of cardiac risk factor modification on both primary and secondary outcomes.

A qualitative study of fourteen African countries' nursing workforce and labour market

AIM

The aim of this study was to describe factors affecting nursing education and labour markets in countries in East, Central, and Southern Africa, and critical areas for investment.

BACKGROUND

An understanding about the relationship between the supply of nurses (determined by types of educational programmes, and the quantity and quality of nurse graduates), and workforce demand is critical to health policy development.

METHODS

Six focus groups and 14 key informant interviews with nursing leaders and experts were conducted. Participants included government chief nursing officers, registrars of regulatory bodies, association leaders and heads of nursing education. The data were transcribed, coded and analysed using inductive techniques.

FINDINGS

Participants discussed challenges and strengths of nursing education, school and regulatory infrastructure, financing mechanisms for the nursing workforce, the state of nursing jobs and scope of nursing practice.

CONCLUSION

Strengthened regulations and leadership are needed to improve investment in nursing, the quality of nursing education, and working conditions and to promote the achievement of better health outcomes.

IMPLICATIONS FOR NURSING POLICY

Clarifying scope of practice for nurses in the health sector and creating competency-based requirements is important. Governments should establish positions that align with updated competencies and provide fair and safe working conditions. The current and ongoing investment case for nursing requires improved data systems and a commitment to use labour market data for decision-making.

Identification of residues important for M. tuberculosis MmpL11 function reveals that function is modulated by phosphorylation in the C-terminal domain

The Mycobacterium tuberculosis cell envelope is a critical interface between the host and pathogen and provides a protective barrier against the immune response and antibiotics. Cell envelope lipids are also mycobacterial virulence factors that influence the host immune response. The mycobacterial membrane protein large (MmpL) proteins transport cell envelope lipids and siderophores that are important for the basic physiology and pathogenesis of M. tuberculosis. We recently identified MmpL11 as a conserved transporter of mycolic acid-containing lipids including monomeromycolyl diacylglycerol (MMDAG), mycolate wax ester (MWE), and long-chain triacylglycerols (LC-TAGs). These lipids contribute to biofilm formation in M. tuberculosis and M. smegmatis, and non-replicating persistence in M. tuberculosis. In this report, we identified domains and residues that are essential for MmpL11_TB lipid transporter activity. Specifically, we show that the D1 periplasmic loop and a conserved tyrosine are essential for the MmpL11 function. Intriguingly, we found that MmpL11 levels are regulated by the phosphorylation of threonine in the cytoplasmic C-terminal domain, providing the first direct evidence of the phospho-regulation of MmpL11 transporter activity in M. tuberculosis and M. smegmatis. Our results offer further insight into the function of MmpL transporters and regulation of mycobacterial cell envelope biogenesis.

Essential Oil Emulsions as Postharvest Sanitizers To Mitigate Salmonella Cross-Contamination on Peppers

Alternative postharvest sanitizers to chlorine are of increasing interest for many organic growers and consumers. An emulsion of clove bud oil (CBO; 0.2 and 0.5%) or thyme oil (0.2 and 0.5%) was evaluated as a sanitizer for produce washing against a five-serovar cocktail of Salmonella on snacking peppers and compared for antimicrobial efficacy with sodium hypochlorite (200 ppm). To further evaluate these compounds, the sanitation efficacy of an emulsion was examined after the addition of 1% organic load (OL). Emulsion treatments at 0.2 and 0.5% thyme oil and 0.5% CBO were the least effected by OL and effectively reduced cross-contamination of Salmonella on clean peppers, in many cases to below the limit of detection (1 CFU/10 g; P < 0.05). Chlorine and 0.2% CBO were rendered ineffective by the addition of OL in preventing cross-contamination and performed similarly to the water control. For surface-inoculated peppers, none of the evaluated treatments performed better than a water-only wash. The antimicrobial efficacy of the essential oil emulsions in the presence of OL indicates these emulsions may be suitable replacements for chlorine in postharvest produce wash systems.

Diphenylether-Modified 1,2-Diamines with Improved Drug Properties for Development against Mycobacterium tuberculosis

New treatments for tuberculosis infection are critical to combat the emergence of multidrug- and extensively drug-resistant Mycobacterium tuberculosis (Mtb). We report the characterization of a diphenylether-modified adamantyl 1,2-diamine that we refer to as TBL-140, which has a minimal inhibitory concentration (MIC99) of 1.2 μg/mL. TBL-140 is effective against drug-resistant Mtb and nonreplicating bacteria. In addition, TBL-140 eliminates expansion of Mtb in cell culture infection assays at its MIC. To define the mechanism of action of this compound, we performed a spontaneous mutant screen and biochemical assays. We determined that TBL-140 treatment affects the proton motive force (PMF) by perturbing the transmembrane potential (ΔΨ), consistent with a target in the electron transport chain (ETC). As a result, treated bacteria have reduced intracellular ATP levels. We show that TBL-140 exhibits greater metabolic stability than SQ109, a structurally similar compound in clinical trials for treatment of MDR-TB infections. Combined, these results suggest that TBL-140 should be investigated further to assess its potential as an improved therapeutic lead against Mtb.

Thermal inactivation kinetics of hepatitis A virus in homogenized clam meat (Mercenaria mercenaria)

AIMS

Epidemiological evidence suggests that hepatitis A virus (HAV) is the most common pathogen transmitted by bivalve molluscs such as clams, cockles, mussels and oysters. This study aimed to generate thermal inactivation kinetics for HAV as a first step to design adequate thermal processes to control clam-associated HAV outbreaks.

METHODS AND RESULTS

Survivor curves and thermal death curves were generated for different treatment times (0-6 min) at different temperatures (50-72°C) and Weibull and first-order models were compared. D-values for HAV ranged from 47·37 ± 1·23 to 1·55 ± 0·12 min for the first-order model and 64·43 ± 3·47 to 1·25 ± 0·45 min for the Weibull model at temperatures from 50 to 72°C. z-Values for HAV in clams were 12·97 ± 0·59°C and 14·83 ± 0·0·28°C using the Weibull and first-order model respectively. The calculated activation energies for the first-order and Weibull model were 145 and 170 kJ mole(-1) respectively.

CONCLUSION

The Weibull model described the thermal inactivation behaviour of HAV better than the first-order model.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study provides novel and precise information on thermal inactivation kinetics of HAV in homogenized clams. This will enable reliable thermal process calculations for HAV inactivation in clams and closely related seafood.

Reliability of intra-abdominal pressure measurements using the modified Kron technique

OBJECTIVES

Assessment of intra-abdominal pressure (IAP) and the likelihood of abdominal compartment syndrome using valid and reliable measures is an important tool in the assessment of critically ill patients. The current method of relying on a single IAP per measurement period to determine patient clinical status raises the question: is a single intermittent IAP measurement an accurate indicator of clinical status or should more than one measurement be taken per measurement period?

METHODS

This study sought to assess the reliability of IAP measurements. Measurements were taken using the modified Kron technique. A total of two transvesical intra-abdominal pressure measurements were undertaken per patient using a standardized protocol. Recordings were taken at intervals of 5 minutes.

RESULTS

The majority of participants (58%) were surgical patients. Thirty-two were males and the mean age was 58 years (SD: 16·7 years). The concordance correlation coefficient between the two measurements was 0·95. Both the scatter and Bland-Altman plots demonstrate that the comparisons of two measurements are highly reproducible.

CONCLUSION

The findings of this study suggest that conducting two IAP measurements on single patient produce comparable results; therefore, there appears to be no advantage in doing two IAP measurements on a single patient. The measurement of an IAP requires the implementation of a standardized protocol and competent and credentialed assessors trained in the procedure.

Optimal patient education for cancer pain: a systematic review and theory-based meta-analysis

PURPOSE

Previous systematic reviews have found patient education to be moderately efficacious in decreasing the intensity of cancer pain, but variation in results warrants analysis aimed at identifying which strategies are optimal.

METHODS

A systematic review and meta-analysis was undertaken using a theory-based approach to classifying and comparing educational interventions for cancer pain. The reference lists of previous reviews and MEDLINE, PsycINFO, and CENTRAL were searched in May 2012. Studies had to be published in a peer-reviewed English language journal and compare the effect on cancer pain intensity of education with usual care. Meta-analyses used standardized effect sizes (ES) and a random effects model. Subgroup analyses compared intervention components categorized using the Michie et al. (Implement Sci 6:42, 2011) capability, opportunity, and motivation behavior (COM-B) model.

RESULTS

Fifteen randomized controlled trials met the criteria. As expected, meta-analysis identified a small-moderate ES favoring education versus usual care (ES, 0.27 [-0.47, -0.07]; P = 0.007) with substantial heterogeneity (I² = 71 %). Subgroup analyses based on the taxonomy found that interventions using "enablement" were efficacious (ES, 0.35 [-0.63, -0.08]; P = 0.01), whereas those lacking this component were not (ES, 0.18 [-0.46, 0.10]; P = 0.20). However, the subgroup effect was nonsignificant (P = 0.39), and heterogeneity was not reduced. Factoring in the variable of individualized versus non-individualized influenced neither efficacy nor heterogeneity.

CONCLUSIONS

The current meta-analysis follows a trend in using theory to understand the mechanisms of complex interventions. We suggest that future efforts focus on interventions that target patient self-efficacy. Authors are encouraged to report comprehensive details of interventions and methods to inform synthesis, replication, and refinement.

Inactivation of Alicyclobacillus acidoterrestris using high pressure homogenization and dimethyl dicarbonate

Vegetative cells and spores of five strains of Alicyclobacillus acidoterrestris (N-1100, N-1108, N-1096, SAC, and OS-CAJ) were screened for their sensitivity to high pressure homogenization (HPH, 0 to 300 MPa) in Bacillus acidoterrestris thermophilic broth. The most and least resistant strains, SAC and OS-CAJ, respectively, were further tested for their sensitivity to inactivation or growth inhibition by dimethyl dicarbonate (DMDC, 250 ppm). The combined effects of HPH and DMDC were then evaluated against SAC spores over a 24-h period after treatment. HPH alone significantly inactivated (P < 0.05) vegetative cells of all five strains. SAC vegetative cells were least affected by HPH, with only about a 0.5-log reduction after the 300-MPa treatment. Spores were not significantly reduced by HPH for any of the five strains. DMDC reduced the initial vegetative cell population by 2 log CFU/ml and significantly increased the time to reach stationary phase. For spores, a 0.5-log decrease from the initial spore population was achieved and growth was not significantly delayed. No significant difference was found between the two strains. Treatment with DMDC plus HPH slightly enhanced the inactivation effect over a 24-h period compared with treatment with HPH alone, but these differences were statistically inconsistent. Although HPH and DMDC treatments may help control vegetative cells of A. acidoterrestris, these treatments may not provide adequate overall control. Neither treatment, alone or in combination, is very effective against spores.

Aqueous extracts of yerba mate (Ilex paraguariensis) as a natural antimicrobial against Escherichia coli O157:H7 in a microbiological medium and pH 6.0 apple juice

Ilex paraguariensis is popularly used in the preparation of a tea infusion (yerba mate), most commonly produced and consumed in the South American countries of Uruguay, Paraguay, Argentina, and Brazil. In this study, aqueous extracts of commercial tea, derived from the holly plant species I. paraguariensis were evaluated for their ability to inhibit or inactivate Escherichia coli O157:H7 in a microbiological medium and modified apple juice. Dialyzed, lyophilized aqueous extracts were screened for antimicrobial activity against E. coli O157:H7 strains ATCC 43894 and 'Cider' in tryptic soy broth (TSB) and apple juice (adjusted to pH 6.0 to allow for growth of the bacterium). A mixture of the two strains was used as the inoculum when apple juice was used as the medium. MBCs were determined to be ca. 5 and 10 mg/ml for ATCC 43894 and 'Cider', respectively, in TSB. Higher concentrations of the extract were required to inactivate E. coli O157:H7 in pH-adjusted apple juice. An approximate 4.5-log reduction was observed for E. coli O157:H7 treated with 40 mg/ml extract. It was concluded that aqueous extracts from commercial yerba mate have potential to be used as antimicrobials in foods and beverages against pathogenic E. coli O157:H7.

Factors influencing self-management in chronic obstructive pulmonary disease: an integrative review

BACKGROUND

Chronic obstructive pulmonary disease is a common, chronic and burdensome condition requiring the individual to engage in a range of self-management strategies. The capacity to engage in self-management is dependent on a range of internal (e.g., personal) and external (e.g., health service) factors.

OBJECTIVES

This paper seeks to define self-management, identify the determinants which influence the individual's ability to cope and adjust to living with chronic obstructive pulmonary disease in the community, and identify implications for clinical practice and research.

DESIGN

Integrative review.

DATA SOURCES

Medline, Embase, PubMed, CINAHL, Google Scholar.

REVIEW METHODS

Integrative review using prospective research questions. Papers were included in the review if they were published in peer reviewed journals and written in English between 2000 and 2010. Articles were accepted for inclusion if they discussed the determinants that influenced self-management of chronic obstructive pulmonary disease in the community. Confirmation of results and discussion themes was validated by specialists in chronic obstructive pulmonary disease and complex care.

FINDINGS

Self-management is less well characterised in chronic obstructive pulmonary disease compared with other chronic conditions. Functional limitation and the need to balance disease management with everyday life are the two key elements that patients face in managing their condition. Provider characteristics, socioeconomic status and health literacy are sparsely discussed yet are known to influence chronic obstructive pulmonary disease self-management.

CONCLUSIONS

Chronic obstructive pulmonary disease self-management must be a key focus internationally as the disease incidence increases. Collaborative care is required between patients and health providers in order facilitate patients in confident management of their condition.

Evidence-based chronic heart failure management programs: reality or myth?

BACKGROUND

Chronic heart failure management programmes (CHF-MPs) have become part of standard care for patients with chronic heart failure (CHF).

OBJECTIVE

To investigate whether programmes had applied evidence-based expert clinical guidelines to optimise patient outcomes.

DESIGN

Prospective cross-sectional survey was used to conduct a national audit.

SETTING

Community setting of CHF-MPs for patients after discharge.

SAMPLE

All CHF-MPs operating during 2005-2006 (n = 55). 10-50 consecutive patients from 48 programmes were also recruited (n = 1157).

MAIN OUTCOME MEASURES

(1) Characteristics and interventions used within each CHF-MP and (2) characteristics of patients enrolled into these programmes.

RESULTS

Overall, there was a disproportionate distribution of CHF-MPs across Australia. Only 6.3% of hospitals nationally provided a CHF-MP. A total of 8000 post-discharge CHF patients (median, 126; IQR, 26-260) were managed via CHF-MPs representing only 20% of the potential national case load. Significantly, 16% of the case load comprised patients in functional New York Heart Association class I with no evidence of these patients having had previous echocardiography to confirm a diagnosis of CHF. Heterogeneity of CHF-MPs in applied models of care was evident with 70% of CHF-MPs offering a hybrid model (a combination of heart failure outpatient clinics and home visits), 20% conducting home visits and 16% an extended rehabilitation model of care. Less than half (44%) allowed heart failure nurses to titrate medications. The main medications that were titrated in these programmes were diuretics (n = 23, 96%), beta-blockers (n = 17, 71%), ACE inhibitors (n = 14, 58%) and spironolactone (n = 9, 38%).

CONCLUSION

CHF-MPs are being implemented rapidly throughout Australia. However, many of these programmes do not adhere to expert clinical guidelines for the management of patients with CHF. This poor translation of evidence into practice highlights the inconsistency and questions the quality of health-related outcomes for these patients.

Action research studies in the intensive care setting: a systematic review

OBJECTIVES

To review published studies using action research in the intensive care unit (ICU) in order to provide an intervention framework to improve clinical outcomes.

DESIGN

Systematic review.

METHODS

Searches of the electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL); Scopus, Medline, Embase, PsycINFO, and the World Wide Web were undertaken using MeSH key words including: 'action research'; 'health care research', 'health services evaluation'; 'intensive care unit'. Reference lists of retrieved articles was also undertaken to identify further articles. All studies were reviewed by two authors using a critical appraisal tool.

RESULTS

The search strategy generated 195 articles. Only 21 studies projects were identified using action research in the ICU. The majority of studies were conducted in the United Kingdom. The participants in the action research studies ranged from 6 to 253. Predominately studies using action research involved nurses in collaboration with patients and family and other health care practitioners to address identified problems in the ICU.

CONCLUSIONS

Based on this review it appears that action research is a promising methodological approach to address clinical practice improvement in the ICU. Studies retrieved focussed primarily on process and formative evaluation but not on clinical outcomes. There is a need to incorporate outcome assessment in action research in the ICU to increase the framework of action research to improve clinical outcomes.

Enough of the problem: a review of time for health care transition solutions for young adults with a chronic illness

AIMS AND OBJECTIVES

In this article, we critically assess the state of the science of transition care in chronic conditions using diabetes care as an exemplar and provide a case for the adoption of the principles of the Chronic Care Model in driving health care reform.

BACKGROUND

Globally, there is an increasing burden of chronic conditions including among adolescents and young adults. As a consequence adolescents are transitioning, at an increasing rate, from paediatric services into mainstream adult services, which are often ill equipped to meet their needs.

DESIGN

Integrative literature review.

METHODS

An integrative literature review method was used to summarise key issues facing adolescents with chronic illness and generate strategies for improving health care services.

CONCLUSION

Strengthening the capacity for transitioning from a service that is family focused to one with an individual orientation requires a paradigmatic shift and clear identification of roles and responsibilities in the health care system. The absence of empirically developed models of care, in a context of growing need, signals the importance of ongoing discussion, debate and research.

IMPLICATIONS FOR CLINICAL PRACTICE

There is a need for a change in philosophical orientation to promote service provision on the basis of need, rather than a model based on diagnosis and chronology. Nurses and other health professionals need to increase their awareness of issues facing adolescents with chronic conditions making the transition to adult health services.

Functional clinical placements: a driver for change

The aim of the project was to create a supervised professional experience placement model involving undergraduate nursing students, families of children with intellectual disabilities and nursing lecturers. Action research provided the methodological framework for developing a new placement model. Five families with children with disabilities, nine nursing students and two nurse academics worked together through the cycles of the action research process to develop a family health promotion intervention to improve the health and wellness of the family members and reduce risk for illness. Awareness, valuing and understanding were key themes derived from the qualitative data. Findings of this project indicate that this model of university-initiated, community-focused professional experience placement is effective in achieving the competency-based learning outcomes required of undergraduate nursing students and is worthy of ongoing exploration.

Two-particle separation energy trends in the superdeformed well

A measurement of the energy and spin of superdeformed states in 190Hg, obtained through the observation of transitions directly linking superdeformed and normal states, expands the number of isotopes in which binding energies at superdeformation are known. Comparison with neighboring nuclei shows that two-proton separation energies are higher in the superdeformed state than in the normal state, despite the lower Coulomb barrier and lower total binding energy. This unexpected result provides a critical test for nuclear models.

Decontamination of fluid milk containing Bacillus spores using commercial household products

Although commercial sanitizers can inactivate bacterial spores in food processing environments, relatively little data exist as to the decontamination of products and surfaces by consumers using commercial household products. Should a large scale bioterrorism incident occur in which consumer food products were contaminated with a pathogenic sporeformer such as Bacillus anthracis, there may be a need to decontaminate these products before disposal as liquid or solid waste. Studies were conducted to test the efficacy of commercial household products for inactivating spores of Bacillus cereus (used as a surrogate for B. anthracis) in vitro and in fluid milk. Validation of the resistance of the B. cereus spores was confirmed with B. anthracis spores. Fifteen commercial products, designed as either disinfectants or sanitizers or as potential sanitizers, were purchased from retail markets. Products selected had one of the following active compounds: NaOCl, HCl, H2O2, acetic acid, quaternary ammonium compounds, ammonium hydroxide, citric acid, isopropanol, NaOH, or pine oil. Compounds were diluted in water (in vitro) or in 2% fat fluid milk, and spores were exposed for up to 6 h. Products containing hypochlorite were most effective against B. cereus spores. Products containing HCl or H2O2 also reduced significant numbers of spores but at a slower rate. The resistance of spores of surrogate B. cereus strains to chlorine-containing compounds was similar to that of B. anthracis spores. Therefore, several household products on the market may be used to decontaminate fluid milk or similar food products contaminated by spores of B. anthracis.

Barriers and facilitators to the implementation of the collaborative method: reflections from a single site

BACKGROUND

A collaborative is an effective method of implementing evidence-based practice across multiple sites through the sharing of experience and knowledge of others in a similar setting, over a short period of time. Collaborative methods were first used in the USA but have been adopted internationally.

AIM

This paper sought to document the facilitators and barriers to the implementation of the collaborative method, based on a single site's experience of participating in a multisite, state-wide heart failure collaborative.

METHOD

Qualitative data was collected using three complementary

METHODS

participant observation, reflective journalling and key informant interviews. Quantitative monitoring of team performance occurred monthly according to prespecified performance indicators.

FINDINGS

Barriers and facilitators that were identified by this study included: organisational factors, team composition, dynamics and networking, changing doctor behaviour, clinical leadership and communication.

CONCLUSION

The findings from this study underscore the importance of leadership, communication and team cohesion for the successful implementation of the collaborative method at individual sites. In addition, the importance of a preparatory stage that deals with known barriers and facilitators to the collaborative method before the commencement of the official study period was highlighted. The potential for the collaborative approach to improve clinical outcomes warrants further systematic evaluation of process issues and consideration of the barriers and facilitators to implementation in various settings.

Clinical leadership in contemporary clinical practice: implications for nursing in Australia

BACKGROUND

Leadership in the clinical practice environment is important to ensure both optimal patient outcomes and successive generations of motivated and enthusiastic clinicians.

AIM

The present paper seeks to define and describe clinical leadership and identify the facilitators and barriers to clinical leadership. We also describe strategies to develop clinical leaders in Australia. Key drivers to the development of nursing leaders are strategies that recognize and value clinical expertise. These include models of care that highlight the importance of the nursing role; evidence-based practice and measurement of clinical outcomes; strategies to empower clinicians and mechanisms to ensure participation in clinical decision-making.

KEY ISSUES

Significant barriers to clinical leadership are organizational structures that preclude nurses from clinical decision making; the national shortage of nurses; fiscal constraints; absence of well evaluated models of care and trends towards less skilled clinicians.

CONCLUSIONS

Systematic, strategic initiatives are required to nurture and develop clinical leaders. These strategies need to be collegial collaborations between the academic and health care sectors in order to provide a united voice for advancing the nursing profession.

Probing shell structure and shape changes in neutron-rich sulfur isotopes through transient-field g-factor measurements on fast radioactive beams of 38S and 40S

The shell structure underlying shape changes in neutron-rich nuclei near N = 28 has been investigated by a novel application of the transient-field technique to measure the first-excited-state g factors in 38S and 40S produced as fast radioactive beams. There is a fine balance between proton and neutron contributions to the magnetic moments in both nuclei. The g factor of deformed 40S does not resemble that of a conventional collective nucleus because spin contributions are more important than usual.

Excitation energies of superdeformed States in 196Pb: towards a systematic study of the second well in Pb isotopes

The excitation energy of the lowest-energy superdeformed band in 196Pb is established using the techniques of time-correlated gamma-ray spectroscopy. Together with previous measurements on 192Pb and 194Pb, this result allows superdeformed excitation energies, binding energies, and two-proton and two-neutron separation energies to be studied systematically, providing stringent tests for current nuclear models. The results are examined for evidence of a "superdeformed shell gap."

Molecular weight of chitosan influences antimicrobial activity in oil-in-water emulsions

The objective of this study was to evaluate the antimicrobial efficiency of chitosans in oil-in-water emulsions. Model emulsions were prepared with 20% corn oil, 1.5% Tween 20, 1.5% Trypticase soy broth, 0.58% acetic acid, and chitosan polysaccharide or chitosan oligosaccharide in concentrations of 0, 0.1, 0.2, 0.5, and 0.7%. A control containing HCl was included to determine the role of acetic acid in the overall antibacterial activity. The pH of samples and controls was adjusted to 4.5. Emulsions were inoculated with Listeria monocytogenes (strains Scott A and 310) or Salmonella Typhimurium DT104 (strains 2486 and 2576) at a level of 10(7) CFU/ml. Inoculated emulsions were incubated at 10 and 25 degrees C for 4 days and analyzed for bacterial count every 24 h. Both tested Salmonella strains were more susceptible to acetic acid than Listeria. However, L. monocytogenes was more affected by chitosan than either Salmonella strain. During the storage at 25 degrees C, initial inoculum in the emulsions with 0.58% acetic acid and 0.1% chitosan polysaccharide was reduced to below the detection limits after 24, 48, 72, or 96 h for L. monocytogenes 310, Salmonella Typhimurium DT104 2576, Salmonella Typhimurium DT104 2486, or L. monocytogenes Scott A, respectively. Chitosan oligosaccharide was less effective against all tested bacteria and showed a concentration-dependent effect. The antimicrobial efficacy of chitosan was reduced at 10 degrees C, and reduction of microbial loads was delayed for approximately 24 h compared with 25 degrees C. Results suggest that addition of 0.1% chitosan polysaccharide would be sufficient to ensure the microbial safety of oil-in-water emulsions regardless of storage temperature.

Cations reduce antimicrobial efficacy of lysozyme-chelator combinations

Reduction of the antimicrobial efficacy of lysozyme-chelator combinations against two Escherichia coli O157:H7 strains on addition of mineral salts was studied. The objective of the study was to determine the effect of type and concentration of mono-, di-, and trivalent mineral salts on the antimicrobial effectiveness of lysozyme and various chelators against E. coli O157:H7. Seven salts (Al3+, Ca2+, Fe2+, Fe3+, K+, Mg2+, and Na+) at 1 to 10 mM were added to aqueous solutions of lysozyme and disodium ethylenediamine tetraacetic acid (EDTA), disodium pyrophosphate (DSPP), or pentasodium tripolyphosphate (PSTPP) at pH 6, 7, or 8 and applied to cultures of E. coli O157:H7 strains 932 and H1730. Inhibitory activity of lysozyme chelator combinations against both strains was completely lost after addition of > or = 1 mM Ca2+ and Mg2+ at pH 7 and 8. At pH 6, antimicrobial activity of lysozyme-EDTA against both strains was retained in the presence of calcium or magnesium cations. DSPP-lysozyme inhibited strain H1730 at pH 6 despite the presence of Mg2+. Concentrations above 4 mM Fe2+ neutralized activity of all lysozyme-chelator combinations. Reversal of inhibition by lysozyme-chelator complexes by the monovalent Na+ and K+ ions depended on E. coli O157:H7 strain type. Neither monovalent cation reversed inhibition of strain 932. However, Na+ and K+ reversed lysozyme-chelator inhibition of strain H1730. The addition of > or = 1 mM Fe3+ or Al3+ was effective in reversing inhibition of both strains by lysozyme and EDTA at pH 6, 7, and 8. Isothermal titration calorimetry was used to determine the amount of ion-specific competitive binding of free cations by EDTA-lysozyme combinations. A mechanistic model for the antimicrobial functionality of chelator-lysozyme combinations is proposed.

Antimicrobial activity of ultrasound-assisted solvent-extracted spices

AIMS

The objective of this research was to determine the antimicrobial activity of conventional and high-intensity ultrasound-assisted (HI-US) solvent-extracted Thai spices, including ginger (Zingiber officinale Rose), fingerroot (Bosenbergia pandurata Holtt) and turmeric (Curouma longa Linn).

METHODS AND RESULTS

Extracts were obtained using hexane, isopropanol and a 7 : 3 isopropanol : hexane mixture as solvents with and without HI-US. The antimicrobial activity of the extracts was assayed against four strains each of Listeria monocytogenes and Salmonella Typhimurium DT 104 using an agar dilution assay. Application of HI-US did not alter antibacterial activity against S. Typhimurium, but antilisterial activity of some HI-US spice extracts decreased. Solvent type affected antimicrobial efficacy of extracts with hexane producing the least antimicrobial activity. Fingerroot extracted with isopropanol-hexane and without HI-US had the best antilisterial effect while HI-US-isopropanol fingerroot extract had the greatest antimicrobial efficacy against S. Typhimurium.

CONCLUSIONS

Application of HI-US reduced time of extraction to 5 min, compared with the 24 h required for conventional extraction and maintained antimicrobial activity against Salmonella but slightly reduced activity against Listeria.

SIGNIFICANCE AND IMPACT OF THE STUDY

HI-US in combination with proper solvent selection may offer a new tool to optimize extraction of spice essential oil for use as antimicrobial agents, and reduce processing time and costs.

Enhanced inhibition of Escherichia coli O157:H7 by lysozyme and chelators

This study examined the effects of three chelating agents (EDTA, disodium pyrophosphate [DSPP], and pentasodium tripolyphosphate [PSTPP]) on the inhibition of the growth of Escherichia coli O157:H7 by lysozyme. The objective of this study was to identify replacement chelators that exhibit synergistic properties similar to those of EDTA. The inhibitory effects of EDTA at 300 to 1,500 microg/ml and of DSPP and PSTPP at 3,000 to 15,000 microg/ml in combination with lysozyme at 200 to 600 microg/ml for up to 48 h at pHs of 6.0, 7.0, and 8.0 on four strains of E. coli O157:H7 was studied with the use of a microbroth dilution assay. The addition of EDTA enhanced lysozyme's inhibitory effect on strains of E. coli O157:H7. EDTA at > or = 300 microg/ml combined with lysozyme at 200 to 600 microg/ml was sufficient to inhibit the growth of the strains at pHs of 6.0 and 8.0. At pH 7.0, lysozyme at 200 to 600 microg/ml and EDTA concentrations of > or = 1,000 microg/ml were effective in inhibiting three of the four strains. DSPP at pH 6.0 was inhibitory at > or = 10,000 microg/ml when combined with lysozyme at 200 to 300 microg/ml. In contrast, PSTPP increased the inhibitory activity of lysozyme more effectively at pH 8.0. Lysozyme at 200 to 600 microg/ml was effective against two strains of E. coli O157:H7 when used in conjunction with PSTPP at > or = 5,000 microg/ml. The remaining strains were inhibited by PSTPP at > or = 10,000 microg/ml. Our results indicate that inhibition occurred with each lysozyme-chelator combination, but the concentrations of phosphates required to increase the antimicrobial spectrum of lysozyme against E. coli O157:H7 were higher than the EDTA concentrations required to achieve the same effect.

Direct decays from superdeformed states in 192Pb observed using time-correlated gamma-ray spectroscopy

Correlations of decays above and below isomeric states in the normally deformed minimum of 192Pb have been used to identify discrete transitions in the decay of the superdeformed (SD) band. The data establish the absolute excitation energy of the lowest observed SD level as 4.425 MeV. Extrapolation to the bandhead indicates that the excitation energy of the superdeformed well in 192Pb is 0.5 MeV lower than in the heavier isotope 194Pb. The results confirm the trend to decreasing excitation energy with decreasing neutron number predicted by both a macroscopic Strutinsky method approach and microscopic mean field calculations.

Growth of Escherichia coli O157:H7, Salmonella typhimurium DT104, and Listeria monocytogenes in dark cutting beef at 10 or 22 degrees C

An experiment was conducted to determine the effects of the dark, firm, and dry (DFD) condition of beef on growth of the foodborne pathogens Escherichia coli O157:H7, Salmonella Typhimurium DT104, and Listeria monocytogenes Scott A in ground beef. Longissimus muscles from a DFD carcass (pH = 6.45) and normal carcass (N; pH = 5.64) were ground and samples obtained (100 and 0% DFD, respectively). Equal amounts of the 0 and 100% DFD ground samples were mixed to obtain 50% DFD samples. Inoculated 0, 50, and 100% DFD samples were packaged into oxygen-permeable overwrap and stored at 10 degrees C for E. coli O157:H7, Salmonella Typhimurium DT104, and L. monocytogenes Scott A or at 22 degrees C for E. coli O157:H7. Growth characteristics of E. coli O157:H7, Salmonella Typhimurium DT104, and L. monocytogenes Scott A did not differ (P > 0.05) between 0 and 100% DFD. Results indicated that the DFD beef used in this study was no more susceptible to growth of E. coli O157:H7, Salmonella Typhimurium, or L. monocytogenes Scott A than N beef.

Antibacterial activity in extracts of Camellia japonica L. petals and its application to a model food system

The potential presence of naturally occurring antimicrobials in petals of Camellia japonica L., a member of the tea family, was investigated against foodborne pathogens in microbiological media and food. Petals of the camellia flower (C. japonica L.) were extracted with methanol and fractionated into basic, acidic, and neutral fractions. The acidic fraction (equivalent to 1.0 g of raw sample per disk) produced an inhibitory zone of 14 to 19 mm (diameter) in a disk assay against the pathogens Salmonella Typhimurium DT104, Escherichia coli O157:H7, Listeria monocytogenes, and Staphylococcus aureus on agar plates. Silica gel adsorption column chromatography, Sephadex LH-20 column chromatography, and preparative purification by high-pressure liquid chromatography were used to purify compounds in the fraction. The mass spectrum of the antibacterial compound isolated had a molecular ion (M+) of m/z 116 and showed good conformity with the spectrum of fumaric acid (HOOC-CH=CH-COOH). An aqueous extract from the petals of C. japonica L. had an inhibitory effect on growth of all pathogens at 37 degrees C in microbiological media by increasing the lag phase. None of the microorganisms was inhibited completely. Milk was used as a model food system. Aqueous extract at a concentration of 100 mg/ml was bacteriostatic against all the foodborne pathogens in the milk stored at 25 degrees C for up to 4 days.

Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score

OBJECTIVES

To determine whether diagnosis by graded compression ultrasonography improves clinical outcomes for patients with suspected appendicitis.

DESIGN

A randomised controlled trial comparing clinical diagnosis (control) with a diagnostic protocol incorporating ultrasonography and the Alvarado score (intervention group).

SETTING

Single tertiary referral centre.

PARTICIPANTS

302 patients (age 5-82 years) referred to the surgical service with suspected appendicitis. 160 patients were randomised to the intervention group, of whom 129 underwent ultrasonography. Ultrasonography was omitted for patients with extreme Alvarado scores (1-3, 9, or 10) unless requested by the admitting surgical team.

MAIN OUTCOME MEASURES

Time to operation, duration of hospital stay, and adverse outcomes, including non-therapeutic operations and delayed treatment in association with perforation.

RESULTS

Sensitivity and specificity of ultrasonography were measured at 94. 7% and 88.9%, respectively. Patients in the intervention group who underwent therapeutic operation had a significantly shorter mean time to operation than patients in the control group (7.0 v 10.2 hours, P=0.016). There were no differences between groups in mean duration of hospital stay (53.4 v 54.5 hours, P=0.84), proportion of patients undergoing a non-therapeutic operation (9% v 11%, P=0.59) or delayed treatment in association with perforation (3% v 1%, P=0.45).

CONCLUSION

Graded compression ultrasonography is an accurate procedure that leads to the prompt diagnosis and early treatment of many cases of appendicitis, although it does not prevent adverse outcomes or reduce length of hospital stay.

Inguinoscrotal bruising: a sign of neonatal adrenal hemorrhage

A 5-day-old baby presented with right inguinoscrotal bruising. The underlying testis and cord were normal on examination. Intra-abdominal bleeding was suspected. Abdominal ultrasound showed right adrenal hemorrhage. This was managed nonoperatively and with supportive therapy; the inguinoscrotal bruising resolved spontaneously.

Microbiology of potatoes and potato products: a review

Many types of spoilage and pathogenic microorganisms exist on fresh, minimally processed, and fully processed potato products. Potatoes are processed into many products including frozen, dried, ready-to-eat, and minimally processed. The microbiological quality of finished potato products is influenced by the natural microflora, processing, handling, and human contact. The natural microflora of potatoes are influenced by soil and airborne inocula, agricultural practices, harvesting methods, and storage conditions. The microflora of processed products are influenced by all of the factors and conditions affecting the natural microflora as well as the processes applied to the product. Increased consumer demand for new and existing potato products highlights the importance of ensuring their microbiological safety. This review considers the sources of microorganisms, microflora, foodborne disease pathogens, and outbreaks associated with, and selected microbiological research involving, potatoes and potato products.

Activity of hydrolysed lactoferrin against foodborne pathogenic bacteria in growth media: the effect of EDTA

Lactoferrin was hydrolysed with pepsin and the antimicrobial activity of the resulting hydrolysate (HLF) was studied in 1% peptone, 0.05% yeast extract, 1% glucose (PYG) medium and tryptic soy broth (TSB). HLF was effective against Listeria monocytogenes, enterohaemorrhagic Escherichia coli and Salmonella enteritidis in PYG, however, the highest studied concentration (1.6 mg ml-1) did not inhibit growth of any of these organisms in TSB. The addition of EDTA enhanced the activity of HLF in TSB, indicating that the decreased activity of HLF may have been due, in part, to excess cations in the medium.

The experience of hope for survivors of acute myocardial infarction (AMI): a qualitative research study

This qualitative study was undertaken to explore the relevance and meaning of the experience of hope for survivors of acute myocardial infarction (AMI). Depth interviews were conducted with eight survivors (n = 8) of AMI at four weeks following discharge from hospital. Analysis of transcribed interviews revealed three distinct narrative themes. These were holding on to human connectedness, finding and harnessing the 'will' to live, and, having faith in the primacy of a higher power. Study findings are discussed in relation to the literature. Findings of the study assist in building knowledge and understanding of the complex phenomenon of hope. Implications for nursing practice and research are drawn from study findings.

Graded compression ultrasonography in the assessment of the "tough decision" acute abdomen in childhood

The diagnosis of acute appendicitis in childhood is frequently difficult. In some situations the need to operate is clear, but in others the decisions may be much "tougher" because the clinical findings are equivocal. This is a retrospective study of a consecutive series of 253 children presenting with "acute abdominal pain? appendicitis" who had graded compression ultrasonography (GCUS) because the clinical scenario did not warrant immediate laparotomy. This represents 30% of all cases seen in the study period. The aim of the study was to examine the role of GCUS and a clinical scoring system (the Alvarado score) in patients in whom the diagnosis is uncertain.

The experiences of female spouses of survivors of acute myocardial infarction: a pilot study of Lebanese-born women in south-western Sydney, Australia

Lebanese migrants form a significant proportion of the population in southwestern Sydney (SWS), and in New South Wales, Australia. This pilot study was undertaken in south-western Sydney, a rapidly expanding and socioeconomically disadvantaged region, to explore the experiences of English speaking women of Lebanese origin whose spouses had recently experienced an acute myocardial infarction (AMI). Semi-structured interviews were conducted with seven Lebanese-born women at 2- and 4-week intervals, following the discharge of their husbands from hospital. Qualitative analysis of narrative text revealed four distinct themes. These were: struggle to resolve distress; intensive monitoring of the AMI survivor; searching for avenues of support; and reflecting on the future. Study findings are discussed in relation to the literature. Implications for nursing practice and research are drawn from study findings.

Effect of oscillatory high hydrostatic pressure treatments on Byssochlamys nivea ascospores suspended in fruit juice concentrates

The effect of continuous (689 MPa with holding times of 5, 15 or 25 min) and oscillatory (one, three or five cycles at 689 MPa with holding times of 1 s) high hydrostatic pressure treatments on the viability of Byssochlamys nivea ascospores suspended in apple and cranberry juice concentrates adjusted by dilution to water activities (aw) of 0.98 and 0.94 was evaluated at 21 and 60 degrees C. Inactivation of the initial spore inocula was achieved after three or five cycles of oscillatory pressurization at 60 degrees C when the aw was 0.98 in both fruit juices. With aw 0.94, the initial inocula were reduced by less than 1 log-cycle after five pressure cycles. Inactivation was not observed within 25 min with continuous pressurization at 60 degrees C. In treatments at 21 degrees C, no effect on spore viability was observed with continuous or oscillatory treatments.

High hydrostatic pressure come-up time and yeast viability

The effects of the come-up time at selected pressures (50 to 689 MPa) on Saccharomyces cerevisiae and Zygosaccharomyces bailii viability were evaluated at 21 degrees C. For Z. bailii the effects of the water activity (a(w)) of the suspension media and the stage of the growth cycle were also investigated. Pressure come-up times exerted an important effect on the yeast survival fraction, decreasing counts as pressure increased. An increased sensitivity to pressure treatments was observed with yeast cells from the exponential growth phase. Lethality increased as a(w) of the suspension media increased. For an a(w) of 0.98 and cells from the stationary growth phase, pressure treatments at less than 200 MPa had no effect on Z. bailii viability; however, no survivors (< 10 CFU/ml) were observed in treatments applied only for the time needed to reach pressures greater than 517 MPa. Yeast survivor curves showed an excellent fit (r > 0.996) when described by a phenomenological model based on the Fermi equation, S(P) = 1/¿1 + exp[(P - Pc)/k]¿, where S(P) is the survival fraction, P is the pressure, Pc is a critical pressure corresponding to 50% survival, and k is a constant representing the steepness of the curve.

Evaluation of Four Pea ( Pisum sativum ) Cultivars in PE-2 Medium for the MPN Enumeration of Anaerobic Spore-Forming Organisms

Untreated 'Alaska' seed peas have traditionally been used to prepare PE-2 medium, a medium used to recover anaerobic bacteria. Three cultivars of seed peas, 'Columbian', 'Yellow', and 'Scotch' were compared to the cultivar 'Alaska' peas in PE-2 for recovery of Clostridium butyricum ATCC 860, Clostridium sporogenes ATCC 7955/NCA 3679, and Thermoanerobacterium thermosaccharolyticum ATCC 25773 determined by using the most probable number (MPN) technique. Organisms were grown in cooked meat medium (CMM) and enumerated by the three-tube MPN method in PE-2 media incubated at 37°C for 48 h. Recovery of C. butyricum and T. thermosaccharolyticum grown in homogenates of commercial cream-style corn and vegetable beef soup were also evaluated. Similar recovery of organisms from stock cultures or from foodstuffs were observed in PE-2 prepared with three of the pea cultivars ('Alaska', 'Columbian', and 'Yellow'). While the 'Scotch' cultivar PE-2 medium yielded recoveries comparable to PE-2 prepared with the other pea cultivars, turbid tubes were occasionally observed from which viable microorganisms could not be recovered. This cultivar is therefore not recommended due to the probability of yielding false positives in the MPN technique.

Thromboembolic risks of left atrial thrombus detected by transesophageal echocardiogram

Patients with left atrial thrombus are considered at high risk for thromboembolic events. The actual prognosis of these patients and the features most predictive of future events are unclear. We performed transesophageal echocardiograms in 2,894 patients over a 6 1/2-year period; 94 (age 69 +/- 11 years, 59 men, 83 in atrial fibrillation) were found to have left atrial thrombus. The thrombi were considered mobile in 45 patients and 33 patients had thrombus with a maximum dimension > or = 1.5 cm. Seven of the 94 patients with prosthetic valves were excluded from follow-up analysis. Over a follow-up period of 25.3 +/- 19.2 months, 17 patients had suffered a stroke or embolic event (event rate 10.4% per year) and 27 had died (mortality 15.8% per year). Cox proportional hazard regression analysis identified a maximum thrombus dimension > or = 1.5 cm (RR 19, p = 0.002), history of thromboembolism (RR 4.2, p = 0.038), and mobile thrombus (RR 5.3, p = 0.02) as predictors of subsequent thromboembolism. Moderate or severe left ventricular dysfunction was the only significant predictor of death (RR 2.9, p = 0.04). Gender, age, warfarin therapy at follow-up, atrial fibrillation, location (cavity vs appendage) of thrombus, and spontaneous echocardiographic contrast were not significant. Aggressive antithrombotic therapy may be indicated in these high-risk patients.

Isolation and identification of antimicrobial furocoumarins from parsley

Photoactive furocoumarins extracted from four varieties of fresh and freeze-dried parsley leaves inhibited a DNA repair-deficient Escherichia coli in a photobiological assay. Using media-modified assays, the human pathogens E. coli O157:H7 and Listeria monocytogenes, the spoilage microorganism Erwinia carotovora, and Listeria innocua were also inhibited. Pseudomonas fragi was not inhibited. Minimum concentrations of Forest Green parsley powder in agar which showed inhibition ranged from 0.12% to 8.0% depending on the microorganism. Ultraviolet light (UV) at 365 nm for 60 min used to photoactivate the furocoumarins in the bioassay had little effect on L. monocytogenes and L. innocua. A slight UV inhibitory effect was detected with E. carotovora. Furocoumarins, psoralen, 8-methoxypsoralen (8-MOP), 5-methoxypsoralen (5-MOP), oxypeucedanin and isopimpinellin were identified using gas chromatography-mass spectrometry. Psoralen, 8-MOP, and 5-MOP were quantified. A difference in relative furocoumarin concentration (weight of furocoumarin per weight of dry parsley leaves) for all varieties of parsley was revealed. The concentration of 5-MOP was significantly greater than 8-MOP (P < 0.05), but not significantly greater than psoralen. Psoralen and 8-MOP were not significantly different in concentration.

How to avoid complications during percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) has advantages over open gastrostomy, and is an accepted technique for children. However, a number of technical problems may be encountered during insertion. This report identifies those problems and proposes precautions that can be taken to reduce their likelihood. Recognized major complications include esophageal injury, colonic perforation, wound infection, gastric erosion by the gastrostomy tube, and later symptomatic gastroesophageal reflux requiring correction by fundoplication.

Technique and complications of percutaneous endoscopic gastrostomy in children

Percutaneous endoscopic gastrostomy (PEG) is now a well-established technique in children. In this study of 63 children (mean age 7.8 years, youngest 2.4 months), technical problems associated with insertion of the gastrostomy tube, and complications related to the procedure, were analysed. Complications included wound infection, oesophageal injury (probably sustained during extraction of the guide wire) and symptomatic gastro-oesophageal reflux (GOR) occurring after PEG insertion. Many of these complications can be avoided or reduced in likelihood by refinements to the technique of insertion.