Bioarchaeology aids the cultural understanding of six characters in search of their agency (Tarquinia, ninth-seventh century BC, central Italy).

Etruria contained one of the great early urban civilisations in the Italian peninsula during the first millennium BC, much studied from a cultural, humanities-based, perspective, but relatively little with scientific data, and rarely in combination. We have addressed the unusual location of twenty inhumations found in the sacred heart of the Etruscan city of Tarquinia, focusing on six of these as illustrative, contrasting with the typical contemporary cremations found in cemeteries on the edge of the city. The cultural evidence suggests that the six skeletons were also distinctive in their ritualization and memorialisation. Focusing on the six, as a representative sample, the scientific evidence of osteoarchaeology, isotopic compositions, and ancient DNA has established that these appear to show mobility, diversity and violence through an integrated bioarchaeological approach. The combination of multiple lines of evidence makes major strides towards a deeper understanding of the role of these extraordinary individuals in the life of the early city of Etruria.

Periprosthetic tibial fractures after cementless low contact stress total knee arthroplasty.

Periprosthetic fractures are a recognized complication of total knee arthroplasty. Fractures may occur intraoperatively or postoperatively, and risk factors have been identified that may predispose an individual to such a complication. We report 7 cases of periprosthetic tibial fractures after low contact stress total knee arthroplasty, a complication encountered by the senior author (D.E.B.) only after a change in practice from a cemented implant to a cementless one. In light of this previously unreported complication in our unit, we attempted to identify common features within this group of patients that may have contributed to fracture occurrence. Statistical analysis revealed a highly significant (P<.005) risk of periprosthetic tibial fracture in patients with a preoperative neutral or valgus knee. Age, gender, and diagnosis did not appear to increase the risk of fracture significantly. All patients displayed evidence of reduced bone mineral density in the lumbar spine and femoral neck regions on dual-energy x-ray absorptiometry scanning. Patients with a preoperative neutral or valgus knee and local evidence of osteopenia represent a high-risk group, in whom particular care in alignment should be taken. In this group, it may be preferable to have the tibial component inserted with cement fixation.

Total knee arthroplasty without patellar resurfacing in isolated patellofemoral osteoarthritis.

Thirty-one patients (33 knees) with symptomatic patellofemoral osteoarthritis and minimal tibiofemoral changes underwent LCS total knee arthroplasty without patellar resurfacing. Average age was 73 years (range, 58-89 years) with a female-to-male ratio of 5:1. Average follow-up was 20 months (range, 12-40 months). All except 4 patients had grade 3 or 4 patellofemoral osteoarthritis. Preoperatively, all patients had significant knee pain. Sleep disturbance was reported in 21 patients. All but 10 patients required walking aids. Average range of motion was 108 degrees (range, 80-125 degrees ). At latest review, 21 knees were pain-free, the remaining 12 knees being described as having only occasional knee pain. Two patients continued to have night pain. Average range of motion was 104 degrees (range, 70-135 degrees ). Lateral patellar tilt improved in all but 5 knees by an average of 7 degrees (range, 1-26 degrees ). Patellar congruency improved in all but 3 knees by an average of 18% (range, 3-63%). None of the patients to date have required revision surgery. Total knee arthroplasty without patellar resurfacing is an effective option in older patients with isolated patellofemoral osteoarthritis.

Respiratory abdominal muscle recruitment and chest wall motion in myotonic muscular dystrophy.

Abdominal muscles are selectively active in normal subjects during stress and may increase the potential energy for inspiration by reducing the end-expiratory lung volume (EELV). We hypothesized that a similar process would occur in subjects with myotonic muscular dystrophy (MMD), but would be less effective, because of to their weakness and altered chest wall mechanics. Fine-wire electromyography (EMG) of the transversus abdominis (TA), internal oblique (IO), external oblique, and rectus abdominis was recorded in 10 MMD and 10 control subjects. EMG activity, respiratory inductive plethysmography, and gastric pressure were recorded during static pressure measurement and at increasing levels of inspiratory resistance breathing. EELV was reduced and chest wall motion was synchronous only in controls. Although the TA and IO were selectively recruited in both groups, EMG activity of the MMD group was twice that of controls at the same inspiratory pressure. In MMD subjects with mildly reduced forced vital capacity, significant differences can be seen in abdominal muscle recruitment, wall motion, work of breathing, and ventilatory parameters.

Protecting drinking water: water quality testing and PHAST in South Africa.

The paper presents an innovative field-based programme that uses a simple total coliform test and the approach of PHAST (Participatory Hygiene And Sanitation Transformation) to help communities exploring possible water quality problems and actions that can be taken to address them. The Mvula Trust, a South African water and environmental sanitation NGO, has developed the programme. It is currently being tested throughout South Africa. The paper provides two case studies on its implementation in the field, and suggests ways in which the initiative can be improved in the future.

Pursed lips breathing improves ventilation in myotonic muscular dystrophy.

OBJECTIVE: To determine the effects of pursed lips breathing on ventilation, chest wall mechanics, and abdominal muscle recruitment in myotonic muscular dystrophy (MMD). DESIGN: Before-after trial. SETTING: University hospital pulmonary function laboratory. PARTICIPANTS: Eleven subjects with MMD and 13 normal controls. INTERVENTION: Pursed lips breathing. OUTCOME MEASURES: Electromyographic (EMG) activity of the transversus abdominis, external oblique, internal oblique, and rectus abdominis was recorded with simultaneous measures of gastric pressure, abdominal plethysmography, and oxygen saturation. Self-reported sensations of dyspnea, respiratory effort, and fatigue were recorded at the end of each trial. RESULTS: Pursed lips breathing and deep breathing led to increased tidal volume, increased minute ventilation, increased oxygen saturation, reduced respiratory rate, and reduced endexpiratory lung volume. Dyspnea, respiratory effort, and fatigue increased slightly with pursed lips breathing. EMG activity of the transversus abdominis and internal oblique muscles increased in MMD only and was associated with an increase in gastric pressure. CONCLUSIONS: Pursed lips breathing and deep breathing are effective and easily employed strategies that significantly improve tidal volume and oxygen saturation in subjects with MMD. Abdominal muscle recruitment does not explain the ventilatory improvements, but reduced end-expiratory lung volume may increase the elastic recoil of the chest wall. Further clinical studies are needed to ascertain if the ventilatory improvements with pursed lips breathing and deep breathing improve pulmonary outcomes in MMD.

Comparison of functional state between bilateral lung volume reduction surgery and pulmonary rehabilitation: a six-month followup study.

STUDY OBJECTIVE: The effectiveness of bilateral lung volume reduction surgery (BLVRS) in the improvement of functional state in severe chronic obstructive pulmonary disease (COPD) has not been reported. This study examined the effects of BLVRS on subjective and objective measures of functional state (FS) and compared these effects with those gained from pulmonary rehabilitation (PR). METHODS: Twenty-eight consecutive patients were studied. Of 13 BLVRS and 15 PR patients enrolled in the study, 12 and 13 patients, respectively, completed the 6-month protocol. Pulmonary function (FEV1, FVC, and FEF25-75) was measured by spirometry. Subjective FS was measured with the activity component of the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ) and objective FS was determined as the 6-min walk distance (6mwD). Additionally, the maximal dyspnea intensity measured with the Borg scale during the 6-min test was recorded. All outcomes were recorded prior to, and six months following treatment. RESULTS: In patients undergoing BLVRS, FEV1 and FVC increased (17.3% and 16.8%) while in those treated with PR alone, FEV1 and FVC decreased (7.6% and 16.1%,p < 0.05). The subjective functional state (PFSDQ) was also significantly different between BLVRS and PR alone (PFSDQ = -49.4% vs. +4.7%, p < 0.05). Although the absolute distance walked over 6 min did not reach statistical significance, the BLVRS group increased the distance by 20% while the PR alone group had a decrease (-28%). Both groups demonstrated a reduction in dyspnea with exercise but the volume reduction patients showed a significantly greater reduction (PR = -1.0; BLVRS = -2.6, p < 0.05). CONCLUSION: BLVRS results in greater improvement in pulmonary function, dyspnea with exercise, and subjective FS when compared to PR 6 months after surgery.

A participatory approach to community-based HIV / AIDS awareness.

PIP: This paper examines a participatory approach to community-based HIV/AIDS awareness campaigns in South Africa. The SARAR methodology, developed by Lyra Srinivasan, Ron Sawyer, and Jake Pfohl, was adapted specifically to the water supply and environmental sanitation sector through the PROWWESS and Participatory Hygiene and Sanitation Transformation (PHAST) initiative. The SARAR methodology of participatory learning is based on the innate ability of the people to address and resolve their own problems. The application of this methodology in HIV/AIDS awareness was explored through a training session held in KwaZulu/Natal, South Africa. The course seeks to demonstrate how participatory methods could intensify mass media campaigns. A summary of this approach, together with the outcome of the workshop, was presented. This paper concludes that participatory methodologies, such as modified versions of SARAR and PHAST, could open up discussions on HIV/AIDS. It could also assist in developing and strengthening existing household-coping strategies, and emphasize alternative ways for health care professionals to play a supportive, proactive, and constructive role at the community level.^ieng

Perception of fatigue and quality of life in patients with COPD.

INTRODUCTION: Although dyspnea is considered the primary activity-limiting symptom in patients with COPD, other symptoms, such as fatigue, are frequently reported. The purpose of this study was to determine the relationship between fatigue and pulmonary function, exercise tolerance, depression, and quality of life in patients with COPD. METHODS: Forty-one patients (age = 62+/-8 years; FEV1 = 1.08+/-0.55 L; FEV1 percent predicted = 35.8+/-17%) from two sites participated in the study. Spirometric measures of pulmonary function were carried out in each patient. The Multidimensional Fatigue Inventory was used to measure five subscales of fatigue: general, physical and mental fatigue, reduction in activity, and reduction in motivation. The St. George Respiratory Questionnaire, used to measure quality of life, has three subscale dimensions (symptom, activity, and impact), as well as an overall or total quality of life score. Depression was measured with the Centers of Epidemiological Studies Depression Scale. In 19 patients, exercise tolerance was determined with the 6-min walking distance. RESULTS: General fatigue correlated with FEV1, percent predicted (r = -0.32, p < 0.05), exercise tolerance (r = -0.55, p < 0.05), depression (r = 0.44, p < 0.01), and overall quality of life (r = 0.75, p < 0.01). Among the dimensions of fatigue, depression correlated with general and mental fatigue only. Physical dimensions of fatigue correlated with an increase in the severity of pulmonary impairment and reduction in exercise tolerance. The cognitive components of fatigue, such as reduction in motivation and mental fatigue, were not found to be highly correlated with physical dimensions of quality of life. All five subscales of fatigue showed relationship to the functional impact dimension and total impairment score in quality of life. CONCLUSIONS: These data show a relationship between dimensions of fatigue and pulmonary function, exercise tolerance, and quality of life in COPD. Based on these results, fatigue is an important symptom requiring evaluation and management in patients with COPD. These data clarified also the relationship between depression and fatigue in this patient population.

Relationship between subjective fatigue and physiological variables in patients with chronic obstructive pulmonary disease.

Patients with chronic illnesses, such as chronic obstructive pulmonary disease (COPD), report an increase in the perception of fatigue in the clinical setting. Subjective fatigue associated with physiological factors has not been reported. The purpose of this study was to determine the relationship between subjective fatigue and pulmonary function, respiratory and peripheral muscle force and exercise capacity in patients with COPD. Nineteen patients with COPD participated in the study [mean (SD) FEV1 38% (17%) predicted]. Fatigue was measured with the Multidimensional Fatigue Inventory 20 (MFI-20) that includes the following subscale dimensions: general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue. The following physical variables were measured: forced expiratory volume in 1 s (FEV1), vital capacity (VC), maximal inspiratory peak pressure (PImax), symptom-limited bicycle exercise capacity (maximum workload) and maximal voluntary isometric muscle force of both left and right quadriceps (Qu), hamstrings (Ha), biceps (Bi) and triceps (Tr). The MFI-20 fatigue dimensions, reduced activity and reduced Motivation, are significantly correlated with FEV1 (% predicted) (r = -0.62, r = -0.55 respectively). No significant correlation was found between the dimensions of fatigue and maximum workload. In contrast the fatigue dimension, physical fatigue, shows significant correlations with seven of eight muscle forces measured (Qu left r = -0.49, right r = -0.54; Ha left r = -0.49, right r-0.38; Tr left r = -0.61, right r = -0.45; Bi left r = -0.46, right r = -0.48). Data from this study show that activity and physical dimensions of subjective fatigue are related to pulmonary function and skeletal muscle force in COPD patients. Interventions to improve skeletal muscle force might improve subjective fatigue in patients with COPD.

Violence and the nursing curriculum: nurse educators speak out.

Violent crime in the United States is increasing at an alarming rate. Nurses are the first to encounter its victims--but are they prepared for them? Two activities at the 1995 NLN convention gathered the opinions, concerns, and recommendations of nurse educators about how education can help better equip nurses to perform the role of violence preventer and care provider.

Violence-related content in the nursing curriculum: a national study.

Educational preparation of nurses is key to their effective participation in prevention, assessment, treatment and care of victims and survivors of violence. This exploratory study examined the extent, placement, and faculty responsible for curricular content on abuse and violence against women, children, and elders. The national study, grounded within an ecological framework, used a 35-item mailed questionnaire that included demographic, course content and curriculum development items. Completed questionnaires were returned from 298 (48%) of programs surveyed. Findings showed that most programs included content related to women, child and elder abuse; each content area was presented in two hours or less; and clinical practice opportunities were primarily coincidental. Fifty-three percent of respondents believed content was adequately addressed; 68% recommended curriculum development workshops to address curricular issues related to violence. The significance of the study is related to the relevancy of current nursing education to social problems of increasing violence and abuse.

Metaphorical communication as aesthetic method for nursing practice.

This paper focuses on metaphorical communication as an aesthetic method for nursing practice. Metaphorical communication is proposed as a healing modality. Use of metaphors in nursing are highlighted, and types of metaphors that may be used for transformation and healing are described.

Aesthetic methods as a means of knowing for nursing.

This paper introduces aesthetic methods as a means of knowing for the nursing profession. The importance of aesthetics for development of nursing knowledge is highlighted. This paper provides the background for the following series of three papers addressing use of aesthetic methods within nursing practice and education.

Respiratory muscle function in patients with chronic obstructive pulmonary disease.

Respiratory muscle (RM) dysfunction is a progressive process, including both RM weakness and fatigue, that may advance to the point of respiratory failure. It occurs as a result of increased RM workloads, altered length-tension relationship of respiratory muscles, malnourished states, and altered cellular environment in chronic obstructive pulmonary disease (COPD). Consideration of multiple patient factors is necessary when identifying patient risk for RM dysfunction and designing plans of care. This article discusses the RM pump, including its measurement, in patients with COPD.

A pharmacodynamic and pharmacokinetic comparison of intravenous quinaprilat and oral quinapril.

Quinaprilat is the active metabolite of quinapril, an orally active angiotensin-converting enzyme (ACE) inhibitor. The dose-response and duration-of-effect after single intravenous doses of quinaprilat and placebo (part A) and after administration of oral quinapril solution and intravenous quinaprilat (part B) were assessed in a randomized, crossover study of two groups of 12 healthy volunteers. Pharmacodynamic effects of quinaprilat and oral quinapril were assessed by measurement of blood pressure changes after an infusion of angiotensin I (A-I) at a dose previously determined to produce an increase in diastolic blood pressure of 25 mmHg under standardized conditions (A-I pressor response). A clear dose-response relationship was demonstrated for quinaprilat in this pharmacodynamic model, with 0.5 mg as the lowest effective dose. Doses of 1.0 mg and higher partially suppressed A-I pressor response for at least 6 hours. Onset of action was observed within 15 minutes of intravenous administration of quinaprilat and was independent of dose, whereas peak effect and duration of action appeared to be dose related. Quinaprilat doses of 2.5 mg and 10 mg achieved approximately 50% and > 80% inhibition of the A-I pressor response, respectively. In part B, these doses of intravenous quinaprilat were compared with oral doses of quinapril previously found to produce 50% (2.5 mg) and 90% (10 mg) inhibition of the A-I pressor response. The magnitude of effect was similar after administration of 20 mg quinapril orally and 10 mg quinaprilat intravenously. Duration of action was longer, however, after administration of intravenous quinaprilat (10 mg) than after oral quinapril (20 mg), due to the higher maximum plasma concentration (Cmax) of quinaprilat. Mean area under the plasma concentration-time curve extrapolated to infinity (AUC0-infinity) of quinaprilat was similar after the 10-mg dose of intravenous quinaprilat and the 20-mg dose of oral quinapril. Based on the concentrations of quinaprilat observed in this study, the absolute bioavailability of quinapril was approximately 50%; intravenous quinaprilat should therefore produce a pharmacodynamic response similar to that obtained with oral quinapril at approximately half the dose.

Functional status instruments: outcome measure in the evaluation of patients with chronic obstructive pulmonary disease.

The purpose of this article is to review the instruments developed to measure functional status in patients with chronic obstructive pulmonary disease. Because the ability to carry out day-to-day activities is of primary importance to patients with chronic obstructive pulmonary disease, it is necessary for clinicians to understand which instruments provide the best measures of patient activity levels. Furthermore, as a critical outcome in managed care services, pulmonary critical pathways, and patient disability, the measurement of functional status in clinical practice assumes greater relevance. Functional status instruments in this review will refer to questionnaires measuring the day-to-day activities of patients. Questionnaires reviewed will include those that provide measures of general health status with activity-specific items, as well as questionnaires specifically designed to evaluate patients with pulmonary disease. The psychometric strengths, reliability and validity, and clinical utility of the instruments will be presented.

Outcomes research: contemporary issues and historical significance for nurse practitioners.

Outcomes research is not new to the discipline of nursing. However, the driving forces of today's health care environment are resulting in increased emphasis on the study of outcomes. This article presents an overview of the scope of outcomes research, including a historical perspective and contemporary issues. Outcomes research provides an opportunity to demonstrate the effectiveness of nurse practitioner practice.

Investigations of the function of the vascular endothelium in portal hypertensive rats.

There were no differences between mesenteric arteries from sham or 14-day portal hypertensive (PH) rats in the potency of or maximum endothelium-dependent relaxations (EDR) to acetylcholine. There were no differences between sham-operated and PH rats in the effects of the combination of the nitric oxide synthase inhibitor NG-monomethyl-L-arginine (100 mumol/l) and methylene blue (10 mumol/l) in causing a significant reduction in the EDR to acetylcholine. The degree of portal-systemic shunting, as measured by 57Co-labeled microspheres, was unaffected by acute administration of NG-monomethyl-L-arginine (50 mg/kg) or methylene blue (5 mg/kg). In conclusion, nitric oxide is the main mediator of EDR in rat mesenteric artery, and no evidence was found for an increased role for endothelial-derived nitric oxide in PH rats.

Respiratory responses to unsupported arm lifts paced during expiration.

Unsupported arm exercise endurance is reduced in both normal subjects and patients with chronic obstructive pulmonary disease in association with an increase in dyspnea and alterations in the pattern of respiratory muscle recruitment. Some report greater difficulty carrying out arm activity paced during the expiratory phase of respiration rather than during inspiration. The purpose of this study was to determine the effect of unsupported arm exercise lifts paced in phase with expiration (EUAL) on (a) diaphragm recruitment measured as the electromyographic amplitude (EMG-DI), (b) the pattern of thoracoabdominal motion measured with inductive plethysmography, and (c) the sensation of dyspnea measured with a 100 mm visual analog scale. Data were collected from 18 normal adult subjects at baseline and during EUAL. When compared with rest, EUAL resulted in significant increases in mean inspiratory and expiratory diaphragm EMG amplitudes, dyssynchronous thoracoabdominal motion, and dyspnea intensity. These changes in diaphragm recruitment and thoracoabdominal motion may in part explain reports of increased dyspnea intensity with unsupported arm exercise.