Simulated versus traditional therapeutic radiography placements: A randomised controlled trial.

INTRODUCTION: Clinical placements provide rich learning environments for health professional pre-registration education but add significant workload pressure to clinical departments. Advances in simulation approaches mean that many aspects of students' clinical learning can be undertaken in the academic environment. There is, however, little data identifying specific pedagogical gains afforded by simulation compared to clinical placement. This study measured the impact of a comprehensive integrated simulation placement on student clinical skill acquisition. METHODS: A virtual department was developed using a range of simulation equipment and software, with actors and service users providing a range of patients for students to engage with. A cohort of 29 first-year undergraduate therapeutic radiography students were randomly assigned to either simulated or conventional clinical placement. Clinical skills assessment scores provided by a blinded assessor were then compared. RESULTS: Mean overall assessment scores for each cohort were within 3% of each other. The simulation cohort had over 10% higher "communication" scores than the traditional group (p = 0.028). The ability to gain both technical and interpersonal skills simultaneously improved learning compared to clinical placement. Students valued the structured approach of the simulated placement and the opportunity to practice techniques in a safe unpressured environment. CONCLUSION: An integrated simulated placement can help students to achieve clinical learning outcomes and lead to improved interpersonal skills. IMPLICATIONS FOR PRACTICE: Use of blended simulation resources can enable students to acquire technical, procedural and interpersonal skills which in turn may enable reduction of overall clinical placement time and departmental training burden.

The Impact of Rimed Ice Hydrometeors on Global and Regional Climate.

Rimed hydrometeors (graupel or hail) are added to a stratiform cloud scheme for global models and tested in a variety of configurations. Off-line tests compare well to other cloud microphysics schemes with rimed ice used in mesoscale models. Tests in single column and climate mode show expected production of small amounts of rimed ice in the middle troposphere and at high latitudes. The overall climate impacts of rimed ice (hail or graupel) at 100-km horizontal grid spacing are small. There are some changes to partitioning between cloud ice and snow that affect upper troposphere water budgets and clouds. High-resolution simulations are conducted with a global but regionally refined grid at 14 km over the Contiguous United States. High-resolution simulations show local production of graupel with realistic size and number concentrations. The maximum graupel frequency at high resolution is over Western U.S. mountain ranges. Differences in total precipitation with the addition of rimed ice in 8-year simulations are statistically significant only for orographic precipitation over the Cascade and Rocky mountains, reducing model biases when rimed ice is included. Rimed ice slightly improves summer precipitation intensity relative to observations. Thus, while the global climate impact of rimed ice in stratiform clouds may be negligible, there are potentially important and systematic regional effects, particularly for orographic precipitation. Rimed ice in cumulus clouds is not yet treated but is an important next step.

Autonomic dysreflexia and associated acute neurogenic pulmonary edema in a patient with spinal cord injury: a case report and review of the literature.

STUDY DESIGN: A case report of a patient with spinal cord injury with autonomic dysreflexia and associated acute neurogenic pulmonary edema. OBJECTIVE: To further describe autonomic dysreflexia as a potential cause of acute neurogenic pulmonary edema; specifically in a population with spinal cord injury. SETTING: James A Haley Veterans Hospital, Tampa, FL, USA. METHODS: A patient with a prior history of C5 AIS (ASIA impairment scale) B spinal cord injury was admitted for bowel preparation before a screening colonoscopy. During the 2-day bowel preparation, the patient developed severe autonomic dysreflexia. Due to persistent hypertension and acute onset respiratory failure, he required transfer to the intensive care setting. RESULTS: Following a complicated course, the patient expired without a definitive cause of death. Autopsy findings showed gross and microscopic evidence of pulmonary edema. CONCLUSIONS: To date, the association between autonomic dysreflexia and acute neurogenic pulmonary edema is not described in the spinal cord or rehabilitation literature. The purpose of this case report is to further describe the overlooked and/or under reported incidence of acute neurogenic pulmonary edema associated with episodes of dysreflexia in a population with spinal cord injury.

Patient preferences versus physician perceptions of treatment decisions in cancer care.

PURPOSE: To examine patient preferences as well as physician perceptions of these preferences for decision making and communication in palliative care. PATIENTS AND METHODS: Medical decision-making preferences (DMPs) were prospectively studied in 78 assessable cancer patients after initial assessment at a palliative care outpatient clinic. DMPs were assessed with a questionnaire using five possible choices ranging from 1 (patient prefers to make the treatment decision) to 5 (patient prefers the physician to make the decision). In addition, the physician's perception of this preference was assessed. RESULTS: Full concordance between the physician and the patient was seen in 30 (38%) of 78 cases; when the five original categories were recombined to cover active, shared, and passive decision making, there was concordance in 35 (45%) of 78 cases. The kappa coefficient for agreement between physician and patient was poor at 0.14 (95% confidence limit, -0.01 to 0.30) for simple kappa and 0.17 (95% confidence interval [CI], 0.00 to 0.34) for weighted kappa (calculated on the three regrouped categories). Active, shared, and passive DMPs were chosen by 16 (20%) of 78, 49 (63%) of 78, and 13 (17%) of 78 patients, and by 23 (29%) of 78, 30 (39%) of 78, and 25 (32%) of 78 physicians, respectively. The majority of patients (49 [63%] of 78; 95% CI, 0.51 to 0.74) preferred a shared approach with physicians. Physicians predicted that patients preferred a less shared approach than they in fact did. Patient age or sex did not significantly alter DMP. CONCLUSION: An individual approach is needed and each patient should be assessed prospectively for DMP.

The addition of an audiocassette recording of a consultation to written recommendations for patients with advanced cancer: A randomized, controlled trial.

BACKGROUND: Communication between physicians and advanced cancer patients is frequently difficult. Patients often report poor levels of satisfaction with communication. The purpose of this study was to assess the impact on patients' recall of and overall satisfaction with their consultation by the addition of an audiocassette recording of a consultation to written recommendations. METHODS: Sixty patients with advanced cancer were randomized to either receive a tape recording of their consultation or receive no tape in addition to written recommendations in this randomized, double-blind trial. Patients gave their global ratings of the clinic, were tested for their recall of information given, and responded to questions about the utilization and role of the cassette in influencing family communication. RESULTS: The addition of the audiocassette to written communications significantly increased patient satisfaction with the clinic (8.7 +/- 1.7 vs. 7.7 +/- 2.0 on a scale of 0-10; P = 0.04) and significantly improved recall of the information given during the consultation (88% +/- 8.7% vs. 80% +/- 15.5%; P = 0.02). Patients expressed a high level of satisfaction with the audiocassette. Patients listened to the tape a median of 2 (range 1-4) times, whereas family members and friends listened to the cassette a median of 2 (range 1-3) times. CONCLUSIONS: The addition of an audiocassette recording of an outpatient consultation to written recommendations for patients with advanced cancer is capable of increasing both the overall patient recall of the visit and satisfaction with the outpatient clinical setting. Patients expressed a high level of satisfaction with the audiocassette.

A randomized controlled trial of local injections of hyaluronidase versus placebo in cancer patients receiving subcutaneous hydration.

BACKGROUND: Most cancer patients develop reduced oral intake or dehydration before death. Subcutaneous hydration (SCH) can be safe and effective. SCH is frequently administered using hyaluronidase to improve fluid absorption. The objective of this study was to determine the effects of hyaluronidase on patient comfort during bolus SCH. PATIENTS AND METHODS: Twenty-one cancer patients requiring parenteral hydration were administered a 500 cc bolus of two-thirds dextrose (5%) and one-third normal saline solution subcutaneously at 08:00 and 16:00 hours during day 1 and day 2. On day 1 patients were randomized on a double-blind basis to receive 150 units of hyaluronidase versus placebo as a bolus into the site of infusion immediately before starting each one-hour infusion. During day 2 patients were crossed over to receive the alternate treatment at a new infusion site. Visual analogue scales (0 = best, 100 = worst) for pain and swelling at the infusion site were completed by each patient. In addition, investigators blindly assessed the site of infusion for the presence of edema, rash, and leakage. RESULTS: No significant differences were observed for pain, swelling, edema, rash or leakage between the placebo and the hyaluronidase scores. After completion of the two days of the study, patients blindly chose hyaluronidase in 1 (5%) case, placebo in 5 (24%) cases, and no preference in 15 (71%) cases (P < 0.01). There was no treatment or interaction effect for pain, except for a period effect (P = 0.045) for the morning bolus administration. There were no treatment, period, or interaction effects for any of the other variables. CONCLUSIONS: Our results suggest that hyaluronidase is not necessary for routine bolus SCH. It may still be useful for a minority of patients who are not able to tolerate infusion well due to swelling or pain.

Identification of iron-regulated proteins of Mycobacterium tuberculosis and cloning of tandem genes encoding a low iron-induced protein and a metal transporting ATPase with similarities to two-component metal transport systems.

Iron plays a central role in the pathogenesis of Mycobacterium tuberculosis, the principal causative agent of tuberculosis. To learn more about iron acquisition by this bacterium, its iron regulated proteins (IRPs) were investigated. Seven IRPs were identified - three increased by high iron concentrations, and four by low iron concentrations. The smallest protein induced by low iron, Irp10, is tightly iron regulated as it is virtually absent in bacteria cultured in the presence of high iron concentrations. The gene (irpA ) encoding this protein and an adjacent open reading frame, mtaA, were cloned and sequenced. The protein encoded by mtaA (Mta72) has striking homology to metal transporting P-type ATPases. This study suggests that Irp10 and Mta72 function as a two-component metal transport system in M. tuberculosis.

Cancer pain management and the role of social work: barriers and interventions.

Quality of life has become increasingly important in the management of cancer, because patients with the disease are surviving longer. Although effective therapies exist, more than half of all cancer patients suffer unrelieved pain during illness and treatment. Undertreated and unnecessary pain represents a failure of the multidisciplinary team, including the social worker, to respond appropriately to the needs of cancer patients. This article increases social workers' awareness of the prevalence of cancer-related pain, identifies the barriers that undermine effective pain relief, and develops a model for social work intervention. Skills such as communication, assessment, problem solving, and psychological support are explored in detail.

Beyond informed consent.

The issue of informed consent ranks among the most heavily debated topics in health care. Nearly all health professionals, at some time in their practice, encounter situations in which they question their own involvement and responsibility in obtaining a consent for medical treatment. Such situations are becoming increasingly common for nurses as the structure of the health care system changes and nurses' roles become more diversified. Nurses are wise to try to understand the principles involved in informed consent and to recognize the potential for dilemmas involving ethics and hospital policies.

Antioxidant activity of saliva and periodontal disease.

The antioxidant activity of saliva has been investigated in 28 apparently healthy individuals and seven dental patients with periodontal disease. The results show that the major aqueous antioxidant component of whole saliva is uric acid, with lesser contributions from ascorbic acid and albumin. All are present at lower concentrations than those found in the plasma water. The total antioxidant activity (TAA) of saliva correlates (r2 = 0.972) with the concentration of uric acid, which contributes more than 70% of the TAA. Stimulation of salivary flow is associated with increased production of antioxidants. The antioxidant potential of saliva does not appear to be compromised in patients with periodontal disease but this may relate to the antioxidant flow from the gingival crevicular fluid.

Predictive testing for Huntington disease: social characteristics and knowledge of applicants, attitudes to the test procedure and decisions made after testing.

An investigation has been made of the social characteristics and knowledge and experience of Huntington disease (HD) for the first 80 individuals considering presymptomatic testing (applicants) at the medical genetics centres in Edinburgh and Glasgow and of attitudes to the test procedure and decisions made after testing for those who received a result. Sixty-one percent of applicants were female and 31% were over 40 years old. Almost all had a symptomatic parent but 38% did not know HD was in their family until they were over 25 years old and 48% had never received genetic counselling. Thirty-eight percent of applicants first heard of the test at the genetic clinic, 20% from a relative and 20% from the media, but none had received information from their GP. Thirty-one applicants did not have the test because they voluntarily withdrew (17 individuals), their family structure was unsuitable or no informative result was possible (11 individuals), or they were diagnosed clinically as being affected (3 individuals). Those who voluntarily withdrew did not differ significantly from the 49 who received a result in social characteristics or knowledge and experience of HD. Twenty-two individuals were found to be at increased risk (IR) (> 50% of becoming affected) and 27 to be at decreased risk (DR) (< 50% of becoming affected). There was a median period of 9 months between entering the test procedure and receiving a result and the main criticism of the procedure was that it took too long to complete and several individuals experienced considerable anxiety while awaiting their result.(ABSTRACT TRUNCATED AT 250 WORDS)

Deletion of the COX7 gene in Saccharomyces cerevisiae reveals a role for cytochrome c oxidase subunit VII in assembly of remaining subunits.

Cytochrome c oxidase from Saccharomyces cerevisiae is composed of nine subunits. Subunits I, II and III are products of mitochondrial genes, while subunits IV, V, VI, VII, VIIa and VIII are products of nuclear genes. To investigate the role of cytochrome c oxidase subunit VII in biogenesis or functioning of the active enzyme complex, a null mutation in the COX7 gene, which encodes subunit VII, was generated, and the resulting cox7 mutant strain was characterized. The strain lacked cytochrome c oxidase activity and haem a/a3 spectra. The strain also lacked subunit VII, which should not be synthesized owing to the nature of the cox7 mutation generated in this strain. The amounts of remaining cytochrome c oxidase subunits in the cox7 mutant were examined. Accumulation of subunit I, which is the product of the mitochondrial COX1 gene, was found to be decreased relative to other mitochondrial translation products. Results of pulse-chase analysis of mitochondrial translation products are consistent with either a decreased rate of translation of COX1 mRNA or a very rapid rate of degradation of nascent subunit I. The synthesis, stability or mitochondrial localization of the remaining nuclear-encoded cytochrome c oxidase subunits were not substantially affected by the absence of subunit VII. To investigate whether assembly of any of the remaining cytochrome c oxidase subunits is impaired in the mutant strain, the association of the mitochondrial-encoded subunits I, II and III with the nuclear-encoded subunit IV was investigated.(ABSTRACT TRUNCATED AT 250 WORDS)

Quality improvement: a new approach to quality assurance.

The use of programs to help administrators and staff of health care facilities assess and monitor the quality of services provided is not new. For years, quality assurance (QA) programs have provided generalized sets of standards against which hospitals and other agencies measure their performance. Recently, there has been a trend towards quality improvement (QI) programs which advocate a more proactive response to quality concerns and emphasize a decentralized use of assessment and evaluation findings to continuously improve the care provided. QI is recognized as holding great opportunities for the enhancement of professional nursing practice and the improvement of patient care. In this paper, the process and design of QI was described and the advantages of this approach were recognized.

Participation of cytochromes in some oxidation-reduction systems in Campylobacter fetus.

Campylobacter species are rich in c-type cytochromes, including forms which bind carbon monoxide. The role of the various forms of cytochromes in Campylobacter fetus has been examined in cell-free preparations by using physiological electron donor and acceptor systems. Under anaerobic conditions, NADPH reduced essentially all of the cytochrome c in crude cell extracts, whereas the reduction level with succinate was 50 to 60%. The carbon monoxide spectrum with NADPH was predominated by the cytochrome c complex; evidence of a cytochrome o type was seen in the succinate-reduced extracts and in membrane fractions. Succinate-reduced cytochrome c was oxidized by oxygen via a cyanide-sensitive, membrane-associated system. NADPH-reduced cytochrome c was oxidized by a cyanide-insensitive system. Partially purified carbon monoxide-binding cytochrome c, isolated from the cytoplasm, could serve as electron acceptor for NADPH-cytochrome c oxidoreductase; the reduced cytochrome was oxidized by oxygen by a cyanide-insensitive system present in the cytoplasmic fraction. Horse heart cytochrome c was also reducible by NADPH and by succinate; the reduced cytochrome was oxidized by a cyanide-sensitive system in the membrane fraction. NADPH and NADH oxidase activities were observed aerobically and under anaerobic conditions with fumarate. NADPH was more active than NADH. NADP was also more effective than NAD as an electron acceptor for the coenzyme A-dependent pyruvate and alpha-ketoglutarate dehydrogenase activities found in crude extracts. These dehydrogenases used methyl viologen and metronidazole as electron acceptors; they could be loci for oxygen inhibition of growth. It is proposed that energy provision via the high-potential cytochrome c oxidase system in the cytoplasmic membrane is limited by oxygen-sensitive primary dehydrogenases and that the carbon monoxide-binding cytochrome c may have a role as an oxygen scavenger.