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 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.

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.

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.

Facilitators and Barriers to Health-Seeking Behaviours among Filipino Migrants: Inductive Analysis to Inform Health Promotion.

Understanding factors that influence health-seeking behaviour of migrants is necessary to intervene for behaviour change. This paper explores Filipino migrants' perceptions of facilitators and barriers to maintaining health in Australia. Open-ended survey item responses reflecting factors that assisted and hindered health following migration to Australia were inductively analysed. Three hundred and thirty-seven of the 552 survey respondents (61%) provided open-ended responses. Responses were grouped into two major categories: individual factors, including personal resources and cultural influences, and environmental factors encompassing both the physical conditions in the host country and health service access. Awareness of practices that enhance health was a major personal facilitator of health-seeking behaviour; however, competing priorities of daily living were perceived as barriers. Cultural beliefs and practices influenced health-seeking behaviour. Despite high self-rated English language skills in this population, new migrants and the elderly cited communication difficulties as barriers to accessing health services. Insight into facilitators and barriers to health-seeking behaviour in this less researched migrant population revealed tools for enhancing engagement in health promotion programs addressing healthy lifestyle.

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.

Gender difference in academic performance of nursing students in a Malaysian university college.

PURPOSE: To examine differences in academic performance between male and female nursing students, and to identify whether professional identity and language usage were explanatory factors of academic performance. BACKGROUND: Although the numbers of men entering the nursing profession are increasing, societal stereotypes and the lack of male role models in nursing may have a negative impact on motivation, and hence, academic performance. METHODS: A total of 147 students who were enrolled in an undergraduate nursing programme in Peninsula Malaysia were surveyed in January 2011. In addition to demographic and academic data, three instruments were administered to measure language acculturation and professional identity. FINDINGS: The mean age of participants was 20.0 (SD: 1.5) years with 81% being female. Almost all students spoke the Malay language at home. Although there were no differences between male and female nursing students in relation to professional identity (P=0.496), male nursing students reported a lower mean English language usage score (9.9 vs. 10.9, P=0.011) and a higher mean Malay language usage score (20.4 vs. 18.8, P=0.017). Males were also found to have lower academic performance than female students, as measured by grade point average (GPA) (2.7 vs. 3.2, P<0.001). Regression analysis revealed gender was the only significant predictor of academic performance (ß=-0.44, P<0.001). CONCLUSIONS: Males represent less than 10% of the nursing workforce in developed countries, with some developing countries experiencing even lower participation rates. Promoting academic support of male nursing students may assist in increasing the number of male registered nurses in the nursing workforce.

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.

Resuscitation of out-of-hospital cardiac arrests in residential aged care facilities in Melbourne, Australia.

INTRODUCTION: CPR in patients in residential aged care facilities (RACF) deserves careful consideration. We examined the characteristics, management and outcomes of out-of-hospital cardiac arrest (OHCA) in RACF patients in Melbourne, Australia. METHODS: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs occurring in RACFs in Melbourne. The characteristics and outcomes were compared to non-RACF patients in the VACAR. RESULTS: Between 2000 and 2009 there were 30,006 OHCAs, 2350 (7.8%) occurring in a RACF. A shockable rhythm was present in 179 (7.6%) patients on arrival of paramedics of whom bystander CPR had been performed in 118 (66%); 173 (97%) received an EMS attempted resuscitation. ROSC was achieved in 71 (41%) patients and 15 (8.7%) patients survived to leave hospital. Non shockable rhythm was present in 2171 patients (92%) of whom 804 (37%) had an attempted resuscitation by paramedics. ROSC was achieved in 176 patients (22%) and 10 patients (1.2%) were discharged alive. Survival from OHCA occurring in a RACF was less than survival in those aged >70 years of age who suffered OHCA in their own homes (1.8% vs. 4.7%, p=0.001). On multivariable analysis, witnessed OHCA (OR 3.0, 95% CI 2.4-3.7) and the presence of bystander CPR (OR 4.6, 95% CI 3.7-5.8) was associated with the paramedic decision to resuscitate. CONCLUSION: Resuscitation of patients in RACF is not futile. However, informed decisions concerning resuscitation status should be made by patients and their families on entry to a RACF. Where it is appropriate to perform resuscitation, outcomes may be improved by the provision of BLS training and possibly AED equipment to RACF staff.

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 programmes: 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: A prospective cross-sectional survey was used to conduct a national audit. SETTING: Community setting of CHF-MPs for patients postdischarge. SAMPLE: All CHF-MPs operating during 2005-2006 (n=55). Also 10-50 consecutive patients from 48 programmes were 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 postdischarge 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 caseload 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% conducting 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%), ß-blockers (n=17, 71%), ACE inhibitors (ACEIs) (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.

Clinical effectiveness in everyday practice: improving outcomes for all patients through a national acute coronary syndrome data collaborative.

The management of acute coronary syndromes (ACS) has an extensive and impressive evidence-base with which to guide clinical practice. Despite this, translation to the clinical environment has proved to be challenging and incomplete and can be attributed to patient, provider and system factors. Causes of suboptimal guideline adherence relate to diverse issues, including patient complexity, barriers in knowledge translation of guideline recommendations and a limited capacity within health services. Addressing these factors may enable more effective guideline implementation. In Australia, the infrastructure for clinical data management is fragmented, uncoordinated and often administratively driven, compromising access to important information, which might improve clinical effectiveness. An integrated approach is required to improve clinical effectiveness in ACS care in Australia. Greater access to information both to assist in clinical decision-making and monitoring outcomes may help direct the focus towards understudied populations and improve performance and clinically relevant outcomes. A peer-led initiative based on common datasets, providing rapid feedback, while developing and disseminating a 'toolbox' of proven and sustainable interventions, could improve clinical effectiveness in the Australian management of ACS and provides a rationale for a national ACS registry.

Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator associated pneumonia in mechanically ventilated patients: a randomised control trial.

BACKGROUND: Ventilator associated pneumonia remains an important concern in the intensive care unit (ICU). An increasing body of evidence shows that mortality and morbidity can be reduced by implementing a range of preventive strategies, including optimizing oral hygiene. AIM: The aim of this feasibility study was to test two oral hygiene strategies on the effects of microbial colonization of dental plaque with respiratory pathogens (primary outcome) and incidence of ventilator associated pneumonia (secondary outcome). METHODS: A single blind randomised comparative study was conducted in a 20-bed adult intensive care unit in a university hospital. Patients with an expected duration of mechanical ventilation more than 48 h were eligible. Patients were randomised to one of three study regimens (Group A control, second hourly oral rinse with sterile water, Group B sodium bicarbonate mouth wash second hourly, and Group C twice daily irrigations with chlorhexidine 0.2% aqueous oral rinse and second hourly irrigations with sterile water). All study options included cleaning with a toothbrush and non foaming toothpaste. RESULTS: Data from a total of 109 patients were analyzed. Group A 43, Group B 33 and Group C 33 (mean age: 58 ± 17 years, simplified acute physiology score II: 44 ± 14 points). On admission no significant differences were found between groups for all clinical data. While Group B showed a greater trend to reduction in bacterial colonization no significant differences could be demonstrated at Day 4 of admission (p=0.302). The incidence of ventilator associated pneumonia was evenly spread between Groups B and C (5%) while Group A was only 1%. CONCLUSIONS: While a number of studies have advocated the use of various mouth rinses in reducing colonization of dental plaque a standardized oral hygiene protocol which includes the use of mechanical cleaning with a toothbrush may be a factor in the reduction of colonization of dental plaque with respiratory pathogens. This feasibility study provides data to inform future adequately powered studies.

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.

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.

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.