GOALS-incisional hernia: a valid assessment of simulated laparoscopic incisional hernia repair.

The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid and reliable measure of basic, non-procedure-specific laparoscopic skills. GOALS-incisional hernia (GOALS-IH) was developed to evaluate performance of laparoscopic incisional hernia repair (LIHR). The purpose of this study was to assess the validity and reliability of GOALS-IH during LIHR simulation. GOALS-IH assesses 7 domains with a maximum score of 35. A total of 12 experienced surgeons and 10 novices performed LIHR on the Surgical Abdominal Wall simulator. Performance was assessed by a trained observer and by self-assessment using GOALS-IH, basic GOALS and a visual analog scale (VAS) for overall competence. Both interrater reliability and internal consistency were high (.76 and .95 respectively). Experienced surgeons had higher mean GOALS-IH scores than novices (32.3 ± 2 versus 22.7 ± 5). There was excellent correlation between GOALS-IH and other measures of performance (GOALS r = .93 and VAS r = .93). GOALS-IH is easy to use, valid and reliable for assessment of simulated LIHR.

Randomized controlled trial of clarithromycin and ethambutol in the treatment of Crohn's disease.

BACKGROUND: A mycobacterial infection may be the cause of Crohn's disease in some patients. Measurement of intestinal permeability may identify Crohn's disease patients with a high likelihood of relapse and may quantify the severity of intestinal injury. AIM: To assess the effect of 3 months of clarithromycin and ethambutol on the disease activity and intestinal permeability in patients with Crohn's disease at high risk of relapse. METHODS: Patients with Crohn's disease, with a lactulose-mannitol permeability test above 0.03, were randomly assigned to receive either clarithromycin, 500 mg twice daily, and ethambutol, 15 mg/kg daily, or identically appearing placebo for 3 months in addition to their regular therapy. The Harvey-Bradshaw index and the lactulose-mannitol test were assessed in a blind fashion every 3 months for 12 months. RESULTS: Thirty-one patients were randomized to receive either drugs (n=15) or placebo (n=16). The groups were similar in age, sex, duration of disease, location of disease, past complications and disease severity. Specifically, there was no difference between the drug or placebo groups in the mean Harvey-Bradshaw index (4.8 vs. 4.4), number with active disease (33% vs. 44%) and mean lactulose-mannitol test (0.06 vs. 0.10). During the 12-month follow-up period, there were no consistent, statistically significant differences in the mean Harvey-Bradshaw index or lactulose-mannitol test between treatment and placebo groups. Individual patients showed either improvement or worsening of these indices, but these were not related to study medication. Specifically, no 'cures' were noted with anti-mycobacterial treatment. CONCLUSIONS: Three months of treatment with clarithromycin and ethambutol does not benefit Crohn's disease patients who are receiving standard medical therapy.

The community services card: does it make a difference to pharmaceutical utilisation?

AIMS: To estimate the utilisation rate, and amount of state subsidy of prescription items per head by age, sex and community Services Card (CSC) for the year ended June 1999. METHODS: Data from a market research company (IMS Health), Health Benefits Limited, Statistics New Zealand and Work and Income New Zealand were used to calculate average per head per year pharmaceutical utilisation rate and subsidy cost for CSC holders and non-holders. RESULTS: For both sexes, and for all age groups, CSC-holders tended to use more prescription items per head and incur higher subsidy cost than non-holders. The standardised CSC utilisation rate was 2.6 times the non-CSC rate. For children, average per-item subsidy cost for CSC-holders was lower than for non-holders; the reverse was true for adults. CONCLUSION: CSC holders had higher pharmaceutical utilisation rates than non-holders at a national level (but not necessarily at a local level). If non-uptake of cards and health status were taken into account, however, it is possible that pharmaceutical utilisation rates were suboptimal amongst those most in need of services. Analyses are urgently required to examine prescribing patterns at a regional level.

Distinct abscisic acid signaling pathways for modulation of guard cell versus mesophyll cell potassium channels revealed by expression studies in Xenopus laevis oocytes.

Regulation of guard cell ion transport by abscisic acid (ABA) and in particular ABA inhibition of a guard cell inward K(+) current (I(Kin)) is well documented. However, little is known concerning ABA effects on ion transport in other plant cell types. Here we applied patch clamp techniques to mesophyll cell protoplasts of fava bean (Vicia faba cv Long Pod) plants and demonstrated ABA inhibition of an outward K(+) current (I(Kout)). When mesophyll cell protoplast mRNA (mesophyll mRNA) was expressed in Xenopus laevis oocytes, I(Kout) was generated that displayed similar properties to I(Kout) observed from direct analysis of mesophyll cell protoplasts. I(Kout) expressed by mesophyll mRNA-injected oocytes was inhibited by ABA, indicating that the ABA signal transduction pathway observed in mesophyll cells was preserved in the frog oocytes. Co-injection of oocytes with guard cell protoplast mRNA and cRNA for KAT1, an inward K(+) channel expressed in guard cells, resulted in I(Kin) that was similarly inhibited by ABA. However, oocytes co-injected with mesophyll mRNA and KAT1 cRNA produced I(Kin) that was not inhibited by ABA. These results demonstrate that the mesophyll-encoded signaling mechanism could not substitute for the guard cell pathway. These findings indicate that mesophyll cells and guard cells use distinct and different receptor types and/or signal transduction pathways in ABA regulation of K(+) channels.

The cost of MRI: changes in costs 1989-1996.

A study was conducted to provide an up-to-date analysis of the costs associated with operating an MRI facility in a mainstream National Health Service (NHS) setting. This paper presents an analysis of the costs associated with the acquisition and operation of an MRI scanner installed at the Walsgrave NHS Trust in Coventry in 1988. Costs arising immediately after the introduction of the MRI facility in 1988 are compared with the costs arising towards the end of the scanner's useful life during the 1995/96 financial year. The findings suggest that although the nominal total costs of MRI have increased marginally, from 403,223 Pounds to 434,037 Pounds (an increase of 30,814 Pounds), the increase in total costs is below the rate of inflation, and the nominal average costs of MRI have fallen from 179.20 Pounds to 115.77 Pounds over the period.

Best practice: what it is and what it is not.

This paper offers a poststructural critique of the concept of best practice and suggests that those practising best practice seek to reinforce modernist notions of health care and health-care delivery. Modernist notions limit possibilities for health-care workers, including nurses, as well as limiting the care delivered to clients. In turn, these mask various outcomes for clients and health care workers. This paper explores the concept of best practice and the discourse on which it is based and offers an alternative perspective on which high quality health-care services can be developed.

NZDep91: A New Zealand index of deprivation.

In New Zealand, existing area-based indices of deprivation were inadequate because of lack of theoretical underpinning and use of comparatively large areas resulting in masking of variation within them. There is growing demand for small area based indices of deprivation for the purposes of resource allocation, research, and community advocacy. This paper describes a new Census-based index of deprivation based on the smallest possible geographical areas using existing Census boundaries. The index uses deprivation variables selected according to established theory, and derived from the 1991 New Zealand Census. Ten age and gender standardised variables were combined using principal components analysis. Each variable is a standardised proportion of people in a small area with a lack of a defined material or social resource. Age/gender standardisation is important to avoid confounding and to improve the performance of indices in resource allocation formulae. The index correlates highly with mortality, hospital discharges, lung cancer registrations and childhood immunisation status.

Lack of dose-response with Pancrease MT for the treatment of exocrine pancreatic insufficiency in adults.

BACKGROUND: Choosing the optimum pancreatic enzyme replacement therapy for patients with exocrine insufficiency remains a problem. An enteric coated enzyme microsphere pancreatic enzyme preparation (Pancrease) has been marketed with several levels of lipase activity, implying that there is a dose-response relationship between dose and effectiveness such that the high potency form appears to be the most cost effective. METHODS: In a randomized, single-blind, cross-over study, we evaluated the effectiveness of a commercial enzyme preparation with different amounts of lipase per dosage unit in adults with exocrine pancreatic insufficiency. Patients received a diet comprising 100 g fat each day for 6 days. With each meal (three per day) they received two capsules of either Pancrease MT4 (8000 unit lipase), Pancrease MT10 (20,000 units lipase), Pancrease MT16 (32,000 units lipase) or placebo. A 72-h quantitative faecal collection was carried out for the last 3 days of the 6-day period. RESULTS: There was a reduction in faecal fat excretion with each of the preparations compared to placebo. The difference failed to reach significance with the 8000 units lipase preparation (P > 0.05) but was significant (P = 0.02) with the 20,000 units lipase and the 32,000 units lipase preparations (faecal fat excretion: placebo = 42.1 +/- 29 g, lipase 8000 = 22.1 +/- 7.3 g, lipase 20,000 = 10.2 +/- 4.5 g and lipase 32,000 = 15.8 +/- 12.5 g, P < for 20,000 units and 32,000 units lipase compared to placebo). CONCLUSION: A dose-response relationship between the amount of lipase administered with each meal and a reduction in faecal fat was not evident. The most potent preparation did not provide additional benefits compared to the less expensive lower potency dosage form.

Comparison of provision and need for publicly-funded personal health services.

AIM: To determine whether health services have been purchased equitably according to population needs at the territorial local authority (TLA) level. METHODS: The project involved the mapping of different categories of personal health service expenditure onto TLA areas. The measure used to compare provision and need was the ratio of observed to expected expenditure. Need beyond weighted populations by age, sex, and ethnicity or community services card status was measured using standardised mortality ratios. RESULTS: The analysis did not suggest that the inverse care law was operating at the level of TLAs. There was no systematic bias against equity. However there is a good deal of scatter in the plots, some of which will be accounted for by data quality problems, and some of which is possibly due to inequitable purchasing. CONCLUSIONS: The inverse care law does not appear to be operating at the level of TLA. The methods piloted in this study represent a useful way of analysing and presenting information on resource allocation. Deficiencies in data quality limit the strength of conclusions which can be drawn from this project. More specific observations could be made if the methods used here were applied to smaller areas, and data quality issues were addressed.

cDNA structure and expression patterns of a low-temperature-specific wheat gene tacr7.

The low-temperature (2 degrees C)-specific wheat cDNA, pTACR7, represents a gene designated tacr7 from hard red winter wheat (HRWW; Triticum aestivum L. cv. Winoka). The term low-temperature-specific (LTS) is used because tacr7 is not induced by ABA or stresses such as salt, dehydration, and heat. pTACR7 was isolated by RT-PCR with mRNA from wheat crown tissue, the oligonucleotide primers derived from the barley cognate pHVCR8 (GenBank accession number L28091). Based on the deduced amino acid sequence, TACR7 is highly hydrophobic, with a single transmembrane domain and an amino acid bias for leucine (19%). Thus, the encoded protein TACR7 is unique among low-temperature-regulated wheat proteins described in the literature. Analysis of steady-state levels of tacr7 transcripts (630 nt) showed accumulation in wheat seedlings, crown tissue, and callus cultures after transfer from control (25 degrees C) to low temperature (2 degrees C). No detectable transcripts were observed by northern blot hybridization with pTACR7 probe from seedling or callus treated with ABA, salt, dehydration, or heat stress. tacr7 transcripts accumulated during 2 degrees C exposure to a greater amount in a freeze-resistant HRWW (FR; SDmut 16029) than in a freeze-susceptible HRWW (FS; SDmut 16169) crown tissue, with the largest difference between genotypes being 30% +/- 3% at 3 weeks.

Predictors of psychosocial adjustment in patients with implantable cardioverter defibrillators.

Predictors of psychological distress/adjustment were examined in 25 patients following placement of ICDs. Patients completed a demographic questionnaire and a standardized questionnaire of psychological symptoms (i.e., Symptom Checklist-90 Revised; SCL-90-R). The number of discharges categorized by the patient as inappropriate and appropriate were also ascertained. The number of ICD discharges categorized as inappropriate and diminished levels of physical activity (r = 0.53 and 0.63, P < 0.01, respectively) did significantly relate to overall psychological distress. In addition, after controlling for age and prior psychiatric and physical health status through a stepwise multiple regression analysis, the occurrence of ICD discharges categorized as inappropriate and diminished physical activity continued to significantly predict overall psychological distress (R2 = 0.41, P < 0.01). However, the number of ICD discharges categorized as appropriate did not significantly predict overall psychological distress. The results of this investigation suggest that further refinement of the ICD could reduce the risk of exposure to potential psychological distress, and an analysis of prior and anticipated patient physical activity levels should be a factor when calibrating minimum ICD discharge threshold levels.

Effects of aspirin and Helicobacter pylori on the gastroduodenal mucosal permeability to sucrose.

BACKGROUND: A non-invasive marker is needed to identify patients with significant gastrointestinal injury due to non-steroidal anti-inflammatory drugs. Gastrointestinal permeability to sucrose has been suggested as such a test. AIMS: To assess the utility of sucrose permeability as a marker of gastroduodenal mucosal injury after single and multiple doses of aspirin, to identify the site of increased sucrose permeability, to explore the relation between sucrose permeability and endoscopic findings, and to evaluate whether Helicobacter pylori infection influenced gastroduodenal sucrose permeability. METHODS: After a fasting urine was obtained, 500 ml of a solution containing 100 g of sucrose was ingested. Urine was collected for five hours and assayed for sucrose by high performance liquid chromatography. Sucrose permeability was also assessed 20 minutes after ingestion of 650 mg of aspirin and eight to 12 hours after a 72 hour course of 650 mg aspirin four times a day. The site of increased permeability was identified after pyloric occlusion with a double balloon tube. RESULTS: Thirty seven healthy volunteers participated. Sucrose permeability (mean (SEM)) increased after both single (195.2 (27) mg and multiple (196.4 (31) mg) doses of aspirin compared with baseline (53.7 (10) mg; p < 0.0005). Balloon pyloric occlusion confirmed that the site of increased sucrose permeability was the stomach. The effect of aspirin on sucrose permeability was similar in those with and without H pylori infection. CONCLUSION: These results confirm the use of sucrose permeability as a marker of aspirin induced gastroduodenal mucosal injury and identify the stomach as the major site of increased permeability. H pylori infection does not seem to change gastric mucosal sucrose permeability either at baseline or after ingestion of aspirin.

Alterations of maternal estrogen levels during gestation affect the skeleton of female offspring.

Estrogens have important effects on bone turnover in both humans and experimental animals models. Moreover, the decreased level of estrogen after menopause appears to be one of the key factors in determining postmenopausal osteoporosis. The presence of estrogen receptor in both osteoblasts and osteoclasts has suggested a direct role of these steroid hormones on bone tissue. Thus, this tissue is now regarded as a specific estrogen target tissue. Exposure to estrogens during various stages of development has been shown to irreversibly influence responsive target organs. We have recently shown that transient developmental neonatal exposure (days 1-5 of life) of female mice to estrogen resulted in an augmented bone density in the adult animals. The aim of the present study was to evaluate whether short-term modification of maternal estrogen levels during pregnancy would induce changes in the skeleton of the developing fetuses and to identify any long-term alterations that may occur. Pregnant mice were injected with varying doses (0.1-100 micrograms/kg maternal BW) of the synthetic estrogen diethylstilbestrol (DES) from day 9-16 of pregnancy. Offspring were weaned at 21 days of age, and effects on bone tissue of the female mice were evaluated in adulthood (6-9 months of age). Prenatal DES treatment(s) did not significantly affect BW. However, a dose-dependent increase in bone mass, both in the trabecular and cortical compartments, was observed in the prenatal DES-exposed female offspring. Furthermore, long bones of DES-exposed females were shorter than controls. Normal skeletal mineralization accompanied these changes in the bone tissue, as shown by a parallel increase in skeletal calcium content. Double tetracycline labeling performed in 6-month-old DES-exposed animals showed an increase in mineral apposition rate in adult DES-exposed mice as compared with untreated control animals, although no significant difference in the circulating estrogen levels was found in animals of this age. Experiments were then performed to evaluate whether perturbation of the estrogen surge at puberty in these diethylstilbestrol (DES)-exposed mice could reverse the observed changes. Femur length was chosen as a marker of potential estrogenic effect. Prepubertal ovariectomy of the prenatally DES-treated animals could only partially reverse the effects observed in the skeleton of the DES-treated animals. Further experiments were performed to evaluate whether these changes could have occurred in utero. CD-1 pregnant female mice were injected with DES (100 micrograms/kg maternal BW) from days 9-15 of gestation. On day 16 of gestation, fetuses were examined and stained by a standard Alizarin Red S and Alcian Blue procedure to visualize calcified and uncalcified skeletal tissue. Estrogen treatment induced an increase in the amount of calcified skeleton as compared with untreated controls and also a decrease in the length of long bones, strongly suggesting a change in both endochondral ossification and endosteal and periosteal bone formation. In summary, these data show, for the first time, that alterations in the maternal estrogenic levels during pregnancy can influence early phases of fetal bone tissue development and subsequently result in permanent changes in the skeleton. Finally, the effect of this short-term estrogen treatment can be seen in the fetal skeleton, suggesting an estrogen-imprinting effect on bone cell-programming in fetal life because treatment effects on bone cell turnover can be observed later in adult life.

Advanced nursing practice: new ideas and new perspectives.

The authors of this paper contend that advanced nursing practice differs substantially from other forms of nursing practice, such as expert and specialist practice. Additionally, they contend that the difference residues in the way that advanced nurse practitioners think about, see and experience clinical practice. Historically, nursing in Australia has been strongly influenced by events and ideas generated in North America. The authors argue this has led to the development of an emphasis on the nature, role and function of specialist and expert nursing practice to the detriment of ascertaining and fostering the notion and nature of advanced nursing practice. This influence of North American nursing has also significantly directed and influenced the way in which we use and understand the term 'advanced nursing practice', and further, that the way in which we use the term does not give full regard to the context of Australian nursing. The authors outline some of the key issues and ideas emerging in South Australia with respect to advanced nursing practice and in particular offer beginning theorizations into the different ways in which advanced nurse practitioners think, see and experience nursing practice.

Australian nursing--moving forward? Competencies and the nursing profession.

The introduction of national competencies for registration as a nurse in Australia has been met with great enthusiasm. While this development clearly brings some positive benefits the authors believe that competencies and competency development must be carefully monitored if Australian nurses are to avoid some of the pitfalls associated with this approach.

Infectious esophagitis.

This article presents the epidemiology, pathogenesis and pathology, clinical manifestations, and diagnosis and treatment of Candida, herpes simplex virus, cytomegalovirus, Mycobacterium tuberculosis, Aspergillus, histoplasmosis, blastomycosis, and HIV. Uncommon AIDS-related esophageal infections are also discussed.