The Osseointegration Group of Australia Accelerated Protocol (OGAAP-1) for two-stage osseointegrated reconstruction of amputated limbs.

AIMS: This study describes the Osseointegration Group of Australia's Accelerated Protocol two-stage strategy (OGAAP-1) for the osseointegrated reconstruction of amputated limbs. PATIENTS AND METHODS: We report clinical outcomes in 50 unilateral trans-femoral amputees with a mean age of 49.4 years (24 to 73), with a minimum one-year follow-up. Outcome measures included the Questionnaire for persons with a Trans-Femoral Amputation, the health assessment questionnaire Short-Form-36 Health Survey, the Amputation Mobility Predictor scores presented as K-levels, 6 Minute Walk Test and timed up and go tests. Adverse events included soft-tissue problems, infection, fractures and failure of the implant. RESULTS: Our results demonstrated statistically significant improvements in all five outcome measures. A total of 27 patients experienced adverse events but at the conclusion of the study, all 50 were walking on osseointegrated prostheses. CONCLUSION: These results demonstrate that osseointegrated prostheses are a suitable alternative to socket-fit devices for amputees experiencing socket-related discomfort and that our strategy offers more rapid progress to walking than other similar protocols. Cite this article: Bone Joint J 2016;98-B:952-60.

Nurses and whistleblowing: the ethical issues.

Whistleblowing - the public exposure of organizational wrongdoing - presents practical and ethical dilemma for nurses, and needs to be seen as part of a spectrum of increasingly confrontative actions against miscreant organizations by their employees. The ethics of whistleblowing can only be understood in relation to its moral purpose, whether that is to achieve a good outcome (a consequentialist view) or fulfil a duty (a deontological view). The consequentialist perspective is unable on its own to resolve problems arising from the balance of good and harm resulting from the act of whistleblowing (where considerable harm might be caused) or of responsibility for that harm. A deontological approach provides an analysis of these problems but raises its own problem of conflicting duties for nurses. However, a strong argument can be made for the precedence of the nurse's duty to the patient over her duty to the employer. Although both duties are based on an implicit or an explicit promise, the promise to a person (the patient) must take precedence over the promise to an organization. It can even be argued that duty to the employer may in fact justify whistleblowing by nurses in some circumstances. However, the consequences of whistleblowing are forced upon nurses in a different way by the fact that the danger of reprisals acts as a deterrent to whistleblowers, however justified their actions may be. A more robust approach to the protection of whistleblowers is needed on the part of the government and the National Health Service (NHS) to remedy this situation.

Corporate moral responsibility in health care.

The question of corporate moral responsibility--of whether it makes sense to hold an organisation corporately morally responsible for its actions, rather than holding responsible the individuals who contributed to that action--has been debated over a number of years in the business ethics literature. However, it has had little attention in the world of health care ethics. Health care in the United Kingdom (UK) is becoming an increasingly corporate responsibility, so the issue is increasingly relevant in the health care context, and it is worth considering whether the specific nature of health care raises special questions around corporate moral responsibility. For instance, corporate responsibility has usually been considered in the context of private corporations, and the organisations of health care in the UK are mainly state bodies. However, there is enough similarity in relevant respects between state organisations and private corporations, for the question of corporate responsibility to be equally applicable. Also, health care is characterised by professions with their own systems of ethical regulation. However, this feature does not seriously diminish the importance of the corporate responsibility issue, and the importance of the latter is enhanced by recent developments. But there is one major area of difference. Health care, as an activity with an intrinsically moral goal, differs importantly from commercial activities that are essentially amoral, in that it narrows the range of opportunities for corporate wrongdoing, and also makes such organisations more difficult to punish.

Nursing by agreement: a contractarian perspective on nursing ethics.

Contractarianism has primarily been a political theory. A good argument can be made for its application to individual and professional ethics. A contractarian perspective on nursing ethics not only provides useful insights into the central relationship in nursing--the nurse and the patient--but also allows understanding of that relationship in the context of other relationships involving the nurse, the nursing profession, and the health care organization. While the nurse-patient contract is limited, its greater moral depth gives it moral priority.

The targeting of phospholipid liposomes to bacteria.

Phospholipid liposomes have been prepared from phospholipid mixtures including dipalmitoylphosphatidylcholine/phosphatidylinositol (DPPC/PI) and DPPC/dipalmitoylphosphatidylglycerol (DPPC/DPPG) mixtures and targeted to adsorbed biofilms of the skin-associated bacteria Staphylococcus epidermidis and Proteus vulgaris and the oral bacterium Streptococcus sanguis. The effects of time, liposome concentration and density of bacteria in the biofilm have been studied in detail for Staphylococcus epidermidis. The targeting (as assessed by the apparent monolayer coverage of the biofilms by liposomes) to the biofilms was found to be sensitive to the mol% of PI and DPPG in the liposomes and optimum levels of PI were found for targeting to each bacterium. The use of PI and DPPG-containing liposomes for the delivery of the bactericide, Triclosan, to biofilms of Staphylococcus epidermidis was studied as a function of the amount of Triclosan carried by the liposomes. All the liposome systems tested inhibited the growth of bacteria from the biofilms after brief (2 min) exposure to Triclosan-carrying liposomes. At low Triclosan levels bacterial growth inhibition by Triclosan-carrying liposomes exceeded that by an equivalent level of free Triclosan. After short periods (min) of exposure of biofilms to Triclosan-carrying liposomes the bactericide was shown to preferentially concentrate in the biofilms relative to its liposomal lipid carrier. The results suggest that phospholipid liposomes with appropriately chosen lipid composition have potential for the targeting and delivery of bactericide to bacteria.

Caring: a new framework for analysis.

The increased attention given to the concept of care within the nursing literature must be considered in the light of the relatively superficial consideration given to the same concept within the educational curriculum. This article offers possible explanations for such brief consideration before discussing the development of a new framework for analysis of care.

Ethics, agency and empowerment in nurse education.

The ethical demands of professional nursing practice are considered, and the concept of Agency is offered as a potentially useful part of the nurses conceptual equipment for such practice. The pressures of working in large organisations are suggested to be inimical to a sense of Agency, and it is also suggested that some of the academic disciplines involved in nurse education are offering an ambiguous view of the issue of Agency. The discipline of Ethics, while also ambiguous on this issue, is presented as offering useful ways of exploring that ambiguity. Several theories of Ethics are considered in relation to human freedom and responsibility, and the issue between determinism and free will is likewise considered. It is suggested that these offer ways of helping the individual to explore and develop their own stance on freedom and responsibility, and thereby on the issue of Agency. This discussion is related to the United Kingdom Central Council (UKCC) Code of Professional Conduct, and the paradox of choice is acknowledged.

Monoclonal antibodies against the capsular K antigen of Escherichia coli (O9:K30(A):H12): characterisation and use in analysis of K antigen organisation on the cell surface.

Monoclonal antibodies were produced against the capsular antigen of Escherichia coli serotype K(A)30, using a mouse hybridoma system. The antibodies also recognised the chemically identical capsular polysaccharide produced by Klebsiella K20. Chemical modification of the K30 polysaccharide indicated that the glucuronic acid residues found in the E. coli K30 capsular antigen were important in the epitope recognised by these antibodies. Use of the antibodies as molecular probes revealed the presence of two discrete forms of the K30 antigen. One form was comprised of high molecular weight polysaccharide, present as a surface capsular layer. The second form of the antigen was of low molecular weight and was associated with lipopolysaccharide fractions from cell surface polysaccharide extracts. Separation of lipopolysaccharide fractions using gel chromatography in the presence of detergent showed that the low molecular weight K-antigenic fraction comigrated with a lipopolysaccharide lipid A core fraction present in encapsulated E. coli K30 bacteria but absent in acapsular mutants.

Transfer and expression of the genetic determinants for O and K antigen synthesis in Escherichia coli O9:K(A)30 and Klebsiella sp. O1:K20, in Escherichia coli K12.

Escherichia coli serotype O9:K(A)30 and Klebsiella O1:K20 produce thermostable capsular polysaccharides or K antigens, which are chemically and serologically indistinguishable. Plasmid pULB113 (RP4::mini-Mu) has been used to mediate chromosomal transfer from E. coli O9:K30 and Klebsiella O1:K20 to a multiply marked, unencapsulated, E. coli K12 recipient. Analysis of the cell surface antigens of the transconjugants confirmed previous reports that the genetic determinants for the E. coli K(A) antigens are located near the his and rfb (O antigen) loci on the E. coli linkage map. The Klebsiella K20 capsule genes were also found to be in close proximity to the his and rfb loci. Electron microscopy revealed significant differences in the structural organization of capsular polysaccharides in these two microorganisms and the morphological differences were also readily apparent in transconjugants expressing the respective K antigens. These results are consistent with the interpretation that at least some of the organizational properties of capsular polysaccharides may be genetically determined, rather than being a function of the outer membrane to which the capsular polysaccharides are ultimately attached.

The effect of glycerol-induced acute renal failure upon cardiac reactivity in the rat: influence of indomethacin treatment and renal pedicle ligation.

Cardiac chronotropic responses to isoprenaline, carbachol and electrical stimulation of the cervical sympathetic and vagal nerves were recorded in rats with glycerol-induced acute renal failure (ARF) and control rats. The experiments involving electrical stimulation of cardiac nerves were performed in rats which either had been pretreated with indomethacin (1 mg kg-1 twice daily for 2 days) or had undergone acute bilateral renal pedicle ligation. The findings from this investigation indicate that the reduced chronotropic responses to vagal stimulation in rats with glycerol-induced ARF are due to a reduction in acetylcholine release mediated by prostaglandins possibly originating from the damaged kidneys. The diminished response to cervical sympathetic stimulation results from a decreased postsynaptic response to beta-adrenoceptor stimulation.

Vascular reactivity in experimental acute renal failure.

Vascular reactivity in-vivo and in-vitro was examined in rats with acute renal failure produced by bilateral nephrectomy or intramuscular glycerol injection. Bilaterally nephrectomized rats displayed enhanced pressor responses to noradrenaline and angiotensin. However, the contractile responses to noradrenaline, angiotensin and potassium chloride of aortic rings and portal vein segments from nephrectomized rats were not significantly different from the responses obtained in vessels from sham-operated controls. Rats with glycerol-induced ARF which were pretreated with indomethacin had significantly lower pressor responses to noradrenaline and angiotensin than similarly treated control animals. Aortic rings from glycerol-injected rats produced significantly smaller contractions to noradrenaline than preparations from controls. This difference was not abolished by incubation of vessels with indomethacin. The findings suggest that the absence of kidneys or the presence of damaged renal tissue and not uraemia itself have pronounced but opposite effects on vascular reactivity. The depression of vascular reactivity in glycerol-induced ARF does not appear to be a result of increased production of prostaglandins.