Transanal endoscopic microsurgery for rectal carcinoids: the largest reported United States experience.

AIM: Rectal carcinoids are often inadequately resected by snare excision during colonoscopy. Transanal endoscopic microsurgery is a minimally invasive procedure with low morbidity that offers full-thickness excision with a low rate of negative margins. It presents an excellent alternative to radical surgery for mid and proximally located lesions. We report the largest United States (US) experience in the use of transanal endoscopic microsurgery for rectal carcinoids. METHOD: Data of patients who had undergone transanal endoscopic microsurgery for rectal carcinoids were prospectively collected and retrospectively analyzed. Patient and tumour characteristics, operative and perioperative details, as well as oncological outcomes were reviewed. RESULTS: Over a 12-year period, 24 patients underwent transanal endoscopic microsurgery for rectal carcinoids. Of these, six (25%) were primary surgical resections and 18 (75%) were performed after incomplete snare excisions during colonoscopy. Three (17%) patients who underwent full-thickness resection after snare excision had residual tumour on histopathological examination. Negative margins were obtained in all cases. No recurrences were noted. CONCLUSION: Transanal endoscopic microsurgery is effective and safe for the surgical resection of rectal carcinoids<2 cm in diameter, with typical features and located more than 5 cm from the anal verge. Transanal endoscopic microsurgery can be used for primary resection or for resection after incomplete colonoscopic snare excision.

Use of botanicals in food supplements. Regulatory scope, scientific risk assessment and claim substantiation. 2005.

BACKGROUND/AIMS: In the European Union, an elaborate legal framework regulates botanical products both under food and medicinal law. The decision as to which legal framework applies to an individual product may differ between the Member States. In the case of botanical food supplements, all food law provisions apply to their manufacturing, composition and marketing, including the new claims legislation. METHODS: Elements from EU and national law, scientific and other publications are brought together to investigate how to clarify the differentiation between the use of botanicals for medicinal and health-promoting purposes on a scientific basis. RESULTS: Guidance on the safety assessment and quality evaluation of botanicals is proposed in light of the different approaches described in the scientific literature with particular attention to the concept of long-term use as an integral part of safety evaluation. Guidance on claims substantiation is also included, taking into consideration the proposed legislation, the concept of long-term experience and grading of evidence. CONCLUSIONS: A model for safety and efficacy assessment of botanical food supplements in the EU is proposed, and should be taken into consideration in the development of legislation and scientific research on botanicals.

Characteristics of the K+-competitive H+,K+-ATPase inhibitor AZD0865 in isolated rat gastric glands.

The gastric H+,K+-ATPase of the parietal cell is responsible for acid secretion in the stomach and is the main target in the pharmacological treatment of acid-related diseases. Omeprazole and other benzimidazole drugs, although having delayed efficacy if taken orally, have high success rates in the treatment of peptic ulcer disease. Potassium competitive acid blockers (P-CAB) compete with K+ for binding to the H+,K+-ATPase and thereby they inhibit acid secretion. In this study, the in vitro properties of AZD0865, a reversible H+,K+-ATPase inhibitor of gastric acid secretion, are described. We used a digital-imaging system and the pH sensitive dye BCECF to observe proton efflux from hand-dissected rat gastric glands. Glands were stimulated with histamine (100 microM) and exposed to a bicarbonate- and Na+-free perfusate to induce an acid load. H+,K+-ATPase inhibition was determined by calculating pHi recovery (dpH/dT) in the presence of omeprazole (10-200 microM) or AZD0865 (0.01-100 microM). The efficacies of both drugs were compared. Our data show that acid secretion is inhibited by both the proton pump inhibitor omeprazole and the P-CAB AZD0865. Complete inhibition of acid secretion by AZD0865 had a rapid onset of activation, was reversible, and occurred at a 100-fold lower dose than omeprazole (1 microM AZD0865 vs. 100 microM omeprazole). This study demonstrates that AZD0865 is a potent, fast-acting inhibitor of gastric acid secretion, effective at lower concentrations than drugs of the benzimidazole class. Therefore, these data strongly suggest that AZD0865 has great potential as a fast-acting, low-dose inhibitor of acid secretion.

An analysis of the nurse practitioner role in palliative care.

The purpose of this study was to examine the nature and contribution of the nurse practitioner (NP) role in an oncology palliative clinic. Quantitative and qualitative data were collected from the practice of one NP. Data were obtained on the performance of the NP role functions. the characteristics of the patients seen by the NP, the interventions delivered by the NP, and the outcomes of care. Descriptive and content analyses were used to analyze the data. The results indicate that the NP in an oncology palliative care clinic engages primarily in the clinical component of the role. The emphasis is on symptom management, patient and family education and counseling, coordination of care, and maintaining continuity of care. The method followed in this case study to examine the contribution of the NP role could be used by other NPs to demonstrate the quality, effectiveness, and efficiency of their care.

Effects of an abilities-focused program of morning care on residents who have dementia and on caregivers.

OBJECTIVE: To conduct a controlled investigation to examine the effects of an abilities-focused program of morning care on the interaction behaviors and functioning of residents with dementia and on caregivers' interaction behaviors and perceptions of caregiving. DESIGN: A quasi-experimental, repeated measures design. SETTING: The study was conducted on four, nursing-home-level cognitive supports units in a geriatric care center. One of the units was randomly selected as the experimental unit; the other three served as controls. PARTICIPANTS: The final sample consisted of 40 residents (20 each in the experimental and three control groups) and 44 caregivers (16 on the experimental unit and 28 on the three control units). INTERVENTION: An educational program on delivering abilities-focused morning care, designed by the authors, was provided to caregivers on the experimental unit. MEASUREMENTS: Measures were taken at baseline and at 3 and 6 months postintervention with regard to residents' interaction behaviors, level of agitation, and level of function and to caregivers' interaction behaviors, perceived ease of caregiving, and level of stress. RESULTS: Repeated measures analysis of variance (RM-ANOVA) was used to compare the experimental and control groups in regard to changes in the outcomes over time. Results indicated that the abilities-focused program had statistically significant effects on (a) residents' personal attending and calm/functional behaviors, level of agitation, and levels of overall and social function, and (b) caregivers' verbal relevance and personal attending, relaxed, and social/flexible behaviors. CONCLUSIONS: The evidence suggests that both residents and caregivers benefit from morning care that is oriented toward the abilities of people with dementia.

The reliability and validity of two health status measures for evaluating outcomes of home care nursing.

The reliability, validity, and sensitivity of the Medical Outcome Study Short Form (SF-36) and the Quality of Life Profile: Senior Version (QOLPSV) for measuring outcomes of home care nursing were evaluated. Data were collected from 50 clients receiving home care nursing services. Twenty-two registered nurses and six registered practical nurses collected client and nursing data on each home visit. Client baseline and outcome measures were collected by two independent evaluators at admission and discharge from the home care service. Internal consistency reliability ranged from.76 to.94 for the eight subscales of the SF-36. Internal consistency reliability ranged from.47 to.82 for the nine subscales of the QOLPSV. The subscales of both instruments had minimal problems with missing responses. The SF-36 was found to be more sensitive than the QOLPSV to change over time. In addition, the subscales of the SF-36 were found to be more sensitive than the subscales of the QOLPSV to several of the nursing variables, such as intensity of the client's nursing condition and skill mix.

Multivariate modeling of missing data within and across assessment waves.

Missing data constitute a common but widely underappreciated problem in both cross-sectional and longitudinal research. Furthermore, both the gravity of the problems associated with missing data and the availability of the applicable solutions are greatly increased by the use of multivariate analysis. The most common approaches to dealing with missing data are reviewed, such as data deletion and data imputation, and their relative merits and limitations are discussed. One particular form of data imputation based on latent variable modeling, which we call Multivariate Imputation, is highlighted as holding great promise for dealing with missing data in the context of multivariate analysis. The recent theoretical extension of latent variable modeling to growth curve analysis also permitted us to extend the same kind of solution to the problem of missing data in longitudinal studies. Data simulations are used to compare the results of multivariate imputation to other common approaches to missing data.

Practice patterns of acute care nurse practitioners.

This study was undertaken to examine the practice pattern of nurse practitioners employed in Ontario acute care settings. A descriptive design, incorporating quantitative and qualitative methods for data collection, was used. The acute care nurse practitioners' practice pattern varied in terms of scope of practice, model guiding practice, reporting relations, and extent of role implementation. Role implementation encompassed activities representing the four role components: clinical practice, education, administration or management, and research. The acute care nurse practitioners engaged most frequently in the clinical component of the role. They performed medical and advanced nursing functions. They emphasized that they do not work in isolation and that they do not replace physicians or residents.

Implementation of the primary care nurse practitioner role in Ontario.

The purpose of this descriptive study was to examine the implementation of the nurse practitioner role in primary care settings. Nurse practitioners who were certified by the College of Nurses of Ontario as Extended Class were surveyed. The questionnaire inquired about the nurse practitioners' professional characteristics, employment settings, scope of practice, practice pattern, and satisfaction with their role. The majority of the 166 respondents working as nurse practitioners were Baccalaureate prepared; has been in the role for a relatively short period of time; were employed in community health centers; and were able to practice to their full potential, within the expanded scope of practice. They saw patients who are primarily healthy or presenting with acute minor illness, and provided care with an emphasis on wellness. They were satisfied with their role. Directions for future research are presented.

Organizational factors influencing nurse practitioners' role implementation in acute care settings.

The purpose of this study was to explore the influence of organizational factors on the Acute Care Nurse Practitioner (ACNP) role implementation. A descriptive correlational design, incorporating quantitative and qualitative methods for data collection was used. The sample of convenience consisted of 57 ACNPs assigned to various medical and surgical programs within acute care hospitals. Ten ACNPs participated in the unstructured qualitative interviews. In addition to the interviews, data pertinent to various organizational factors, including role formalization, receptivity of the role by others, perceived autonomy, role strain, and additional factors that may interfere with role implementation, were collected through a self-report structured questionnaire. A four-diary day was completed to gather data on role implementation. Descriptive and correlational statistics were used to analyze the quantitative data. The qualitative data were content analyzed. The ACNPs engaged most frequently in activities reflective of the clinical practice component of the role and less frequently in the non-clinical components (i.e., education, administration, and research). Results of the quantitative and qualitative analyses indicated that lack of formal clear job description, conflicting demands and expectations, lack of receptivity of the role by others, lack of autonomy, and increased workload were negatively correlated with the ACNP role implementation. The ACNP role implementation varies across practice settings. This variability should be accounted for when examining outcomes of ACNP care.

A conceptual framework for evaluating the nurse practitioner role in acute care settings.

The conceptualization and enactment of the ACNP role varies across settings, potentially leading to variability in outcome achievement. A conceptual framework for evaluating the ACNP role is proposed. The framework is an adaptation of the Nursing Role Effectiveness Model which was developed to facilitate the identification and investigation of nursing-sensitive outcomes. The framework represents the complex system of interrelated factors that are present in the ACNP practice situation and that affect role effectiveness. It includes three components: (i) structure--encompassing patient, ACNP and organizational variables; (ii) process--consisting of the ACNP role components (clinician, educator, researcher and administrator) and the ways in which the role is enacted; and (iii) outcomes--including patient- and cost-related outcomes. The framework proposes specific relationships among the structure, process and outcomes components. Empirical support for the framework propositions is provided, based on a review of pertinent literature. Implications for future ACNP impact studies are discussed.

The therapeutic use of music for dyspnea and anxiety in patients with COPD who live at home.

The purposes of this repeated measures study were to examine the feasibility of using music as an intervention for dyspnea and anxiety in patients with chronic obstructive pulmonary disease (COPD) who live in their homes and to examine the effect of music on anxiety and dyspnea. Twenty-four participants who experienced dyspnea at least once a week were studied over a 5-week period. Baseline data were collected on Week 1. Measures of anxiety and dyspnea were taken on Week 2, prior to and immediately following the use of music. These measures were repeated on Week 5. There was a significant decrease in dyspnea following the use of music as reported in the music diary (p < .001). There was a significant decline in anxiety (p < .05) and dyspnea (p < .01) following the use of music on Week 2. There was no significant change in anxiety or dyspnea over the 5-week period.

An abilities assessment instrument for elderly persons with cognitive impairment: psychometric properties and clinical utility.

In this article the psychometric properties of an Abilities Assessment Instrument (AAI), developed to assess the self-care, social, interactional and interpretive abilities of older people with cognitive impairment (CI) related to dementia, are described. The sample consisted of 112 institutionalized older men with CI and 60 institutionalized older men without CI. The psychometric evaluation of the AAI indicated that: (a) it is reliable in terms of test-retest (Pearson's r range .93-.99), interrater (Pearson's r range .95- .99), and internal consistency evaluations (Cronbach's alpha .90-.98), as well as through confirmatory factor analysis; and (b) that it is valid with respect to content validity (CVI 87.3%), concurrent validity (Pearson's r correlations ranging from -.67-.80 on the London Psychogeriatric Rating Scale [LPRS], and from -.76-.85 on the Functional Assessment Stages Scale [FAST]), and construct validity with significant differences between subjects with and without CI (t values ranging from 5.13-9.30). The AAI is a reliable and valid instrument that can be used to provide assessment data.

Measuring the intervention in effectiveness research.

Inconsistent implementation of the intervention in the field setting presents a threat to the validity of the conclusions of an effectiveness study. Inconsistent implementation results in variability in the actual dosage of the intervention received by the participants, which leads to variability in outcomes achievement and, consequently, to Type II error. This article discusses the methodological implications of inconsistent intervention implementation and advances a strategy as a solution to this problem. The strategy proposes to quantify the dosage of the intervention as a continuous variable and to use this variable in the statistical analysis. The benefits of this strategy are illustrated with an empirical example from the Self-Help Intervention Project.

Finding value in nursing care: a framework for quality improvement and clinical evaluation.

Fiscal constraints have heightened attention to health care costs and patient outcomes as measures of health care system effectiveness. Determining which patient and costs outcomes nurses may be held accountable for requires differentiating the impact of dependent, independent and interdependent nursing activities. A nursing role effectiveness model that includes a number of structural variables is offered to help track quality improvement and research activities. Some of the nurse-sensitive patient outcomes that have been identified include: freedom from complications, clinical outcomes, functional health outcomes, knowledge outcomes, perceived health benefit (or satisfaction), and costs outcomes. This model can be used to evaluate the effectiveness of current as well as evolving nurse roles, processes, and structural changes.

Linking outcomes to nurses' roles in health care.

As the health care industry refines quality assurance and quality improvement standards, the accountability of individual care providers is intensifying. Care providers work within a system of interdependent roles and functions and collaborate to attain the common goal of quality care. A conceptual model was developed which relates the achievement of specific outcomes to nurses' independent, dependent, and interdependent roles and functions. Empirical literature was used to identify outcomes associated with nurses' role functions. Outcomes associated with nurses' independent role functions included the prevention of complications, clinical outcomes, knowledge of diseases and treatments, satisfaction, and cost outcomes. Outcomes associated with nurses' dependent role included adverse incidents which caused problems or prolonged hospital stays. Outcomes associated with nurses' interdependent role included interdisciplinary team functioning.