Association of postural balance and falls in adult patients receiving haemodialysis: A prospective cohort study

BACKGROUND

Static postural balance performance is often impaired in people receiving haemodialysis (HD) for the treatment of stage-5 chronic kidney disease (CKD-5). However, the question as to whether lower postural balance is associated with adverse clinical outcomes such as falls has not been addressed yet.

RESEARCH QUESTION

We conducted a prospective cohort study to explore the association between static postural balance and falls in people receiving HD. We hypothesised that higher postural sway would be associated with increased odds of falling.

METHODS

Seventy-five prevalent CKD-5 patients receiving HD (age: 61.8 ± 13.4 years) from three Renal Units were enrolled in this prospective cohort study. At baseline, postural balance was assessed with a force platform in eyes open (EO) and eyes closed (EC) conditions. Centre of pressure (CoP) measures of range, velocity and area were taken for the analysis. Falls experienced by study participants were prospectively recorded during 12 months of follow-up. Secondary outcomes included timed-up and go, five-repetition sit-to-stand test and the Tinetti falls efficacy scale (FES).

RESULTS

In multivariable logistic regression analysis, higher CoP range in medial-lateral direction during EC was associated with increased odds of falling (OR: 1.04, 95 %CI: 1.00-1.07, p = 0.036). In ROC curve analysis, CoP velocity in EO exhibited the greatest prognostic accuracy (AUC: 0.69, 95 %CI: 0.55-0.82), however this was not statistically different from CoP measures of area and range. None of the postural balance measures exceeded the prognostic accuracy of the FES (AUC: 0.70, 95 %CI: 0.58-0.83, p = 0.005).

SIGNIFICANCE

This prospective cohort study showed that higher postural sway in medial-lateral direction was associated with increased odds of falling in people receiving HD. CoP measures of range, velocity and area displayed similar prognostic value in discriminating fallers from non-fallers. The overall utility of static posturography to detect future fall-risk may be limited in a clinical setting.

Optimizing the design of invasive placebo interventions in randomized controlled trials

Background

Placebo‐controlled trials play an important role in the evaluation of healthcare interventions. However, they can be challenging to design and deliver for invasive interventions, including surgery. In‐depth understanding of the component parts of the treatment intervention is needed to ascertain what should, and should not, be delivered as part of the placebo. Assessment of risk to patients and strategies to ensure that the placebo effectively mimics the treatment are also required. To date, no guidance exists for the design of invasive placebo interventions. This study aimed to develop a framework to optimize the design and delivery of invasive placebo interventions in RCTs.

Methods

A preliminary framework was developed using published literature to: expand the scope of an existing typology, which facilitates the deconstruction of invasive interventions; and identify placebo optimization strategies. The framework was refined after consultation with key stakeholders in surgical trials, consensus methodology and medical ethics.

Results

The resulting DITTO framework consists of five stages: deconstruct treatment intervention into constituent components and co‐interventions; identify critical surgical element(s); take out the critical element(s); think risk, feasibility and role of placebo in the trial when considering remaining components; and optimize placebo to ensure effective blinding of patients and trial personnel.

Conclusion

DITTO considers invasive placebo composition systematically, accounting for risk, feasibility and placebo optimization. Use of the framework can support the design of high‐quality RCTs, which are needed to underpin delivery of healthcare interventions.

Baroreflex function, haemodynamic responses to an orthostatic challenge, and falls in haemodialysis patients

BACKGROUND

Stage 5 chronic kidney disease patients on haemodialysis (HD) often present with dizziness and pre-syncopal events as a result of the combined effect of HD therapy and cardiovascular disease. The dysregulation of blood pressure (BP) during orthostasis may be implicated in the aetiology of falls in these patients. Therefore, we explored the relationship between baroreflex function, the haemodynamic responses to a passive orthostatic challenge, and falls in HD patients.

METHODS

Seventy-six HD patients were enrolled in this cross-sectional study. Participants were classified as "fallers" and "non-fallers" and completed a passive head up tilting to 60o (HUT-60°) test on an automated tilt table. ECG signals, continuous and oscillometric BP measurements and impedance cardiography were recorded. The following variables were derived from these measurements: heart rate (HR) stroke volume (SV), cardiac output (CO), total peripheral resistance (TPR), number of baroreceptor events, and baroreceptor effectiveness index (BEI).

RESULTS

The forty-four participants who were classified as fallers (57.9%) had a lower number of baroreceptor events (6.5±8.5 vs 14±16.7, p = .027) and BEI (20.8±24.2% vs 33.4±23.3%, p = .025). In addition, fallers experienced a significantly larger drop in systolic (-6.4±10.9 vs -0.4±7.7 mmHg, p = .011) and diastolic (-2.7±7.3 vs 1.8±6 mmHg, p = .027) oscillometric BP from supine to HUT-60° compared with non-fallers. None of the variables taken for the analysis were significantly associated with falls in multivariate logistic regression analysis.

CONCLUSIONS

This cross-sectional comparison indicates that, at rest, HD patients with a positive history of falls present with a lower count of baroreceptor sequences and BEI. Short-term BP regulation warrants further investigation as BP drops during a passive orthostatic challenge may be implicated in the aetiology of falls in HD.

The utility of whole body vibration exercise in haemodialysis patients: a pilot study

Background

Exercise improves physical capacity in patients with end-stage renal disease on haemodialysis (HD), but few patients engage in it. Whole-body vibration exercise (WBVE) is a novel protocol that has been shown to benefit frail elderly patients’ rehabilitation. We assessed the utility of WBVE before HD sessions and tested methods to inform the design of a randomized controlled trial (RCT).

Methods

Physical condition and quality of life were assessed at enrolment and repeated 2 weeks later in a pilot study of 49 patients undergoing regular HD. All patients then undertook 8 weeks of WBVE, thrice weekly for 3 min, after which the assessments were repeated and results compared (paired t-tests). Further assessments were made after a 4-week layoff. Patients completed a post-study questionnaire about their experiences of using WBVE. The reproducibility of WBVE and effects on measures of functionality, muscle strength, indirect exercise capacity, nutritional status, bone health and quality of life were recorded to undertake a power calculation for an RCT.

Results

Of 49 patients enrolled, 25 completed all assessments. The dropout rate was high at 49%, but overall, WBVE was an acceptable form of exercise. Functionality as assessed by the 60-s sit-to-stand test (STS-60) improved significantly by 11% (P = 0.002). Some quality of life domains also improved significantly. All improvements were maintained 4 weeks after discontinuing WBVE.

Conclusions

WBVE was acceptable, safe, easily incorporated into the routine of HD and was associated with useful improvements in physical function sufficient to justify a RCT.

Outcome reporting in bariatric surgery: an in-depth analysis to inform the development of a core outcome set, the BARIACT Study

Outcome reporting in bariatric surgery needs a core outcome set (COS), an agreed minimum set of outcomes reported in all studies of a particular condition. The aim of this study was to summarize outcome reporting in bariatric surgery to inform the development of a COS. Outcomes reported in randomized controlled trials (RCTs) and large non-randomized studies identified by a systematic review were listed verbatim and categorized into domains, scrutinizing the frequency of outcome reporting and uniformity of definitions. Ninety studies (39 RCTs) identified 1,088 separate outcomes, grouped into nine domains with most (n = 920, 85%) reported only once. The largest outcome domain was 'surgical complications', and overall, 42% of outcomes corresponded to a theme of 'adverse events'. Only a quarter of outcomes were defined, and where provided definitions, which were often contradictory. Percentage of excess weight loss was the main study outcome in 49 studies, but nearly 40% of weight loss outcomes were heterogeneous, thus not comparable. Outcomes of diverse bariatric operations focus largely on adverse events. Reporting is inconsistent and ill-defined, limiting interpretation and comparison of published studies. Thus, we propose and are developing a COS for the surgical treatment of severe and complex obesity.

Serum pepsinogen levels andOstertagia ostertagipopulations in clinically normal adult beef cattle

Serum pepsinogen levels and Ostertagia ostertagi populations in clinically normal grass-fed bullocks were investigated in three groups of 10 prime cattle aged between 2.5 and 2.75 years slaughtered in late summer (February), early autumn (March) and late autumn (May) respectively. Apart from occasional foci of mucosal hyperplasia abomasa were grossly normal. Serum pepsinogen levels ranged between 0.2 and 2.5 i.u./l with group means of 1.4, l.5 and 1.3 i.u./l. O. ostertagi counts ranged between 0 and 5,194 with group means of 734,630 and 701 worms. The composition of the worm populations varied with a higher proportion of adults recovered in February and very few worms from most cattle in March, suggesting the termination of a parasite generation. An increase in numbers of early fourth-stage larvae in May indicated exposure to a new generation. These changes were not reflected in the pepsinogen levels. The findings are discussed in relation to the adequacy of the pepsinogen assay as a diagnostic aid in field infections, animal age, and correlations between pepsinogen levels and parasite populations.

Telephone follow-up after treatment for breast cancer: views and experiences of patients and specialist breast care nurses

AIMS AND OBJECTIVES

To explore the views of patients and specialist breast care nurses on telephone follow-up after treatment for breast cancer.

BACKGROUND

A recent randomised controlled trial demonstrated that nurse-led telephone follow-up led to high levels of patient satisfaction with no physical or psychological detriment. This study aimed to explore in more detail the views of patients randomised to telephone follow-up and the nurses who conducted telephone appointments.

DESIGN

Qualitative.

METHOD

Individual interviews with 28 patients and four specialist breast care nurses. Content analysis was used to analyse the interview data.

RESULTS

Telephone follow-up was convenient for patients and provided continuity of care. Speaking on the telephone was perceived as a more 'normal' activity than attending hospital outpatient clinics. A structured approach was appreciated, instilling feelings of confidence that all questions had been asked and no errors had been made. Specialist nurses emphasised the high level of skill required to deliver the intervention and perceived that the telephone approach was well able to meet the individual needs of patients.

CONCLUSIONS

Positive views on telephone follow-up were reported. An experienced and skilled practitioner, with effective communication skills, is required to deliver the intervention and a period of training is recommended. Nurse-led telephone interventions have a broader applicability to other disease conditions, although more work is needed to develop appropriate interventions and evaluate their effectiveness.

RELEVANCE TO CLINICAL PRACTICE

Nurses at advanced levels of practice are uniquely placed to deliver such complex interventions. However, a period of initial training with effective peer support and channels for ongoing feedback are essential for administering an intervention that relies on audio rather than visual cues.

Promoting the health of people with chronic obstructive pulmonary disease: patients' and carers' views

AIMS AND OBJECTIVES

The aim of this study was to generate in-depth insights into patients' and family members' understanding of the causation, progression and prevention of chronic obstructive pulmonary disease and the role of health promotion with this population. In particular, we were interested in identifying the ways patients and family members considered that they could maximise their (patients') health, in the presence of this disease.

BACKGROUND

Chronic obstructive pulmonary disease is highly prevalent and a significant cause of morbidity and mortality, impacting on quality of life and healthcare expenditure. Health promotion is, therefore, an important consideration. There are few examples in the literature of health promotion programmes for this population, including those directed at smoking cessation, which also focus on the family or significant others.

DESIGN

An exploratory, descriptive design was employed.

METHOD

Semi-structured, audio-recorded interviews were conducted with 14 patients and 12 family caregivers. Interviews were transcribed verbatim and thematically analysed using content analysis procedures which captured the meaning of the data.

RESULTS

The three main themes were 'health promotion: what's that?', 'community resources for health promotion' and 'it wasn't just the smoking'. Many participants seemed unaware that their health might benefit from a healthier life style and provided little spontaneous information on any activities they carried out to maintain or improve their health.

CONCLUSIONS

This study highlighted a dearth of health promoting activity amongst people affected by chronic obstructive pulmonary disease. The reality for most patients was to manage the day-to-day demands that the symptoms of the disease imposed on them. Our data suggest that a more wide-ranging approach, encompassing aspects of health promotion, might be welcomed by many patients and their family carers.

RELEVANCE TO CLINICAL PRACTICE

The findings from this study highlight gaps in patients' and carers' understanding of the potential role of health promotion in chronic obstructive pulmonary disease and areas for intervention by health professionals. With the increase in smoking rates of women and predicted future increases in chronic obstructive pulmonary disease, it is imperative that health professionals find effective ways to provide support and health promotive care for patients and families.

A narrative review of interventions to support family carers who provide physical care to family members with cancer

OBJECTIVES

Most reports of cancer caregivers' needs focus on information and psychosocial needs. Less is known about practical knowledge and support carers need to provide physical care in the home. This review aimed to identity and critique studies of the development and/or evaluation of interventions to enable family carers to provide physical/practical care to a family member with cancer.

DESIGN

Narrative review.

DATA SOURCES

Studies which included adult carers who provided care to a family member with cancer (any stage). Search sources included Psych Info., Cochrane Central Register of Controlled Trials, Embase Ovid, Embase, Ovid Medline, CINAHL, other databases, systematic and other reviews.

REVIEW METHODS

All types of study designs were included. Initially, multiple and broadly defined search strategies and terms were used to capture the range of potential studies; later more refined procedures were applied.

RESULTS

In total, 19 studies were included in the review. Interventions focused on skills development (n=1), managing symptoms (n=9), problem solving (n=5) and learning (n=4). Few studies were identified with well-defined and evaluated interventions to assist carers to provide physical care for their family member with cancer.

CONCLUSIONS

Future research is needed to develop well-defined interventions on practical skills and evaluate the outcomes for patients and caregivers.

Relationship work in an early childhood home visiting program

A significant component of the work of public health nurses and paraprofessional home visitors who provide home visits to families with young children involves establishing relationships to effectively deliver the visiting program. The purpose of this qualitative and descriptive study was to describe the relationships among participants in a home visiting program in one regional health authority in the Canadian province of Manitoba. Interviews were carried out with 24 public health nurses, 14 home visitors, and 20 parents. The findings related to establishing, maintaining, and terminating relationships as well as factors influencing relationship work are described. Public health nurses and home visitors put significant effort into the work of establishing relationships with each other and their clients and require adequate training, sufficient human resources, and support from the program's administration to sustain these relationships.

Issues related to delivering an early childhood home-visiting program

PURPOSE

To describe the issues related to delivering an early childhood home visiting program, BabyFirst, from the perspective of public health nurses and lay home visitors (paraprofessionals).

STUDY DESIGN AND METHODS

This descriptive, qualitative interpretive study had a sample of 24 public health nurses and 14 lay home visitors. One in-depth, semi-structured, audio-taped interview was conducted with each participant. Transcribed data were analyzed using content analysis techniques.

RESULTS

Public health nurses and lay home visitors identified several issues associated specifically with the use of lay home visitors and more broadly with the delivery of the BabyFirst program. These are discussed in the following categories: issues related to (a) the lay home visitors, (b) the BabyFirst families, and (c) the general administration of the program.

CLINICAL IMPLICATIONS

Findings from this study provide information about the issues related to providing home-visiting services delivered by lay home visitors that can be applied to policy and practice development. The findings suggest that in addition to careful selection of prospective applicants, considerable resources should be provided in preparing public health nurses and home visitors for their respective roles. The concerns identified by nurses and home visitors suggest the need to target the following three areas: (a) training and retention of nurses and home visitors, (b) program delivery, and (c) enrollment of families. Attention to the issues discussed in this article has implications for improving the BabyFirst home-visiting program and other similar early childhood programs.

Caring for patients with COPD and their families in the community

Community matrons have a key role to play in the management of patients with long-term conditions. With the expected increase in prevalence of Chronic Obstructive Pulmonary Disease (COPD), largely due to cigarette smoking, the management and care of patients with COPD is a priority for the NHS. This paper examines the current and future role of community matrons in the management of patients with COPD. Community matrons have a potential role in providing evidence based care and could fill a gap in the implementation of effective interventions to help patients and family members stop smoking. A family focused approach to assessment and case management are important to achieving quality care and management of these patients. Recommendations are made with respect to the improvement of service provision for individuals and families with COPD.

Early childhood home visiting programme: factors contributing to success

AIM

This paper reports a study of the factors that public health nurses, home visitors and parents consider important for the success of an early childhood home visiting programme.

BACKGROUND

The primary aim of early child home visiting programmes is to promote healthy and safe growth and development of infants and children in at-risk families. Few studies have focused on actual programme components which foster this outcome.

METHODS

The research was a descriptive, qualitative evaluation. Success of the programme was defined as positive changes in families which were seen as directly related to participation. The 58 participants were 24 public health nurses, 14 home visitors and 20 parents. One in-depth semistructured audio-taped interview was conducted with each participant between October 2003 and February 2004. All interviews were transcribed and analysed using open coding; themes and categories were developed and reviewed for congruence of coding.

FINDINGS

Participants discussed several factors that they considered important for the success of the programme: its particular characteristics, the programme activities and the healthcare providers.

CONCLUSION

Components contributing to the success of early childhood home visiting programmes include a strength-based philosophy, voluntary enrollment of parents, regularly scheduled home visits, a curriculum to structure the home visitor's interventions, and careful attention to the selection, training, and supervision of home visitors.

Can we improve dysphagia referrals?

We set out to examine whether a multidisciplinary out-patient dysphagia referral triage service would shorten the duration of a patient's referral process and direct patients to the correct specialty. A review was carried out of patients referred with dysphagia before and after the introduction of a multidisciplinary out-patient dysphagia service, from February 2001 to April 2001 and from January 2002 to March 2002, inclusive.

One hundred and eight patients were referred in total. The length of time until the first appointment was reduced from four to three weeks (median; range one to 23; p<0.001). The number of instrumental investigations was reduced, with a median of one instrumentation per patient under the new service, compared with two in those under the standard service (p<0.001). Attendance to hospital was also reduced, with 45 per cent of patients under the new service requiring only one appointment, compared with 13 per cent in those under the standard service (p<0.001).

The multidisciplinary out-patient dysphagia service was associated with significant reductions in waiting times, in the number of instrumental investigations and in the duration of the patient's referral process.

Contributors to white matter damage in the frontal lobe in Alzheimer's disease

Abnormalities of cerebral white matter are present in a majority of patients with Alzheimer's disease (AD) and probably contribute to motor dysfunction and cognitive impairment. The white matter abnormalities are usually attributed to degenerative vascular disease and cerebral amyloid angiopathy (CAA) but the evidence is scanty or inconclusive. In the present study we examined sections of frontal lobe from 125 autopsy-confirmed cases of AD and assessed the relationship of degenerative large and small vessel disease, CAA, parenchymal Abeta load and APOE genotype, to several objective measures of white matter damage: extent of immunolabelling for glial fibrillary acidic protein (GFAP), axonal accumulation of amyloid precursor protein (APP), axon density in superficial and deep white matter, and intensity of staining for myelin. We found no association between atherosclerosis, arteriolosclerosis, CAA or APOE genotype and white matter damage. However, labelling of white matter for GFAP correlated strongly with the parenchymal Abeta load (P = 0.0003) and with APP accumulation (P = 0.008). Our findings suggest that severity of frontal white matter damage in AD is closely related to parenchymal Abeta load and that in most cases the contribution of degenerative vascular disease, CAA and APOE is relatively minor.

Prevalence and correlates of smoking during pregnancy: a comparison of aboriginal and non-aboriginal women in manitoba

BACKGROUND

Prenatal smoking rates vary substantially among racial and ethnic groups. Although prevalence of smoking among Aboriginal people in Canada is higher than in the general population, little is known about smoking rates during pregnancy among Aboriginal women or the characteristics of Aboriginal women more likely to smoke during pregnancy. The study purpose was to describe and compare the prevalence and correlates of smoking during pregnancy among Aboriginal and non-Aboriginal women giving birth in the Canadian province of Manitoba.

METHODS

Data were obtained from interviews with 684 postpartum women who delivered a live singleton infant in two tertiary hospitals in Manitoba. Stratified analysis was used to describe effect-measure modification for correlates of smoking among the Aboriginal and non-Aboriginal groups. A multivariable logistic regression was conducted for the total sample.

RESULTS

A significantly higher proportion of Aboriginal women (61.2%) than non-Aboriginal women (26.2%) smoked during pregnancy. No correlates of smoking during pregnancy were specific to Aboriginal women, but several maternal characteristics were associated with smoking among non-Aboriginal women. After controlling for other factors, significant correlates of smoking during pregnancy for the total sample included inadequate prenatal care, low support from others, single marital status, illicit drug use, Aboriginal race/ethnicity, and noncompletion of high school among non-Aboriginal women.

CONCLUSIONS

The high prevalence of smoking during pregnancy, particularly among Aboriginal women, necessitates coordinated efforts aimed at smoking prevention and cessation.

Relationship of neurofibrillary pathology to cerebral amyloid angiopathy in Alzheimer's disease

Over 90% of patients with Alzheimer's disease (AD) develop cerebral amyloid angiopathy (CAA). Severe dyshoric CAA, in which amyloid extends into the surrounding brain parenchyma, may be associated with adjacent clustering of tau-immunopositive neurites but the relationship of CAA to neurofibrillary pathology has not been systematically investigated. In the present study this relationship was examined in sections of frontal, temporal and parietal cortex from 25 AD patients with moderate to severe CAA and 26 with mild or absent CAA. We measured immunolabelling of abnormally phosphorylated tau adjacent to A beta-laden and non-A beta-laden arteries and arterioles, and in cortex away from arteries and arterioles. We also analysed the possible influence of APOE genotype on these measurements. There were no significant differences between the lobes in measurements of tau labelling, either around blood vessels or elsewhere in the cortex. However, tau labelling around A beta-laden arteries and arterioles significantly exceeded that around non-A beta-laden blood vessels (P<0.001) and this, in turn was greater than the labelling of cortex away from blood vessels (P<0.001). There was no association between APOE epsilon 4 and the immunolabelling density for tau, whether around amyloid- or non-amyloid-laden arteries and arterioles, or in the cerebral cortex away from these. We propose that both CAA and peri-vascular accumulation of hyperphosphorylated tau may be a consequence of elevated levels of soluble A beta around cortical arteries and arterioles.

The description and evaluation of a longitudinal pilot study of a smoking relapse/reduction intervention for perinatal women

BACKGROUND

Up to 70% of women who quit smoking while pregnant will relapse during the first postnatal year. In this study, a community-based, ecological approach guided the development and implementation of a smoking cessation intervention for perinatal women.

AIMS

The aims of this pilot project were to: (1) develop and implement a community-based intervention to assist women to stop smoking or prevent smoking relapse during the pre- and postnatal periods, (2) provide feedback on participants' perceptions of the helpfulness of the intervention, (3) compare perceptions of the helpfulness of the intervention between women who received the intervention during the prenatal vs. postnatal periods, and (4) identify additional components of the intervention which need to be included in future research.

DESIGN/METHODS

Using a participative process and a detailed review of the literature, researchers, health care professionals and women (pregnant or postnatal) developed a multifaceted intervention. The intervention included four core components, which all women received: home visit by the intervention nurse, follow-up telephone call(s), resource package, and letter of congratulations. Additional optional components included: telephone help line, support groups, referrals and other services. Forty-two women who were pregnant or had recently delivered participated. Descriptive and evaluation data were collected from participants using questionnaires and telephone interviews. The research was approved by the university Research Ethics Board.

FINDINGS

Participants found the core components of the intervention to be helpful in their smoking cessation goals, particularly the home visit and resource material. The support groups and smoking help line were not used. There were no differences in how helpful the components of the intervention were perceived to be between women who received it in the prenatal or postnatal periods.

CONCLUSIONS

Future research is needed to evaluate the effectiveness of the intervention.

APOE epsilon 4 influences the pathological phenotype of Alzheimer's disease by favouring cerebrovascular over parenchymal accumulation of A beta protein

The relative amounts of amyloid beta-protein (A beta) in cerebral blood vessels and parenchyma vary considerably amongst patients with Alzheimer's disease (AD). Although several mechanisms have been proposed to explain this variability, the underlying genetic and environmental determinants are still unclear, as are the functional consequences. Polymorphisms in APOE, the gene for apolipoprotein E (ApoE), influence the risk of developing AD and of deposition of A beta within the brain. We examined the relationship between the APOE genotype and the relative extent of accumulation of A beta as plaques within the cerebral parenchyma and in cortical blood vessels in the form of cerebral amyloid angiopathy (CAA), in autopsy brain tissue from 125 AD cases and from 53 elderly, neurologically normal controls of which 19 had CAA without other neuropathological features of AD. In the AD cases, we also assessed whether the severity of CAA was related to the age of onset and duration of dementia, risk factors for atherosclerotic vascular disease, and histologically demonstrable cerebral infarcts or foci of haemorrhage. The APOE genotype was determined by a standard polymerase chain reaction-based method. Paraffin sections of frontal, temporal and parietal lobes were immunolabelled for A beta and the parenchymal A beta load (total A beta minus vessel-associated A beta) was quantified by computer-assisted image analysis. CAA severity was scored for cortical and leptomeningeal vessels. The relevant clinical data were obtained from the database of the South West Brain Bank. In AD, we found the severity of CAA to be strongly associated with the number of epsilon 4 alleles (P < 0.0001) but the parenchymal A beta load to be independent of APOE genotype. Cases with severe CAA had a lower parenchymal A beta load than had those with moderate CAA (P = 0.003). Neither the severity of CAA nor the parenchymal A beta load correlated with age of onset, duration of disease or age at death, and the severity of CAA also did not correlate with the presence of cerebral infarcts or foci of haemorrhage. These findings indicate that possession of the APOE epsilon 4 allele favours vascular over parenchymal accumulation of A beta in AD. This may influence the pathogenesis of neurodegeneration in epsilon 4-associated AD.

Reports of information and support needs of daughters and sisters of women with breast cancer

The aim of this study was to describe the information and support needs of women who have primary relatives with breast cancer. The Information and Support Needs Questionnaire (ISNQ) was developed and revised from previous qualitative and pilot studies. The ISNQ addressed concepts of the importance of, and the degree to which, 29 information and support needs related to breast cancer had been met. The study sample consisted of 261 community-residing women who had mothers, sisters, or a mother and sister(s) with breast cancer. Data were collected using a mailed survey. In addition to the ISNQ, additional items addressed family and health history, breast self-care practices, perception of the impact of the relative's breast cancer and other variables. Also included were established and well-validated measures of anxiety and depression. The findings document women's priority information and support needs. The information need most frequently identified as very important was information about personal risk of breast cancer. Other highly rated needs addressed risk factors for breast cancer and early detection measures. Generally, the women perceived that their information and support needs were not well met. These findings illuminate needs of women for more information and support when they have close family relatives with breast cancer and opportunities for primary care providers to assist women in addressing their needs.

Health promotion and tobacco control: student nurses' perspectives

This article reports findings about student nurses' understanding of the nursing role in health promotion related to tobacco issues. These findings were derived from the data of a larger project, examining smoking practices of baccalaureate nursing students in Manitoba, Canada. The study was conducted with second-year, third-year, and fourth-year university nursing students studying at several sites throughout the province (N = 272). From the data analysis of the interviews, class forums, and open-ended survey questions, five themes emerged (i.e., who they are-who they are becoming, central beliefs and attitudes, learning the facts, practice world-limited options, role conflict). Students expressed considerable uncertainty and conflict concerning individual autonomy around decisions about tobacco use. This resulted in confusion about themselves as role models and their use of health promotion interventions.

The influence of question wording on assessments of interest in genetic testing for breast cancer risk

The purpose of this study was to compare the results of different measures of interest in genetic testing for breast cancer risk. A telephone survey of a random sample of women without breast cancer was conducted in British Columbia, Canada. Interest in genetic testing for breast cancer risk was measured in three ways: (1) an unprompted assessment of interest, (2) assessment of interest when prompted with a hypothetical offer of testing, and (3) assessment of interest when provided with supplementary information. Substantial differences in reported levels of interest in genetic testing were observed across the different assessment approaches, with the unprompted assessment of interest resulting in lowest levels of interest. The highest levels of interest were observed when the assessment of interest was prompted with a hypothetical offer of testing. Factors predicting interest in genetic testing varied depending on the assessment measure used. These findings suggest that more attention must be given to measurement issues, including complete reporting of measures used in research, development of standardized approaches to assessing interest in genetic testing, and more rigorous psychometric evaluations of measures of interest in genetic testing.

Tobacco use and baccalaureate nursing students: a study of their attitudes, beliefs and personal behaviours

AIM

To report findings about student nurses' attitudes, beliefs and personal behaviour in relation to tobacco issues.

RATIONALE

Nurses have the potential to influence clients' behaviours and public policy concerning tobacco use. However, a review of the literature suggests that this is not happening. Further understanding of nursing students' attitudes, beliefs and behaviours regarding tobacco use is needed in order to develop strategies which can positively impact on their future health promotion role.

METHODS

A cross-sectional survey of the total population of baccalaureate nursing students in one Canadian province was employed. Students were asked to complete a self-administered questionnaire, which included questions related to their smoking history; stage of behavioural change, and beliefs and attitudes towards tobacco. Students also completed the Health Promotion Lifestyle Profile (HPLP) and the Fagerström Nicotine Tolerance Scale.

FINDINGS

Two hundred and seventy-two students (61.9%) responded. Sixty (22.1%) indicated that they smoked daily or in social situations. These smokers were found to have a fairly low level of nicotine dependence and although 91.4% said they wanted to quit, few were actively engaged in the quitting process (16.9%). When comparing the beliefs and attitudes of smoking and non-smoking students, proportionally more of the non-smokers agreed that smokers will need close family/friends to help them quit; that the health of society should be protected by laws against smoking; and that nurses should set a non-smoking example. Non-smokers indicated more health promoting behaviours on items in the HPLP especially on the variables of physical activity, nutrition and stress management.

CONCLUSIONS

Nurses have the potential to influence clients' behaviours and public policy concerning tobacco use. Developing future nurses with the knowledge and skill to do so needs to be an important emphasis of nursing curricula.

Double agency in clinical research

The current focus on evidence-based practice in nursing may result in nurses playing 2 roles concurrently--that is, acting as researcher and caregiver at the same time and with the same people. Given the fiduciary nature of the patient-caregiver relationship, this double agency can give rise to problems, both real and perceived. In this paper, the issues associated with assuming dual roles in research with humans will be examined, particularly in relation to recruitment and informed consent, data collection, and participant withdrawal from a study. In addition, strategies to prevent or minimize problems related to double agency are identified, with attention to the guidance provided by professional codes of ethics and the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans.

Women's interest in genetic testing for breast cancer risk: the influence of sociodemographics and knowledge

The objective of this study was to assess women's interest in genetic testing for breast cancer risk. Randomly selected samples of 761 women without breast cancer from the general population of British Columbia, Canada, and 260 women with breast cancer from the provincial cancer registry participated in a telephone survey that assessed interest in genetic testing for breast cancer risk, knowledge of hereditary breast cancer and genetic testing, and sociodemographics. Women with breast cancer did not possess superior knowledge of breast cancer genetics compared with women from the general population. Of the women with breast cancer, 30.8% reported interest in testing or had been tested, compared with 28.5% of women without breast cancer. Controlling for differences in age, education, personal history of breast cancer, and knowledge of genetics, women with at least one relative with breast cancer were 2.3 times more likely to express interest in genetic testing for breast cancer risk than those with no family history. There were significant interactions between breast cancer status and education and between age and knowledge of breast cancer genetics. Women without breast cancer and with a positive family history, who were between 20 and 40 years of age, were most likely to be interested in testing. The women with breast cancer who were interested in testing tended to be approximately 50 years of age, had a positive family history, and had more years of education. Women with a family history of breast cancer, well-educated women with breast cancer, and younger women, particularly those with knowledge of genetic testing, are important target audiences for community-based education on genetic testing for breast cancer risk.

Rural families' perspectives on having a child with cancer

The goal of this study was to explore and describe the experience of being or having a child with cancer in a rural geographic area. An exploratory, descriptive study was conducted that used semistructured, in-depth, tape-recorded interviews as the primary data collection method. Ten rural families who each had a child with cancer formed the sample. Data were analyzed with qualitative analysis procedures. Families' descriptions revealed that their experiences were fraught with challenges that were due to living a great distance from the cancer treatment center. Descriptions of their experiences are presented in this report. Recommendations for health care professionals, particularly pediatric oncology nurses, to assist rural families in coping with their challenges are also offered.

A smoking reduction and cessation program with registered nurses: findings and implications for community health nursing

A smoking reduction and cessation program was implemented with registered nurses in 3 Canadian provinces. Nurses (n = 117) participated in either an 8-week group or self-directed program using a resource specifically designed for nurses. Questionnaires were administered prior to and at the end of the 8-week interventions and at 6 and 12 months postintervention. Statistically significant changes at 8 weeks in nurses' smoking practices were found on the number of nurses continuing to smoke, mean number of cigarettes smoked, and movement in the stage of behavioral change. Attrition and variation in patterns of quitting over the 12-month study period made assessing participants' longer term outcomes difficult. This study highlights the complexity of assisting nurses to quit smoking and of implementing and evaluating a program based on accepted community health models of practice.

An exploratory study of clinical decision-making in five countries

PURPOSE

To identify the cognitive processes nurses use in their decision-making in long- and short-term care settings in five countries, and the demographic variables associated with their decision-making. METHOD AND SAMPLES: The instrument used was a 56-item questionnaire that has been shown to be reliable in earlier studies. The sample consisted of five convenience samples of registered nurses working in either geriatric wards (n = 236) or acute medical-surgical wards (n = 223) in hospitals or nursing homes in Canada, Finland, Sweden, Switzerland, and the United States.

FINDINGS

Five models of decision-making were identified on the basis of factor analysis. They represent both analytical and intuitive cognitive processes. Analytical cognitive processes were emphasized in information collection, problem definition, and planning of care, and intuitive cognitive processes were emphasized in planning, implementing, and evaluating care. Professional education, practical experience, field of practice, and type of knowledge were significantly associated with decision-making models as well as with country of residence of the participants. The highest proportion of analytically oriented decision-makers was found among nurses in long-term care, the decision-making of nurses in short-term care was more intuitively oriented.

CONCLUSIONS

The results indicate that decision-making of participants varied from country to country and in different nursing situations. Future research should be focused on reasons for these differences, the relationship between the task and the nurses' type of knowledge, and how nurses use their knowledge to make decisions in different nursing situations.

Falling through the cracks. Women's experiences of ineligibility for genetic testing for risk of breast cancer

OBJECTIVE

To describe experiences of women seeking information about their risk of hereditary breast cancer who fail to meet strict eligibility criteria for genetic counseling and testing.

DESIGN

Qualitative descriptive study.

SETTING

Hereditary cancer program in western Canada.

PARTICIPANTS

Women who had received notification of their ineligibility for referral for hereditary breast cancer risk assessment (n = 20) and some of their referring physicians (n = 10). Of 28 attempted contacts, five women had moved, one declined the invitation to participate, and two could not be interviewed because of scheduling conflicts. Ten of 20 physicians declined the invitation to participate.

METHOD

In-depth, open-ended telephone interviews were conducted. Transcribed interviews were systematically analyzed to identify salient themes.

MAIN FINDINGS

Three themes emerged. The first theme, "It's always on your mind," points to the profound concern about breast cancer that underlies women's experiences in seeking genetic testing. The second theme, "A test is a test," reflects women's beliefs that the test was relatively simple and similar to other medical tests in that it would provide a definitive answer. The third theme, "Falling through the cracks," captures the experience of ineligibility. Women reacted with a range of emotional responses and were left frustrated in their search for more specific information about their personal risk for breast cancer. Although women were encouraged to contact their physicians, few did.

CONCLUSION

These findings point to the psychological consequences in women who seek genetic testing for risk of breast cancer when they are told they are ineligible and they are not given adequate information and support.

Advanced practice nursing in Canada: has the time really come?

Nurse practitioners in Canada have experienced many of the problems facing those in the UK. In this paper, first presented at this year's meeting of the Commonwealth Nurses' Federation, the authors explain the events.

Public health nurses' decision making in Canada, Finland, Norway, and the United States

The purpose of this study was to describe the decision-making processes of 369 public health nurses in Canada, Finland, Norway, and the United States, and to discuss any differences observed among these countries. The results indicate that public health nurses used different decision-making models on the job and that these models varied considerably. Five different decision-making models were identified, each exhibiting features of different decision-making theories. The differences between decision making of public health nurses in different countries were statistically significant. The differences in decision making appear to be due to differences in health care systems in the 4 countries and the nature of the nursing task and context.

Knowledge, skills and experiences for community health nursing practice: the perceptions of community nurses, administrators and educators

Nursing in Canada is committed to preparing all new graduates at the baccalaureate level for entry to nursing practice by the year 2000. This goal has major implications for community health nursing education and practice. Health care reform is also expected to move care out of the hospital and into the community. It was against this backdrop that the researchers mounted a study on the educational preparation needed for graduates to begin to practice community health nursing. In this paper, the knowledge, professional and personal skills, and experiences that graduates need to begin community practice are reported. The study was carried out within an action-research framework. All major groups of stakeholders involved in community health nursing throughout the study province were involved in the project. This included nurses and administrators from two public health agencies (provincial and municipal), home care nurses, home health nurses (i.e. non-governmental visiting nurses), community health centres, provincial health care and nursing consultants, and faculty from two universities. In addition to the generation of relevant research findings for use by the educational institutions, the study was initiated to set the stage for future and ongoing interactions between the researchers and community experts to implement the findings from the project. Data were collected from 118 participants by means of 27 focus groups of community nurses, administrators and educators. Interviews were tape-recorded, transcribed and analysed using latent content analysis and constant comparison techniques. Findings indicated that qualified nurses from university programmes need a wide range of knowledge, skills and experiences to begin to practice community health nursing. Detailed accounts of these requirements are outlined and the implications for practice and education put forward.

Information, support, and communication needs of women with a family history of breast cancer

In this article, the role of information, support, and communication in promoting adaptation to the risk of breast cancer is reported. These variables emerged from an in-depth study of women at risk for breast cancer because of breast cancer in one or more of their primary (first degree) relatives. Fifty-five women with mothers, sisters, mother and sister, or mother and another primary relative were interviewed using in-depth semi-structured, tape-recorded interviews. After transcription, data were analyzed using qualitative analysis procedures. A three-phase process of adaptation to the risk of breast cancer was uncovered, which was subsequently validated with two study participants. Information, support, and communication emerged as important factors in facilitating the adjustment of women throughout the three phases of the process: as women "lived" the breast cancer experience of their relative; as they developed a perception of their personal risk for breast cancer; and finally as they put the risk of breast cancer "in its place." Despite the importance of information and support, most women had difficulty meeting these needs. Also, communication patterns both within the family and with health professionals were generally not helpful for these women. Issues related to the ill relative as "manager" of cancer-related information, the "ownership style" of the woman at risk, and the accessibility and availability of resources influenced women's adaptation to feelings of risk. Women's needs for information, support, and communication and facilitating factors are described in detail, and recommendations for clinical practice and research offered.

Age-sensitive T cell phenotypes covary in genetically heterogeneous mice and predict early death from lymphoma

We have assessed several age-sensitive indicators of immune status in young (i.e., 6 to 11-month-old) mice of a genetically heterogeneous population to see if these varied in parallel and to determine if one or more of the status indices predicted life span or cancer incidence. We report that the number of memory (i.e., CD44hi) T cells within the CD8 subset is correlated with number of memory cells in the CD4 population, and inversely correlated with the number of naive (i.e., CD45RBhi) CD4 cells at both 6 and 11 months of age, suggesting that the conversion of naive to memory cells may occur at similar rates in both T cell subsets. Mice that ranked high in the proportion of memory T cells (within the CD4 and CD8 pools) at 6 months of age tended to retain their ranking at 11 months, suggesting that the pace or extent of memory cell formation may be a consistent trait that distinguishes mice at least within a genetically heterogeneous population. Mice that at 6 months of age exhibited high levels of CD4 or CD8 memory T cells, low levels of naive CD4 cells, or low levels of T cells able to proliferate in response to Con A and IL-2 were found to be significantly more likely than their littermates to die within the first 18 months of life. Cases of follicular cell lymphoma, lymphocytic and lymphoblastic lymphoma, and hepatic hemangiosarcoma were seen within the group of mice dying at early ages.(ABSTRACT TRUNCATED AT 250 WORDS)

Difficult work: health visitors' work with clients in the community

The purpose of this paper is to discuss health visitors' construction of difficult work as uncovered in their descriptions of actual cases. The grounded theory approach was used to uncover the processes by which health visitors work with clients in the community. Forty-five experienced health visitors participated in the research. Data were collected using semi-structured, conversational interviews, field notes, and a short data collection form. Findings identified three types of situations in their work which created difficulty for health visitors: concerns about client safety, inappropriate use of health visitor services, and client denial and blocking. Several approaches to dealing with difficult situations were identified. These were labelled as: "more of the same", "wait for a bit", "withdrawal", "fall back on routine visiting", "try something else", and "open up the problem situation/confrontation". The use of approaches was related to factors in the context in the situation in which the health visitor found herself, and factors related to the health visitor and her particular style of practice. This paper assists in understanding how health visitors work with clients in the community to influence health.

The inheritance of genetic markers in microspore-derived plants of barley Hordeum vulgare L

Biochemical, molecular and morphological markers have been used to monitor the segregation of alleles at major gene loci in microspore-derived lines of four spring barley crosses and their parents. Significant deviations from the expected Mendelian ratios were observed for four of the ten markers studied in the cross. Distorted ratios were associated with loci located on chromosomes 4H and 6H. The differential transmission of alleles was in favour of the responsive parent (Blenheim) used in the anther culture studies. For the α-Amy-1 locus on chromosome 6H, the preferential transmission of Blenheim alleles was most pronounced in the haploid regenerants that were colchicine treated. These results are discussed in relation to the genetic control of androgenetic response in barley and with respect to the exploitation of another culture in barley improvement.

Nurse-client interactions in community-based practice: creating common ground

Although research activity is increasingly aimed at examining health outcomes of community health nursing care, little empirical literature systematically describes the nurse-client interaction. In this pilot study nurse-client interactions were evaluated to describe their detailed elements. Nineteen such interactions occurring in a Canadian public health department were videotaped by a professional filming crew. The clinical situations included home visits, school health interviews and screening, health classes, and clinic work. The audio portion of the nurse-client exchanges were transcribed from the videotapes onto a computer and analyzed using content analysis. Semi-structured interviews were conducted with nurses and clients after the filming to elicit their perceptions of the interactions. Field notes describing nonverbal and contextual data were also collected and analyzed. The central process identified during the interactions was called "creating common ground." This integrating conceptual schema captured the give and take as each participant defined territory and revealed information. The process varied depending on care context, process skills of the nurse, and willingness of the client to engage.

The theoretical basis for nursing at the community level: a comparison of three models

Although literature on community health nursing identifies a nursing role at the community level, there is a lack of clarity about the elements and expected outcomes of this role. In this paper three models of community health practice are presented and discussed in terms of their effectiveness as a basis for nursing practice at the community level. These models are (1) the public health model, (2) community participation model, and (3) community change model. Factors that affect the effectiveness of nursing to work at the community level are also discussed and questions for reflection and debate raised.

The relationship of heart-girth to liveweight of female goats in New Zealand

The correlations between heart-girths (measured as the smallest thoracic circumference) and liveweight were determined for 96 Saanen, 100 Angora and 101 feral female goats all of New Zealand origin. The correlation coefficients were 0.94, 0.94 and 0.90 for Saanens, Angoras and ferals respectively. To facilitate liveweight estimation for calculating doses of non-mineralised anthelmintics and to minimise under-dosing it is suggested that a straight-line equivalent of the upper 95% confidence curve be used. Care should be exercised in using girth measurements in small animals where the error could be high. They are not recommended for use when mineralised drenches or potentially dangerous drugs are being administered.

Lifestyle counselling: the need for diagnostic clarity

Three approaches to changing lifestyle behaviours are hypothesized. The argument that diagnostic accuracy is essential for selection of appropriate nursing interventions is developed and illustrated with clinical examples. The diagnoses of information deficiency, information and behavioural control deficiency, and contextual awareness deficiency guide the interventions for the problem of obesity.

Questioning: an intervention for health promotion

In the health professions, questioning is traditionally viewed as a way of gathering information from a client as well as a way of developing the affective domain or how the client feels. The development of the cognitive domain, or how the client thinks, receives less attention. This article describes a clinical nursing approach using Bloom's Taxonomy to question clients' thinking behavior. Examples from nurses' files are used to clarify this approach.

Nursing interventions for health promotion

Selected nursing interventions for health promotion in well individuals are described. Over a two-year period, two clinical nurse specialists developed and used client record keeping, role playing, audio and video feedback, imagery, visual mapping and experimentation as health promotion interventions. Clinical examples and client outcomes are discussed. Health promoting interventions are clearly distinguished from disease prevention approaches as described in the literature.