The development and validation of a needs assessment tool for use with YOUng adult survivors of a CentrAl Nervous system tumor (YOU-CAN)

Background

Adolescent and young adult (AYA) survivors of a central nervous system (CNS) tumor represent a vulnerable group who can experience: social isolation, low rates of employment, and achieving independence can be compromised, leading to poorer quality of life compared with survivors of other cancer types. The aim of this study is to develop and evaluate the validity of a needs assessment tool (NAT) for AYA survivors of a CNS tumor.

Methods

Items generated using data from 29 qualitative studies and cognitive interviews (n = 8) produced NAT V1.1 (49 items). 128 of 316 eligible participants attending neuro-oncology clinics at 4 NHS sites between June 2022 and March 2023 completed the NAT V1.1 to allow for item reduction and refinement and to evaluate reliability and validity. A pilot study (n = 6) using YOU-CAN in routine follow-up concluded the study.

Results

Hierarchical analysis and Rasch analysis identified 18- and 15-items for removal, respectively. YOU-CAN, comprised of the remaining 16 items, demonstrates excellent test-retest reliability (intra-class correlation coefficient, 0.901, n = 40) and sufficient correlation with the European Quality of Life questionnaire and Supportive Care Needs Survey (Pearson r = 0.433 and 0.590, respectively). Pilot testing showed YOU-CAN triggered discussions of unmet needs in consultations and highlighted the importance of multidisciplinary support.

Conclusions

YOU-CAN is a valid and reliable instrument containing items related to concerns about physical and emotional health; family and relationships; self-acceptance; and independence. Future efforts should examine YOU-CAN's feasibility, and develop guidance for managing unmet needs. Routine use of YOU-CAN may improve the identification of otherwise undiscussed unmet needs and opportunities to deliver personalized support.

Measurement Properties of Patient-Reported Outcome Measures for Adolescent and Young Adult Survivors of a Central Nervous System Tumor: A Systematic Review

Purpose: To identify and evaluate patient-reported outcome measures (PROMs) for assessing survivorship-related concepts for adolescent and young adult (AYA) survivors of central nervous system (CNS) tumors. Methods: We searched five electronic databases. Two researchers independently screened all titles for inclusion and used consensus-based standards for the selection of health measurement instruments (COSMIN) guidance to grade the quality of evidence for each measurement property. Results: Four studies met eligibility criteria: single-item pain thermometer; single-item fatigue thermometer; 37-item pediatric functional assessment of cancer therapy-brain tumor survivors, measuring quality of life; and 12-item Perceived Barriers Scale to assess barriers to employment. The Perceived Barrier Scale showed high-quality evidence for internal consistency and moderate quality evidence for construct and structural validity. Evidence for the measurement properties of the other PROMs was low-to-moderate quality. Conclusion: We found one PROM with sufficient evidence for good measurement properties to support its use. This warrants development and evaluation of further PROMs to inform ongoing supportive care for this population. Implications for Cancer Survivors: The Perceived Barriers Scale is sufficiently validated and could be considered to guide support for AYA survivors of CNS tumors to achieve their employment goals.

Patient-reported outcome (PRO) instruments used in patients undergoing adoptive cell therapy (ACT) for the treatment of cancer: a systematic review

INTRODUCTION

Adoptive cell therapy (ACT) is a rapidly evolving field. Patient-reported outcomes (PROs) allow patients to report the impact of treatment on their quality of life during and after treatment. The systematic review aims to characterise the breadth of PROs utilised in ACT cancer care and provide guidance for the use of PROs in this patient population in the future.

METHODS

A systematic search was conducted (MEDLINE, PsycINFO, Embase and CINAHL) in August 2021 by two reviewers. Search terms covered the following: "adoptive cell therapy", "patient-reported outcomes" and "cancer". Studies were included if they used a PRO measure to report the impact of ACT. The methodological quality of PROs was assessed. Forward and backward reference searching was conducted of any relevant papers. A quality grading scale was applied based on Cochrane and Revenson criteria for classification of high-quality studies. Key data from the studies and the included PROs was extracted by two researchers and tabulated.

RESULTS

One-hundred nine papers were identified; 11 papers were included. The majority of studies were single-arm trials or observational studies. Twenty-two different PROs were identified; none was ACT specific. The PROMIS-29 and EQ-5D were most commonly used. Few studies collected PRO data in the first 1-2 weeks. Four studies followed patients up for over a year, and a further four studies followed patients for approximately 3 months.

DISCUSSION

None of the PROs identified have been designed specifically for ACT. Appropriateness of existing instruments should be considered. It should be considered whether it is appropriate to collect data more frequently in the acute stage and then less frequently during follow-up. It should be considered if one tool is suitable at all time points or if the tool should be adapted depending on time since treatment. More research is needed to identify the exact timings of PRO assessments, and qualitative work with patients is needed to determine the most important issues for them throughout the treatment and follow-up.

809 USE OF NEW MOBILITY SCORE AND A TRANS-DISCIPLINARY APPROACH TO REDUCE HOSPITAL LOS, RETURN TO ORIGINAL RESIDENCE, AND MORTALITY

Introduction

The National Hip Fracture Database indicated Guy’s and St Thomas’ Trust ranked in the fourth quartile nationally with reference to hospital length of stay (LOS), return to original residence (ROR), and mortality in hip fracture patients in 2018. This quality improvement project aimed to improve and maintain these key factors via a two-stage process.

Methods

Stage one involved implementation of four key interventions through a trans-disciplinary focus group, comprising ortho-geriatricians, orthopaedic surgeons, physiotherapists (PT), occupational therapists (OT), nursing staff, and a transfer of care navigator (TCN). Firstly, the New Mobility Score (NMS) was employed as a tool to guide estimated length of stay. Secondly, use of preoperative OT assessment allowed early evaluation of patient expectations concerning discharge planning. Third, facilitation of the discharge process was optimised by the recruitment of a TCN. Lastly, attendance of a senior orthogeriatrician during the daily board round was established. Stage two involved education of new members of the trans-disciplinary team to ensure that the key interventions listed above were maintained on hip fracture patients.

Results

Following stage one, average acute hospital LOS and overall LOS decreased from 20.1 to 15.1 days and 22.4 to 18.3 days, respectively. Rate of ROR within 120 days of discharge improved from 72.4% to 86.9%, while mortality rates fell from 7.1 to 3.4. Following stage two, overall LOS improved to 17.1 days, while acute LOS and mortality were maintained at 15.6 and 3.9 days, respectively. While ROR fell to 82.8%, this remained higher than the national average at 69.9%.

Conclusions

Utilisation of NMS and multi-disciplinary input effectively improved ROR, while reducing length of hospital stay and mortality rates in hip fracture patients. Education of new members of the trans-disciplinary team allowed sustained improvement despite challenges faced during the COVID-19 pandemic.

883 A Closed-Loop Audit to Improve Admissions Documentation in A Busy ENT Department

Aim

Accurate and thorough admissions documentation is crucial for patient safety and effective care. We amended the admissions pro-forma used on a busy adult ENT ward to improve adherence to a modified version of Royal College of Surgeons of England guidelines.

Method

Baseline documentation of the 25 parameters of interest was assessed using electronic medical records for all emergency and pre-operative admissions over a 4-week period (n = 75). A new pro-forma was introduced, and the documentation over the following 4 weeks (n = 75) was assessed in the same way. Statistical analysis was done using Excel and RStudio (z-test for two proportions, p-value ≤ 0.05).

Results

The two groups were similar in age, gender, length of stay, and presenting complaint. The new pro-forma was completed for more admissions than the prior version (91% vs 77%) and resulted in documentation improvements in 19 out of 25 parameters. 9 of these were statistically significant, including initial vital signs and differential diagnosis. Parameters that improved, but not significantly, include admission source, medication history, and cognitive assessment. Across the 8 weeks, using a pro-forma (n = 126) significantly improved documentation of 11 parameters compared to freehand clerking (n = 24).

Conclusions

Adequate documentation at admission can help with immediate patient care, and act as a point of reference during extended stays. We were able to increase use of a pro-forma and produce meaningful documentation improvements quickly. Further work is required to assess why certain parameters are infrequently completed, and how future pro-forma iterations can become more user-friendly.

Mapping the cancer patient information landscape: A comparative analysis of patient groups across Europe and North America

AIM

Little is known about how patient groups provide information for patients. We invited 838 patient groups from Europe and North America to participate in an online survey.

METHODS

The survey covered: (i) availability, accessibility and quality of information provided; (ii) methods by which patient groups communicate; (iii) ways in which patient groups acquire information and confirm its veracity/accuracy; (iv) how people access information online.

RESULTS

European patient groups were significantly less effective in providing medical-related information than their North American counterparts in: clinical trials, potential causes of cancer, medical research, diagnosis/screening, symptoms, treatments (all p < 0.0001); Recommendations of best practice/care (p < 0.03), healthcare services(p = 0.029) and complimentary medicine (p = 0.01). Clinical trials (p = 0.0006), medical research (p = 0.006) and diagnosis/screening (p = 0.0024) were also areas where North American patients were more likely to require medical-related information. Similar patterns emerged for non-medical information with nutrition (<0.0001), watchful waiting (p = 0.0003), self-management of care (p = 0.0003), prevention (p = 0.002) and emotional issues (p = 0.016) being less effectively communicated by European patient groups. Nutrition was also an area where North American patients were more likely to require non-medical-related information. The main barriers in accessing online information which showed differences between European and North American patients were: perceived lack of need, mainly due to faith in their doctors (p = 0.0001); limited access to the internet (p = 0.0005), limited computer skills (p = 0.02); and lower income (p = 0.027).

CONCLUSION

These results emphasise the more mature nature of cancer patient engagement/information provision in North America, providing valuable insights and guidance to inform development of more robust and effective cancer patient information communication platforms in Europe.

The European Cancer Patient's Bill of Rights, update and implementation 2016

In this implementation phase of the European Cancer Patient's Bill of Rights (BoR), we confirm the following three patient-centred principles that underpin this initiative:The right of every European citizen to receive the most accurate information and to be proactively involved in his/her care.The right of every European citizen to optimal and timely access to a diagnosis and to appropriate specialised care, underpinned by research and innovation.The right of every European citizen to receive care in health systems that ensure the best possible cancer prevention, the earliest possible diagnosis of their cancer, improved outcomes, patient rehabilitation, best quality of life and affordable health care. The key aspects of working towards implementing the BoR are:Agree our high-level goal. The vision of 70% long-term survival for patients with cancer in 2035, promoting cancer prevention and cancer control and the associated progress in ensuring good patient experience and quality of life.Establish the major mechanisms to underpin its delivery. (1) The systematic and rigorous sharing of best practice between and across European cancer healthcare systems and (2) the active promotion of Research and Innovation focused on improving outcomes; (3) Improving access to new and established cancer care by sharing best practice in the development, approval, procurement and reimbursement of cancer diagnostic tests and treatments.Work with other organisations to bring into being a Europe based centre that will (1) systematically identify, evaluate and validate and disseminate best practice in cancer management for the different countries and regions and (2) promote Research and Innovation and its translation to maximise its impact to improve outcomes.

Characterising legacy spent nuclear fuel pond materials using microfocus X-ray absorption spectroscopy

Analysis of a radioactive, coated concrete core from the decommissioned, spent nuclear fuel cooling pond at the Hunterston-A nuclear site (UK) has provided a unique opportunity to study radionuclides within a real-world system. The core, obtained from a dividing wall and sampled at the fill level of the pond, exhibited radioactivity (dominantly (137)Cs and (90)Sr) heterogeneously distributed across both painted faces. Chemical analysis of the core was undertaken using microfocus spectroscopy at Diamond Light Source, UK. Mapping of Sr across the surface coatings using microfocus X-ray fluorescence (μXRF) combined with X-ray absorption spectroscopy showed that Sr was bound to TiO2 particles in the paint layers, suggesting an association between TiO2 and radiostrontium. Stable Sr and Cs sorption experiments using concrete coupons were also undertaken to assess their interactions with the bulk concrete in case of a breach in the coating layers. μXRF and scanning electron microscopy showed that Sr was immobilized by the cement phases, whilst at the elevated experimental concentrations, Cs was associated with clay minerals in the aggregates. This study provides a crucial insight into poorly understood infrastructural contamination in complex systems and is directly applicable to the UK's nuclear decommissioning efforts.

Bioengineering bacteriophages to enhance the sensitivity of phage amplification-based paper fluidic detection of bacteria

Bacteriophage (phage) amplification is an attractive method for the detection of bacteria due to a narrow phage-host specificity, short amplification times, and the phages' ability to differentiate between viable and non-viable bacterial cells. The next step in phage-based bacteria detection is leveraging bioengineered phages to create low-cost, rapid, and easy-to-use detection platforms such as lateral flow assays. Our work establishes the proof-of-concept for the use of bioengineered T7 phage strains to increase the sensitivity of phage amplification-based lateral flow assays. We have demonstrated a greater than 10-fold increase in sensitivity using a phage-based protein reporter, maltose-binding protein, over the detection of replicated T7 phage viron itself, and a greater then 100-fold increase in sensitivity using a phage-based enzymatic reporter, alkaline phosphatase. This increase in sensitivity enabled us to detect 10(3)CFU/mL of Escherichia coli in broth after 7h, and by adding a filter concentration step, the ability to detect a regulatory relevant E. coli concentration of 100CFU/100mL in inoculated river water after 9h, where the current standard requires days for results. The combination of the paper fluidic format with phage-based detection provides a platform for the development of novel diagnostics that are sensitive, rapid, and easy to use.

Clinical trial designs for rare diseases: studies developed and discussed by the International Rare Cancers Initiative

BACKGROUND

The past three decades have seen rapid improvements in the diagnosis and treatment of most cancers and the most important contributor has been research. Progress in rare cancers has been slower, not least because of the challenges of undertaking research.

SETTINGS

The International Rare Cancers Initiative (IRCI) is a partnership which aims to stimulate and facilitate the development of international clinical trials for patients with rare cancers. It is focused on interventional--usually randomized--clinical trials with the clear goal of improving outcomes for patients. The key challenges are organisational and methodological. A multi-disciplinary workshop to review the methods used in ICRI portfolio trials was held in Amsterdam in September 2013. Other as-yet unrealised methods were also discussed.

RESULTS

The IRCI trials are each presented to exemplify possible approaches to designing credible trials in rare cancers. Researchers may consider these for use in future trials and understand the choices made for each design.

INTERPRETATION

Trials can be designed using a wide array of possibilities. There is no 'one size fits all' solution. In order to make progress in the rare diseases, decisions to change practice will have to be based on less direct evidence from clinical trials than in more common diseases.

International models of investigator-initiated trials: implications for Japan

BACKGROUND

Academic/institutional investigator-initiated clinical trials benefit individuals and society by supplementing gaps in industry-sponsored clinical trials.

MATERIALS

In May 2010, experts from Japan, the Republic of Korea, the UK, and the United States, met at a symposium in Tokyo, Japan, to discuss how policies related to the conduct of clinical trials, which have been shown to be effective, may be applied to other regions of the world.

RESULTS

In order to increase the availability of anticancer drugs world-wide, nations including Japan should examine the benefits of increasing the number of investigator-initiated clinical trials. These trials represent one of the most effective ways to translate basic scientific knowledge into clinical practice. These trials should be conducted under GCP guidelines and include Investigational New Drug application submissions with the ultimate goal of future drug approval.

CONCLUSIONS

To maximize the effectiveness of these trials, a policy to educate health care professionals, cancer patients and their families, and the public in general on the benefits of clinical trials should be strengthened. Finally, policies that expedite the clinical development of novel cancer drugs which have already been shown to be effective in other countries are needed in many nations including Japan to accelerate drug approval.

Exploring the development of a cultural care framework for European caring science

The aim of this paper is to discuss the development of a cultural care framework that seeks to inform and embrace the philosophical ideals of caring science. Following a review of the literature that identified a lack of evidence of an explicit relationship between caring science and cultural care, a number of well-established transcultural care frameworks were reviewed. Our purpose was to select one that would resonate with underpinning philosophical values of caring science and that drew on criteria generated by the European Academy of Caring Science members. A modified framework based on the work of Giger and Davidhizar was developed as it embraced many of the values such as humanism that are core to caring science practice. The proposed caring science framework integrates determinants of cultural lifeworld-led care and seeks to provide clear directions for humanizing the care of individuals. The framework is offered to open up debate and act as a platform for further academic enquiry.

Addressing the health needs of the homeless

Several authors have alluded to the complex health needs of the homeless population in the UK. The correlation between homelessness and a wide range of health problems has been explored in the literature. This paper presents a literature review exploring the biological, psychosocial and sexual health needs of single homeless people. The relationship between health and homelessness is analysed in relation to theories of health inequalities, which suggest that being homeless may be both a cause and a consequence of ill health. The contemporary nurse can play a vital role in helping to overcome the barriers that homeless people face when accessing health services. This paper explores the skills and approaches that nurses in a wide variety of settings can employ in addressing the health issues of homeless clients.

An evaluation of a European teacher exchange programme

This longitudinal study evaluated a European teacher exchange programme within a UK School of Nursing and Midwifery. A cross case study design was employed over a three year period. A range of data methods were used which gave a clear, detailed and rich picture of the exchange experience. Overall analysis of the data generated two key themes, namely that of value and role identity. The study highlighted factors which were deemed to have positive and negative influences on the teacher exchange experience. It is concluded that a teacher exchange programme is of value to the School, by aiding personal and professional development and internationalisation. Recommendations from the study are included in the paper.

The shifting foundations of nursing

In this paper we argue that the concerns generated by the development of Foundation Degrees and the Assistant and Associate Practitioner roles have rekindled some of the unresolved debates regarding the status and identity of nursing and nurses. Through the application of the sociological theories of professionalisation and nostalgia we have identified the shifting and unresolved nature of nursing. We argue that these theories continue to have resonance in the current climate of change and 'upskilling' of the health care workforce and argue, that the shifts illuminated are perhaps so significant as to demonstrate that we have entered a post-nursing era.

Anatomical origins of ocular dominance in mouse primary visual cortex

Ocular dominance (OD) plasticity is a classic paradigm for studying the effect of experience and deprivation on cortical development, and is manifested as shifts in the relative strength of binocular inputs to primary visual cortex (V1). The mouse has become an increasingly popular model for mechanistic studies of OD plasticity and, consequently, it is important that we understand how binocularity is constructed in this species. One puzzling feature of the mouse visual system is the gross disparity between the physiological strength of each eye in V1 and their anatomical representation in the projection from retina to the dorsal lateral geniculate nucleus (dLGN). While the contralateral-to-ipsilateral (C/I) ratio of visually evoked responses in binocular V1 is approximately 2:1, the ipsilateral retinal projection is weakly represented in terms of retinal ganglion cell (RGC) density where the C/I ratio is approximately 9:1. The structural basis for this relative amplification of ipsilateral eye responses between retina and V1 is not known. Here we employed neuroanatomical tracing and morphometric techniques to quantify the relative magnitude of each eye's input to and output from the binocular segment of dLGN. Our data are consistent with the previous suggestion that a point in space viewed by both eyes will activate 9 times as many RGCs in the contralateral retina as in the ipsilateral retina. Nonetheless, the volume of the dLGN binocular segment occupied by contralateral retinogeniculate inputs is only 2.4 times larger than the volume occupied by ipsilateral retinogeniculate inputs and recipient relay cells are evenly distributed among the input layers. The results from our morphometric analyses show that this reduction in input volume can be accounted for by a three-to-one convergence of contralateral eye RGC inputs to dLGN neurons. Together, our findings establish that the relative density of feed-forward dLGN inputs determines the C/I response ratio of mouse binocular V1.

Observation of dipole-like gap solitons in self-defocusing waveguide lattices

We observe dipole-like gap solitons in two-dimensional waveguide lattices optically induced with a self-defocusing nonlinearity. Under appropriate conditions, two mutually coherent input beams excited in neighboring lattice sites evolve into a self-trapped state, whose spatial power spectrum and stability depend strongly on the initial excitation conditions. Our experimental observations are compared with numerical simulations.

Tales of sociology and the nursing curriculum: revisiting the debates

The relationship between nursing and sociology has been extensively debated for more than two decades [Cox, C.A., 1979. Who cares? Nursing and sociology: the development of a symbiotic relationship. Journal of Advanced Nursing 4, 237-252; Cooke, H., 1993. Why teach sociology? Nurse Education Today 13, (3) 210-216; Sharpe, K., 1994. Sociology and the nursing curriculum: a note of caution. Journal of Advanced Nursing 20, (2) 391-395; Sharpe, K., 1995. Why indeed should we teach sociology? A response to Hannah Cooke. Nurse Education Today 15, (1) 52-55; Sharpe, K., 1996. Feedback - sociology and the nursing curriculum: a reply to Sam Porter. Journal of Advanced Nursing 23, (7) 1275-1278; Balsamo, D., Martin, S.I., 1995a. Developing the sociology of health in nurse education: towards a more critical curriculum. Part 1. Andragogy and sociology in Project 2000. Nurse Education Today 15, 427-432; Balsamo, D., Martin, S.I., 1995b. Developing the sociology of health in nurse education: towards a more critical curriculum. Part 2. Linking methodology and epistemology. Nurse Education Today 15, 427-432; Porter, S., 1995. Sociology and the nursing curriculum: a defence. Journal of Advanced Nursing 21, (6) 1130-1135; Porter, S., 1996. Why teach sociology? A contribution to the debate. Nurse Education Today, 16, 170-174; Porter, S., 1997. Sociology and the nursing curriculum: a further comment. Journal of Advanced Nursing 26, (1) 214-218; Porter, S., 1998. Social Theory and Nursing Practice. Macmillan, Basingstoke; Corlett, J., 2000. The perceptions of nurse teacher, student nurses and preceptors of the theory-practice gap in nurse education. Nurse Education Today 20, 499-505; Allen, D., 2001. Review article: nursing and sociology: an uneasy marriage?. Sociology of Health and Illness 23, (3) 386-396; Pinikahana, J., 2003. Role of sociology within the nursing enterprise: some reflections on the unfinished debate. Nursing and health Sciences 5, (2) 175-180; Holland, K., 2004. Sociology and the nursing curriculum; editorial. Nurse Education in Practice 4, 81-82; Mowforth, G., Harrison, J., Morris, M., 2005. An investigation into adult nursing students' experience of the relevance and application of behavioural sciences (biology, psychology and sociology) across two different curricula. Nurse Education Today 25, 41-48]. Much attention has been given to the role, utility and value of sociology mostly within pre-registration but also post-registration nursing curricula. Through an initial analysis of a series of letters appearing in The Nursing Times over a 12 week period in 2004, and using an analytical framework of four tales (realist, critical, deconstructive and reflexive) we revisit this relationship. Unlike previous debates our argument is that this relationship is more usefully viewed as emblematic of the legitimation crisis inherent in all modern projects. We argue that in order to move beyond the 'utility' discussion, an interrogation of the knowledge claims of both nursing and sociology is required.

Troponin testing for chest pain in primary healthcare: a survey of its use by general practitioners in New Zealand

AIM

Serum troponin is now the preferred biochemical marker for myocardial infarction. The aim of this study was to investigate general practitioner (GP) knowledge and use of serum troponin testing in primary healthcare.

METHODS

We sent a postal survey about troponin testing to all GPs in the Wellington region (n=299) of New Zealand.

RESULTS

Of the 299 surveys sent, 216 replies were received (72%). 54% (n=115) of participants were male and 58% (n=113) in full time practice. 92% were using troponin tests (58% monthly). ECG (79%) and serum troponin (78%) were the tests most commonly used to triage patients with chest pain. GPs had excellent knowledge of false negative scenarios (84% correctly identified false negative if test undertaken within 6 hours) and less knowledge of false positive scenarios (39% answered 'Don't know').

CONCLUSIONS

The majority of GPs use serum troponin tests, and have sufficient knowledge of the test for use in a primary care setting. Most GPs use the tests appropriately, although a small proportion of doctors may defer rapid admission to hospital while waiting for the test result (7%) or manage the patient within general practice (5%) in those patients who have chest pain considered 'possibly' due to myocardial infarction.

Troponin testing for chest pain in primary healthcare: a New Zealand audit

AIM

Serum troponin is a widely used biomarker for the diagnosis of myocardial infarction (MI). The aim of this audit was to document the actual clinical circumstances when serum troponin tests are used to assess chest pain in primary healthcare.

METHODS

We undertook an audit of general practitioner (GP) serum troponin requests made to community laboratories in the Wellington region over a 5-week period in 2004.

RESULTS

433 tests were ordered by 201 GPs and 10 tests were positive. We faxed 396 questionnaires to identifiable GPs requesting the tests and received 292 replies (74%). The time between initial onset of symptoms and troponin testing was biphasically distributed with peaks at 7-12 hours and 3.5 days. An ECG was performed in less than 50% of the cases. The GP's estimate of the likelihood of their patient's symptoms being due to MI was strongly influenced by both positive and negative test results. Patients were referred acutely to hospital on less than 5% of occasions.

CONCLUSIONS

GPs used troponin testing mostly for late presentations some days after chest pain, to 'rule-out' MI. When used acutely, referral for admission occasionally awaited the troponin test result.

Class, Inequalities and Nursing Practice Miers Margaret (Ed) Class, Inequalities and Nursing Practice 267pp Palgrave 9780333966129 0333966120

A welcome addition to the excellent Sociology and Nursing Practice series. In common with the others in the series, this book provides an accessible but much needed theoretical exploration of sociological thinking and its relationship to nursing. The first part offers an overview of the key sociological theories and their relationship to the notions of class, and the relationship between class and health.

Reflections across boundaries: the European nursing module

This article explores the development and implementation of an internationally agreed module, the European Nursing Module. This module comprises 4 weeks of student learning and is coordinated by a network of 26 colleges in 14 European countries. It is hoped that through the module, students are helped to acquire cultural sensitivity, which leads toward the development of a culturally competent health care practitioner. The development of the module, the student experience, and the added value of the network are shared. It is argued that considerable cultural learning can occur from short international electives when students and teaching staff are well prepared and sensitised to cultural issues prior to their exchange.

Myringotomy and ventilation tube insertion: a ten-year follow-up

Eighty children who had myringotomy performed for otitis media with effusion in 1984 were reviewed in 1994. This had involved surgery on 158 ears. Three aspects of ear condition were studied: hearing loss, tympanic membrane perforation, and tympanosclerosis. Hearing losses were present in 13 ears (8.2 per cent), involving 10 children (12.5 per cent), although losses were under 20 dB in seven of these ears (five patients). Of the six ears with losses more than 20 dB (3.8 per cent), in five patients bilateral losses of 30 dB were due to a recurrence of effusions, a large dry posterior perforation was the cause of a 30 dB loss, an infected anterior perforation had caused a 30 dB loss, an ear which had a cholesteatoma, and had a mastoidectomy and ossiculoplasty in 1987, had a 30-40 dB loss, and one ear which had a Type 1 tympanoplasty in 1994 had a 50 dB loss. Therefore in only three ears (1.9 per cent) could hearing loss be associated directly with myringotomy and ventilation tube insertion. Perforations had persisted unilaterally in seven patients, three having had tympanoplasties. Of the remaining perforated tympanic membranes, two were free of symptoms, one had only a slight hearing loss, and one had a more significant loss with recurrent infection. Tympanosclerosis was only found in those ears which had ventilation tubes inserted (and not those which had myringotomy only), occurring in 48 ears (31 per cent, of 39 per cent of those which had a ventilation tube inserted). There was no link between tympanosclerosis and hearing loss. The site of tympanosclerosis was not restricted to the site of myringotomy, and in many cases was present only in other areas of the tympanic membrane. There was a tendency for more extensive tympanosclerosis to occur in those ears which had more ventilation tube insertions. The risk of perforation in particular lends support to a policy of 'watchful waiting'.

Increased release of interleukin-1 beta, interleukin-6, and tumor necrosis factor-alpha by bronchoalveolar cells lavaged from involved sites in pulmonary tuberculosis

Mycobacterium tuberculosis and its components have been shown to stimulate mononuclear phagocytes in vitro to release interleukin-1 beta (IL-1 beta), tumor necrosis factor-alpha (TNF-alpha), and interleukin-6 (IL-6). Animal models of tuberculosis (TB) also demonstrate the presence of cytokines in granulomas. We hypothesized that bronchoalveolar lavage (BAL) cells from patients with pulmonary TB would have increased spontaneous release of IL-1 beta, IL-6, and TNF-alpha and would have a concomitant alveolitis. We performed BAL on 26 patients with active TB and on six normal volunteers. BAL fluid from radiographically involved and uninvolved sites was evaluated separately for cell types and the spontaneous release of cytokines. The alveolar inflammation in involved sites was characterized by an increase in lymphocytes (miliary TB, 38 +/- 10%; involved sites, 22 +/- 4%; uninvolved sites, 13 +/- 2%; normal, 5 +/- 2%) and neutrophils (involved sites, 21 +/- 7%; uninvolved sites, 3 +/- 2%). There was a significant increase in the spontaneous release of IL-1 beta (501 +/- 280 pg/ml), TNF-alpha (782 +/- 165 pg/ml), and IL-6 (473 +/- 157 pg/ml) from involved sites of TB patients that was 5- to 20-fold greater than uninvolved sites, normal controls, or miliary TB. Northern analysis revealed increased gene expression of IL-1 beta, TNF-alpha, and IL-6 from the involved sites from two patients with TB compared with two negative controls. We conclude that BAL cells, especially alveolar macrophages, are activated in the alveolar inflammation of active TB and spontaneously release increased quantities of IL-1 beta, IL-6, and TNF-alpha, and that these cytokines are likely to be involved in directing granuloma formation and control of M. tuberculosis infection.