Commentary: symptoms not associated with disease: an unmet public health challenge.
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Comorbidity↗
Biomedical subjects
Jane Walker
Publications and source records attributed to Jane Walker.
Facilitating undergraduate nurses clinical practicum: the lived experience of clinical facilitators.
Clinical practicum experience for undergraduate nurses remains undisputed as an essential component of any program. Exposure to the reality of professional practice and its integration of explicit, with tacit knowledge, is invaluable in producing skilled clinicians. Currently there are many issues that have arisen regarding clinical practice education for undergraduate nurses in Australia including; ongoing financial support and resourcing of clinical placements. Developing an understanding of these issues is central to the provision of quality clinical education. The aim of this study is to reveal dimensions of the lived experience of being a clinical facilitator, a popular model of nursing clinical education, to come to an understanding of how facilitation actually takes place in the clinical environment. The Hermeneutic phenomenological approach used in this study has brought to light five essential themes that elucidate the phenomena of facilitation. Those themes have been identified as; knowing your own limitations, employing the notion of stepping in or stepping back, developing alliances, acknowledging the reciprocity of the learning experience, and identifying appropriate clinical buddies. The recommendations from this study will have an impact on current issues and will inturn, influence the quality of clinical education for all stakeholders.
Adult↗
Bodily symptoms: new approaches to classification.
OBJECTIVE: To examine the current approach to classifying bodily symptoms in both psychiatry and medicine and to suggest better alternatives. METHODS: Theoretical analysis, narrative review, and theoretical proposal. RESULTS: The assumptions that (a) bodily pathology can always explain bodily symptoms, (b) psychopathology can always explain bodily symptoms in the absence of bodily pathology, and (c) dichotomizing bodily symptoms into "medical" and "psychiatric" types is clinically useful were all found to have questionable validity and utility. CONCLUSION: Alternative multiaxial diagnostic approaches for the classification of bodily symptoms are proposed. These are intended to (a) give greater prominence to bodily symptoms in their own right, (b) allow etiology to be conceptualized in terms of multiple factors, and (c) provide the basis for integrating medical and psychiatric approaches to patient care.
Chronic Disease↗
Screening for familial ovarian cancer: failure of current protocols to detect ovarian cancer at an early stage according to the international Federation of gynecology and obstetrics system.
PURPOSE: To assess the effectiveness of annual ovarian cancer screening (transvaginal ultrasound and serum CA-125 estimation) in detecting presymptomatic ovarian cancer in women at increased genetic risk. PATIENTS AND METHODS: A cohort of 1,110 women at increased risk of ovarian cancer were screened between January 1991 and March 2004; 553 were moderate-risk individuals (4% to 10% lifetime risk) and 557 were high-risk individuals (> 10% lifetime risk). Outcome measurements include the number and stage of screen-detected cancers, the number and stage of cancers not detected at screening, the number of equivocal screening results requiring recall/repetition, and the number of women undergoing surgery for benign disease. RESULTS: Thirteen epithelial ovarian malignancies (12 invasive and one borderline), developed in the cohort. Ten tumors were detected at screening: three International Federation of Gynecology and Obstetrics (FIGO) stage I (including borderline), two stage II, four stage III, and one stage IV. Of the three cancers not detected by screening, two were stage III and one was stage IV; 29 women underwent diagnostic surgery but were found not to have ovarian cancer. CONCLUSION: Annual surveillance by transvaginal ultrasound scanning and serum CA-125 measurement in women at increased familial risk of ovarian cancer is ineffective in detecting tumors at a sufficiently early stage to influence prognosis. With a positive predictive value of 17% and a sensitivity of less than 50%, the performance of ultrasound does not satisfy the WHO screening standards. In addition, the combined protocol has a particularly high false-positive rate in premenopausal women, leading to unnecessary surgical intervention.
Adult↗
Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial.
AIMS AND OBJECTIVES: To assess the effectiveness of pre- and post-operative physiotherapy at home for unilateral total knee replacement (TKR). METHODS: In this pragmatic randomized controlled trial set in participants' homes (four primary care trust areas) and physiotherapy outpatients in a South Yorkshire teaching hospital trust, 160 osteoarthritis patients waiting for unilateral TKR were randomly allocated to intervention (home) group (n=80) or control (hospital outpatient) group (n=80). The intervention group had pre- and post-operative home visits for assessment and treatment by a community physiotherapist. Outcome measures were health-related quality of life (HRQoL), measured by the Western Ontario McMaster Osteoarthritis index (WOMAC) and the Short Form 36 health survey (SF-36) pre-operatively and at 12 weeks post-TKR operation; patient satisfaction; and NHS resource use. RESULTS: No significant differences were observed between the two treatment groups in the primary outcome measure, the WOMAC pain score, or any other HRQoL score. The home group had a significantly greater mean number of physiotherapy sessions than the hospital group [mean difference 5.2 sessions, 95% confidence interval (CI)=-6.3 to -4.1; P=0.001]. There was no significant difference in the total NHS costs per patient between groups. However, home physiotherapy for TKR was significantly more expensive (mean difference-pound136.5, 95% CI=- pound160 to-pound113; P=0.001). Patients were equally satisfied with physiotherapy at home or in hospital; however, more of the home group would choose their location for physiotherapy again. CONCLUSIONS: Although home physiotherapy was as effective and as acceptable to patients as hospital outpatient physiotherapy for unilateral TKR, it was more expensive. Additional pre-operative home physiotherapy did not improve patient-perceived health outcomes.
Aged↗
Working together: a qualitative study of effective group formation amongst GPs during a cost-driven prescribing initiative.
BACKGROUND: The need to control escalating NHS prescribing costs has become another, for many, contentious factor for GPs to consider when prescribing. Furthermore, despite not having a history of collaboration, GPs now need to work together within Primary Care Trusts. There is little in the medical literature about the development of GP groups. We present data from an evaluation of a cost-driven GP group prescribing initiative which fitted within Tuckman's framework of how groups become established, function and bring about changes to produce outcomes. OBJECTIVE: Our aim was to gain insight into GPs' experiences of working together in a group prescribing initiative. METHODS: Qualitative semi-structured interviews were conducted face-to-face with 32 GPs from a commissioning group pilot (nine GP practices) in Southern Derbyshire in 1999. The interviews were transcribed and analysed using thematic analysis. RESULTS: Initial reactions to the initiative included feeling anxious and imposed upon. However, reservations about divisive effects on practices and individuals behaving defensively proved largely unfounded. Meeting together enabled participants to discover that their similarities outweighed their differences. Prescribing changes did occur, often facilitated by the support of having group policies. However, for many participants, the most valued outcomes were process orientated: increased interaction between practices and a greater sense of group cohesion. These were regarded by some as providing the basis for further change. CONCLUSION: The experiences of the GPs reflected Tuckman's sequential model of group development to a large extent. The 'storming' phase was less problematical than anticipated. This model provides a useful framework against which to judge how near a group is to achieving goals.
Cooperative Behavior↗
Spreading of Sir3 protein in cells with severe histone H3 hypoacetylation.
Heterochromatin formation in yeast involves deacetylation of histones, but the precise relationship between acetylation and the association of proteins such as Sir3, Sir4, and the histone deacetylase Sir2 with chromatin is still unclear. Here we show that Sir3 protein spreads to subtelomeric DNA in cells lacking the transcription-related histone acetyltransferases GCN5 and ELP3. Spreading correlates with hypoacetylation of lysines in the histone H3 tail and results in deacetylation of lysine 16 in histone H4. De-repression of genes situated very close to the ends of the chromosomes in gcn5 elp3 suggests that Sir3 spreads into subtelomeric DNA from the tip of the telomere. Interestingly, growth defects caused by gcn5 elp3 mutation can be suppressed by SIR deletion, suggesting that Sir proteins become detrimental for growth when chromatin is severely hypoacetylated.
Acetylation↗
A description of clinical nurse specialist programs in the United States.
Changes have occurred in clinical nurse specialist educational requirements in recent years, and it is not known how programs have responded. The purpose of this descriptive survey was to identify the number of clinical nurse specialist programs in the United States, describe curricula, and examine enrollment and employment trends. This report contains data from 157 separate clinical nurse specialist programs/majors representing 139 different schools. The mean number of credit hours for semester- and quarter-based programs was 41.4 and 52.2, respectively. The mean number of clinical/practical clock hours was 416.2. Approximately half of the respondents (56%) used the National Association of Clinical Nurse Specialists to guide curricula. Nearly 66% of the programs had from 1 to 10 applicants during the previous year. The majority (68%) indicated that their graduates do not have difficulty finding employment after graduating. These findings indicate that efforts to revise curricula and clarify the CNS role must continue.
Clinical Competence↗
National Association of Clinical Nurse Specialists responds to National Organization of Nurse Practitioner Faculties' Criteria for evaluation of nurse practitioner programs.
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Certification↗
Charting a course for your future: a directory of clinical nurse specialist programs in the United States.
Interest in clinical nurse specialist (CNS) programs is increasing rapidly, and schools of nursing are responding to the demand by expanding existing programs and opening new programs. In 2000, the Education Committee of the National Association of Clinical Nurse Specialists (NACNS) surveyed master's-degree programs throughout the country and identified programs that educate CNSs. From that work, it created an updated directory of current CNS programs. This article discusses common requirements of CNS programs, suggests questions that prospective students should consider when selecting a CNS program, and provides a current list of CNS programs in the United States.
Curriculum↗
Transcriptional inhibition of genes with severe histone h3 hypoacetylation in the coding region.
Changes in histone acetylation at promoters correlate with transcriptional activation and repression, but whether acetylation of histones in the coding region of genes is important for transcription is less clear. Here, we show that cells lacking the histone acetyltransferases Gcn5 and Elp3 have widespread and severe histone H3 hypoacetylation in chromatin. Surprisingly, severe hypoacetylation in the promoter does not invariably affect the ability of TBP to bind the TATA element, or transcription of the gene. By contrast, similar hypoacetylation of the coding region correlates with inhibition of transcription, and inhibition correlates better with the overall charge of the histone H3 tail than with hypoacetylation of specific lysine residues. These data provide insights into the effects of histone H3 hypoacetylation in vivo and underscore the importance of the overall charge of the histone tail for transcription.
Acetylation↗
The impact of a general practice group intervention on prescribing costs and patterns.
BACKGROUND: The formation of primary care groups (PCGs) and trusts (PCTs) has shifted the emphasis from individual practice initiatives to group-based efforts to control rising prescribing costs. However, there is a paucity of literature describing such group initiatives. We report the results of a multilevel group initiative, involving input from a pharmaceutical adviser, practice comparison feedback, and peer review meetings. AIM: To determine the impact of a prescribing initiative on the prescribing patterns of a group of general practices. DESIGN OF STUDY: A comparative study with non-matched controls. SETTING: Nine semi-rural/rural practices forming a commissioning group pilot, later a PCG, in Southern Derbyshire with nine practices as controls. METHOD: Practice data were collated for overall prescribing and for therapeutic categories, between the years 1997/1998 and 1998/1999 and analysed statistically. Prescribing expenditure trends were also collated. RESULTS: Although both groups came well within their prescribing budgets, in the study group this was for the first time in five years. Their rate of increase in expenditure slowed significantly following the initiative compared with that of the comparison group, which continued to rise (median practice net ingredient cost/patient unit (nic/PU) increase: Pound Sterling0.69 and Pound Sterling3.80 respectively; P = 0.03). The study group's nic/PU dropped below, and stayed below, that of the comparison group one month after the start of the initiative. For most therapeutic categories the study group had lower increases in costs and higher increases in percentage of generic items than the comparison group. Quality markers were unaffected. CONCLUSION: We suggest that practices with diverse prescribing patterns can work together effectively within a PCT locality to control prescribing costs.
Budgets↗
Prescribing costs and patterns: authors' response.
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Cost-Benefit Analysis↗
A longitudinal study of bone density in midlife women.
A longitudinal study of 386 healthy Black and White women aged 35-60 years was conducted to determine the effects of physical activity and other related factors on lumbar bone mineral density over 24 months. Bone mineral density of the lumbar spine, L2-L4, was measured using dual energy x-ray (Hologic 1000). Physical activity levels in three dimensions (leisure, household, and occupational) from both a lifelong and current perspective were obtained by questionnaire. Body mass index was calculated from measured weight in kilograms divided by measured height in meters squared. Calcium, caffeine, and alcohol intake was estimated using a food frequency questionnaire. Age, race, and smoking were determined by self-report. Radioimmunoassays of follicle stimulating hormone (FSH) and estradiol were used to validate self-reports of menopausal status. Multiple regression analysis revealed that race, age, weight, FSH, calcium, and years of tobacco intake formed the best model at baseline (r(2) = 0.32) and at 24 months (r(2) = 0.303). Physical activity was not a significant predictor for bone mineral density at either time point. There were cross-sectional changes of bone mineral density with race, age, and menopausal status. Black women had significantly higher bone mineral density than White women. However, an age-related decline in bone mineral density was exhibited in both Black and White women. Perimenopausal women had significantly lower bone mineral density as compared with premenopausal women. Furthermore 37 (9.6%) women at baseline and 34 (11%) at 24 months were designated at risk for fracture.
Absorptiometry, Photon↗