bluuebunny/crossref_metadata_2025 huggingface dataset:
Sleep quality and responses to insufficient sleep in women on different work shifts
Authors: EDÉLL‐GUSTAFSSON ULLA M.
Published: March 2003

• The aim of this study was to examine degrees of cognitive behavioural effects of fatigue, mood changes and somatic responses to sleep loss in women with and without sufficient sleep, and to explore possible links between effects of sleep loss and specific sleep disturbances in selected groups.

• A total 156 women working in a casualty department on different work shifts responded to a questionnaire which measured sleep quality, strain and symptoms related to working conditions, as well as effects of sleep loss.

• About 40% of the women had perceived insufficient sleep during the last 6 months. They perceived significantly worse sleep quality and a higher degree of strain according to working conditions than the others. Palpitation and dysphoria as effects of sleep loss were independently predicted by sleep quality. Dysphoria was also predicted by difficulty in falling asleep. Cognitive behavioural effects of fatigue was predicted by disturbed sleep. Palpitation effects led to a 10‐fold increase in the probability of cognitive behavioural effects of fatigue. The effects were most prominent among women suffering from gastrointestinal problems of long duration and chronic pain.

• Responses to reduced sleep quality in women constitute a form of stress, with sympathetic activation, increased susceptibility to infection, moderate cognitive impairment, mood changes and somatic distress.
The relationship between organizational climate and the content of daily life for people with dementia living in a group‐dwelling
Authors: NORBERGH KARL‐GUSTAF , HELLZÉN OVE , SANDMAN PER‐OLOF , ASPLUN KENNETH
Published: March 2003

• One factor influencing the outcome of care may be nursing staff's experience of the organizational work climate. The aim of the study was to investigate how people with dementia spend their time in group‐dwelling units (GD) with either a creative or less creative organizational climate.

• For the study, two GD units assessed as having a creative organizational climate and two units assessed as having a less creative climate were selected. Eighteen residents living in the units assessed as creative and 20 residents living in the units assessed as less creative participated in the study.

• For measuring the organizational climate the Creative Climate Questionnaire was used. Observations of residents' activities were classified according to the Patient Activity Classification. For measuring residents' functional ability the Multi‐Dimensional Dementia Assessment Scale was used. Their cognitive capacity was measured with the Mini Mental State Examination.

• Residents living in the units assessed as having a creative organizational climate spent 45.2% of the time with nursing staff, while those in the less creative climate spent 25.6% (P < 0.001). Time spent with fellow residents in the creative climate was 13.9% and in the less creative climate 31.3% (P < 0.001). There was no significant difference between the units according time spent with relatives and time spent alone.

• Since the purpose of GD is to offer care adapted to the abilities and psychosocial needs of people suffering from dementia, a less creative climate can be a threat to the aims of GD. In order to maintain these, it is important for managers to be aware of the work climate and its impact on care for people with dementia.
An exploration of the occurrence of pressure ulcers in a British spinal injuries unit
Authors: ASH DAVID
Published: March 2003

• Spinal cord injury (SCI) is associated with increased risk of pressure ulcers, but there are few published data about this in the United Kingdom (UK). This article represents a quantitative exploration of the occurrence of pressure ulcers in a UK spinal injuries unit (SIU).

• The technique used is a retrospective review of records: details of 144 completed first admissions for SCI between 1998 and 2000 were entered on to a database (SPSS) for analysis.

• Thirty‐two per cent of patients already had pressure ulcers on admission to the SIU, while a total of 56% experienced an ulcer at some stage between injury and discharge from the SIU.

• Four pressure ulcer risk assessment scales were used (Waterlow, Braden, Norton and SCIPUS‐A). These appeared to have moderate predictive power in this population.

• Pressure ulcers were found to be associated with increased length of hospital stay, density of lesion, surgical stabilization of neck injury before transfer to the SIU, tracheostomy on admission to the SIU and delayed transfer to the SIU after injury.

• Implications for practice are discussed.
Pain and quality of life among older people with rheumatoid arthritis and/or osteoarthritis: a literature review
Authors: JAKOBSSON ULF , HALLBERG INGALILL RAHM
Published: March 2003

• The aim of this study was to review the research literature on pain and quality of life (QoL) and the relationship between these variables among people aged 75 years and above with rheumatoid arthritis and/or osteoarthritis.

• A Medline and CINAHL search was carried out using MeSH terms rheumatoid arthritis, osteoarthritis, QoL and pain in various combinations.

• Seventeen articles were identified that met the requirements for methodological quality and inclusion criteria. No study focused only on respondents aged 75 years or over. The studies had varying representation of this age group. Pain was common in both groups and was found to increase with age and disease duration among those with rheumatoid arthritis but not among those with osteoarthritis. Increased pain could lead to depression. Pain, functional limitation and increased age were found to decrease QoL among those with rheumatoid arthritis and osteoarthritis alike. Social support was found to buffer against negative effects on QoL among those with osteoarthritis while no moderating effects were found in rheumatoid arthritis.

• Increased age was found to relate to pain (rheumatoid arthritis) and decrease QoL (both rheumatoid arthritis and osteoarthritis). It is, however, hard to draw any firm conclusions about older people's pain and QoL because of the lack of studies including respondents aged 75 years or over. Thus, research about pain and QoL, especially focusing on the old and the very elderly with rheumatoid arthritis/osteoarthritis, is needed. It also seems justified to say that nursing care should especially focus on older people and that these people should be assessed for their level of pain, functional limitations and QoL especially in the case of having rheumatoid arthritis and/or osteoarthritis.
Observation of pain assessment and management − the complexities of clinical practice
Authors: Manias Elizabeth , Botti Mari , Bucknall Tracey
Published: March 2003

? Pain assessment and management are complex issues that embrace physiological, emotional, cognitive, and social dimensions.

? This observational study sought to investigate nurse–patient interactions associated with pain assessment and management in hospitalized postsurgical patients in clinical practice settings.

? Twelve field observations were carried out on Registered Nurses' activities relating to pain with their assigned patients. All nurses were involved in direct patient care in one surgical unit of a metropolitan teaching hospital in Melbourne, Australia. Six observation times were identified as key periods for activities relating to pain, which included change of shift and high activity periods. Each observation period lasted 2 hours and was examined on two occasions.

? Four major themes were identified as barriers to effective pain management: nurses' responses to interruptions of activities relating to pain, nurses' attentiveness to patient cues of pain, nurses' varying interpretations of pain, and nurses' attempts to address competing demands of nurses, doctors and patients.

? These findings provide some understanding of the complexities impacting on nurses' assessment and management of postoperative pain. Further research using this observational methodology is indicated to examine these influences in more depth. This knowledge may form the basis for developing and evaluating strategic intervention programmes that analyse nurses' management of postoperative pain and, in particular, their administration of opioid analgesics.
Uncertain terms of sedation in ICU. How nurses and physicians manage and describe sedation for mechanically ventilated patients
Authors: Egerod Ingrid
Published: March 2003

? Sedation which is used for intubated patients may prolong mechanical ventilation by increasing the risk of complications. The aim of the study was to illuminate the specific terminology and unrecognized contextual factors which may influence nurses' and physicians' sedation practices.

? The main research questions were: How do nurses and physicians describe sedation? and How does the level of nursing skill relate to the level of sedation? The hypotheses were that sedation practices are inconsistent and that experienced nurses provide a better quality of sedation than less experienced nurses. The hypotheses were supported by the study.

? The research strategy was case study research with triangulation of sources and methods and a multicentre multiple‐case design. Four university hospitals in Copenhagen, Denmark, and 14 cases were included in the study. The findings were based on secondary analysis of observation, interviews and chart review.

? The theoretical framework for the study was the problem‐solving model, in which sedation was assumed to be provided according to indication (clinical problem), intervention (clinical decision) and expected outcome (clinical end‐point). Indications could be patient‐related, ventilator‐related, or patient–ventilator related. Interventions could be related to the choice of agent, dose or administration method and the outcome was the level of sedation.

? Sedative therapy was prescribed by physicians and administered by nurses. The four sites in the study did not use guidelines for sedation and did not use sedation level assessment tools. The study shows that when the terminology is unclear, the indications, interventions and outcomes become unclear.
Quality of life as a concept for developing learning disability nursing practice?
Authors: Northway Ruth , Jenkins Robert
Published: March 2003

• This paper offers a critical examination of how the concept of Quality of Life might be used to enhance learning disability nursing practice.

• Quality of Life will increasingly influence the provision and evaluation of services and practice in the field of learning disability. Attempting to define and assess Quality of Life is, however, problematic because of the complexity and multidimensional nature of the concept.

• The use of domains to measure Quality of Life is advocated by many researchers for both objective and subjective measures and use of Quality of Life as an evaluation tool is seen as a way of improving the life quality of people with learning disabilities. However, there are concerns that the use of such an approach could perpetuate professional agendas rather than empower people with learning disabilities themselves.

• To date, Quality of Life approaches have not had a major impact on learning disability nursing. However, it is suggested that they can be helpful as sensitizing concepts, a basis for collaborative care planning and a framework for evaluation.

• Recommendations are made for education, practice and research.
Combination of clomipramine and nortriptyline in the treatment of obsessive‐compulsive disorder: a double‐blind, placebo‐controlled trial
Authors: Noorbala  , Hosseini  , Mohammadi  , Akhondzadeh
Published: March 2003

Objective:
There is growing interest in investigating noradrenergic functions in obsessive‐compulsive disorder (OCD) because some antidepressants with strong effects on serotonin reuptake blockade fail to relieve obsessive‐compulsive symptoms. We undertook a trial to investigate whether the combination of clomipramine with nortriptyline was more effective than clomipramine alone

Method:
Thirty patients who met the DSM‐IV criteria for OCD completed the study. Patients were allocated in a random fashion, 15 each to clomipramine 150 mg/day plus nortriptyline 50 mg/day and clomipramine 150 mg/day plus placebo

Results:
Although both protocols significantly decreased the scores of the Yale‐Brown obsessive‐compulsive scale over the trial period, the combination of clomipramine and nortriptyline showed a significant superiority over clomipramine alone in the treatment of OCD

Conclusion:
As this study indicates, a rapid onset of action is one of the advantages of this combination. This study supports further investigation of the noradrenergic‐serotonergic hypothesis in OCD
Evaluation of two types of online help for application software
Authors: Dutke S. , Reimer T.
Published: March 2003

Abstract  A recent trend in application software design is to extend online help systems in order to support exploratory and self‐paced learning. Two different information formats, lists of action steps that have to be taken to achieve a goal (operative help) and explanations about how a function works (function‐oriented help), were evaluated to assess their effects on learning performance. In two experiments, adult computer novices (N = 60 and N = 20) learned to use experimental graphics software by task‐based exploration. After one half of the tasks, the type of tasks changed so that the acquired action schema could no longer be applied. Results indicated that participants who had access to function‐oriented help were coping more successfully with the schema change than participants who received operative help. The relevance to the design of software training and online help systems is discussed.
Altitudinal gradients in tropical forest composition, structure, and diversity in the Sierra de Manantlán
Authors: G. J. Antonio Vázquez , Givnish Thomas J.
Published: March 2003

1 Data on the composition, structure and diversity of plant communities were gathered along a 1000‐m altitudinal transect from tropical seasonal dry forest to cloud forest on calcareous Cerro Grande in Jalisco, México.

2 A total of 470 species, 292 genera and 103 families of vascular plants occurred in 43 samples of 0.1 ha, stratified at 100‐m elevational intervals between 1500 and 2500 m a.s.1. There were 97 tree species, 76 shrubs, 70 vines, 181 terrestrial herbs, 39 epiphytes, 3 hemiparasites, 3 succulent rosette shrubs and 1 saprophyte.

3 Forest composition varied continuously with altitude, based on the Shipley & Keddy (1987) test, ordination via reciprocal averaging, and elevational trends in the Sorenson similarities of samples at adjacent altitudes. supporting the individualistic hypothesis of plant community organization.

4 Understorey herbs, shrubs and vines showed the greatest decline in species number with increasing altitude. This pattern is hypothesized to result from the more open, more frequently disturbed, and more completely deciduous canopies at lower, drier elevations. The proportion of evergreen woody plants was greater at higher altitudes, reflecting less seasonal aridity and greater soil leaching. The proportion of endozoochorous species increased with altitude, while the proportion of pterochorous and ectozoochorous species decreased, reflecting trends in the hypothesized efficacy of these mechanisms of seed dispersal.

5 Total basal area of woody plants > 2.5 cm d.b.h. and basal area per tree both increased roughly fourfold between 1500 and 2500 m.

6 Species richness decreased sharply with altitude, due mainly to decreases in terrestrial herbs, and (to a lesser extent) shrubs and vines. The average number of species per 0.1 ha declined from 134 at 1500 m to 43 at 2500 m. The numbers of species, genera and families per sample declined linearly with elevation. Species composition of samples within an altitudinal band showed greater horizontal turnover (β diversity) at lower elevations, showing that low‐elevation forests are not only locally more diverse, but spatially more patchy. Community composition varies roughly six times as rapidly with elevation as with the same distance horizontally.

7 A cascading series of effects of elevation on soil fertility, anti‐herbivore defences, and the level of density‐dependent mortality may account for the observed drop in diversity with elevation, and would be consistent with lower β diversity and greater basal area at higher elevations.
Designs for greenhouse studies of interactions between plants
Authors: Gibson David. J. , Connolly John , Hartnett David. C. , Weidenhamer Jeffrey. D.
Published: March 2003

1 Designs for greenhouse studies of interactions between plants are reviewed and recommendations for their use are provided.

2 Papers published over a 10‐year period showed the replacement series design to be the most popular, especially in studying crop–weed interactions. Fifty per cent of the studies involved only two species, although studies testing the interaction between different genotypes of only a few species were also popular.

3 Limitations imposed by the choice of design, the variables measured, and the analysis used on the range of inferences that may be validly drawn from the experiment are frequently not well understood or appropriate for the questions that appear to be addressed. One example is the failure to distinguish the outcome of competition (the long‐term outcome of interaction) and the effects of species on each other.

4 Studies in which only final yield is measured are severely limited as to the inferences which may be drawn. Effects due to interspecific interaction during the course of the experiment cannot then be separated from pre‐existing differences, and interpretation may be biased towards species whose individuals were initially larger. In addition, measurements at several times are necessary to understand the changing dynamics of species interaction.

5 Simple pair‐wise mixtures can assess the effect of treatment factors on the outcome of competition. Replacement series and related diallel designs generally produce results that may be size‐biased even when initial interspecific differences are known. Additive designs (including target–neighbour designs), despite confounding density with species proportions, offer considerable scope for addressing mechanistic questions about interspecific interactions. Designs that allow response surface analysis can avoid many of the problems inherent in the other methods, but all need to be adjusted for initial interspecific differences. Designs for multiple species experiments are still largely untested, although several designs have been used. At the level of the individual plant, hexagonal fan designs permit study of the effects of varying the spatial pattern, and the densities and the relative proportions of interacting species, but suffer from lack of independence and lack of randomization.
Habitat associations of trees and seedlings in a Bornean rain forest
Authors: Webb Campbell O. , Peart David R.
Published: March 2003

1 In species‐rich mixed dipterocarp rain forest in Indonesian Borneo, we evaluated evidence for tree species associations with physical habitat variables (physiography for adults and seedlings, and light for seedlings). A total of 325 species were included in the analysis.

2 A stratified random sample of 28 tree and seedling plots (0.16 ha and 36 m2, respectively) was taken from a 150‐ha study area on homogeneous parent rock (granite) between 110 and 270 m a.s.l.

3 In a principal component analysis (PCA), based on an abundance index of all tree species, plots segregated into three groups. These corresponded closely with the three physiographically defined habitat types assigned in the field: (i) plateaux with a deep humus layer, (ii) sharp ridges and upper slopes, and (iii) gullies and lower slopes near permanent streams. Segregation of plots by habitat was weaker when seedling (rather than tree) species abundance was used in the PCA.

4 In single species analyses, using Monte Carlo randomization tests, we found significant associations with the three physiographic habitat types in 17 out of 49 abundant species for trees, and in 5 out of 22 abundant species for seedlings. In PCA and single species analyses, weaker associations with habitat for seedlings than for trees suggest higher mortality of seedlings in ‘suboptimal’ habitats.

5 Seedlings of 8 out of 45 abundant species were also significantly and positively associated with high light availability (measured in 2 × 2 m subplots, using hemispherical photographs).

6 Combining light and physiographic habitat associations, 20 out of the 45 abundant species were associated with at least one habitat factor as either adults or seedlings.

7 Thus, the distributions and abundances of many species are influenced by local heterogeneity in physical habitat variables. However, about half of the abundant species (25 of 45) showed no significant habitat association as adults or seedlings, and in no case did the relative abundance of any species exceed 5% in its ‘preferred’ habitat.
Reduced growth and seed set following chemical induction of pathogen defence: does systemic acquired resistance (SAR) incur allocation costs?
Authors: Heil Martin , Hilpert Andrea , Kaiser Werner , Linsenmair K. Eduard
Published: March 2003

1  Although most theories on plant defence assume that costs will result from the production and maintenance of defensive traits, studies on the costs of induced defence against pathogens are comparatively rare.

2  We focus on fitness costs resulting from the chemical induction of systemic acquired resistance (SAR), a rather unspecific form of defence, which can be induced by and is effective against a broad spectrum of bacteria, fungi and viruses.

3  We used a model system in which we treated wheat plants that were protected against fungi by ‘traditional’ fungicides with BION® (a benzothiadiazole which induces pathogen resistance). Treated plants were therefore compelled to invest in defence without gaining any profit from the induction.

4  Treated plants achieved lower biomass than untreated controls, and developed fewer shoots and ears and therefore produced fewer seeds. The effects were most pronounced in plants that suffered from a shortage of nitrogen, and were observed only when pathogen resistance was induced during lateral shoot production. Later treatment revealed no significant effects.

5  We discuss whether the differences between treated and control plants can be interpreted as a consequence of allocation costs. Such costs could result from metabolic competition between processes involved in plant growth and the synthesis of defence‐related compounds.
Species richness–standing crop relationship in stream bryophyte communities: patterns across multiple scales
Authors: Virtanen Risto , Muotka Timo , Saksa Marita
Published: March 2003

We tested for a unimodal (‘hump‐backed’) relationship between species richness and standing crop at various spatial scales in stream bryophyte communities. Bryophyte species and their biomasses were determined from 20 to 25 quadrats in eight river and six stream sites in northern Finland.

 Regression analyses revealed a quadratic relationship between richness and biomass in only two of the river sites and a positive correlation in one other. A quadratic relationship was detected in three stream sites and richness increased linearly with biomass in another.

 We also tested for the hump‐shaped pattern across individual stream boulders, representing an elevational gradient from continuously submerged to permanently dry conditions, with an intermediate zone with fluctuating water level.

 Species richness‐standing crop relationship conformed to the hump‐backed model only when samples from all three microhabitats were included in the analysis. A significant positive correlation occurred in the exposed low biomass end of the gradient which is characterized by semi‐aquatic species, whereas the relationship tended to be negative in permanently submerged areas with high biomass of large canopy‐forming species. Quadrats close to the water level had intermediate standing crop and highest species richness.

 Species dominant at either end of the gradient appeared unable to monopolize space in the intermediate zone where disturbances (e.g. scouring by ice) detach mosses from the substratum, creating vacant gaps for colonization. The unimodal relationship between richness and biomass is likely to occur only in streams that contain large boulders protruding above the water line, thus providing scope for community diversification along very short vertical distances.
Consequences of plant population size and density for plant–pollinator interactions and plant performance
Authors: Mustajärvi Kaisa , Siikamäki Pirkko , Rytkönen Saara , Lammi Antti
Published: March 2003

Habitat fragmentation and the resulting decline in the local abundance of plant species can affect biological interactions. We examined the effects of abundance on plant–pollinator interactions by observing the pollinator service and subsequent reproductive output of a mostly outbreeding, but self‐compatible, plant,Lychnis viscaria, in experimental populations of different sizes (number of individuals) and densities (distance between individuals).

 Bumblebees, the main pollinators ofL. viscaria,preferred larger populations, but visitation rates were higher in sparser populations. Pollinators were attracted to the larger inflorescences in sparse populations, which were also more visible due to their larger area for a given size.

 Bumblebees probed more flowers within plants in sparse populations, probably due to the larger inflorescences and longer flight distances between individuals.

 Subsequent reproductive success (capsule production) was higher in sparse populations, due to differences in pollination success and resource competition, and their interaction. In self‐compatible species, such asL. viscaria, reproductive success may be determined more by resource availability, whereas self‐incompatible plants may be more sensitive to changes in pollinator abundance.

 We conclude that plant–pollinator interactions are sensitive to changes in both the size and spatial arrangement of plant populations, which can affect their demography and genetics. In this study, species density had a greater effect than size and the unexpectedly beneficial effects of low density may be due to greater resource availability.
Crown development in tropical rain forest trees: patterns with tree height and light availability
Authors: Sterck Frank J. , Bongers Frans
Published: March 2003

Monitoring of two canopy species Dicorynia guianensis and Vouacapoua americana (Caesalpiniaceae) in a tropical rain forest in French Guiana was used to investigate vegetative crown development at five organizational levels: leaf, metamer, extension unit, sympodial unit and whole crown. The effects of light availability and tree height on different traits were evaluated in trees < 25 m in height and compared with taller individuals (25–37 m). Path‐analysis is used to illustrate the consequences of trait changes at multiple levels of organization for the whole crown level.

 Tree height and canopy openness influenced crown development at each organizational level. Crowns in higher light levels had lower specific leaf area, greater leaf spacing, greater extension of all branches, and greater extension of the leader shoot. With increasing tree height, crowns had a lower specific leaf area, greater leaf area index and greater relative crown depth.

 Vouacapoua showed some responses to light not seen in Dicorynia. In particular, Vouacapoua increased meristem activity with light, but the lack of response in Dicorynia may be due to moderate light levels rather than inability to respond.

 Low leaf‐display costs at low light availability may enable trees to survive light suppression.

 Light availability cannot explain trait changes with tree height. Alternative explanations for trait changes with tree height are discussed.

 Several of the relationships between plant traits and tree height or canopy openness became non‐linear when taller trees (25–37 m) were included. In these taller trees, vegetative growth was reduced at all organizational levels, particularly in Vouacapoua, which does not grow as tall as Dicorynia.

 Qualitatively, plant responses to light did not differ between trees of different height, and were similar to seedling and sapling data in the literature. Responses were, however, quantitatively different, suggesting that small saplings cannot serve as model organisms for crown development in taller trees.
Relationship between vegetation and soil seed banks in an arctic coastal marsh
Authors: Chang E. R. , Jefferies R. L. , Carleton T. J.
Published: March 2003

The effects of habitat degradation on the soil seed bank at La Pérouse Bay, Manitoba are described. Foraging by lesser snow geese leads to loss of vegetation, coupled with changes in soil abiotic conditions and an increase in salinity.

The density of seeds and the relative abundance in the seed bank of species characteristic of undisturbed sites decrease following degradation, while the relative abundance of invasive species increases. Vegetation loss had the greatest impact on seed banks of stress‐tolerant species and the least impact on species with many widely dispersed seeds.

The above‐ground vegetation and below‐ground seed bank were less similar in undamaged plots than in disturbed plots. In spite of the low degree of similarity, redundancy analysis of the data indicated that approximately half of the variation in the soil seed bank could be explained by the vegetation data and vice versa.

More recently degraded soils had richer soil seed banks than those from older disturbances. Site‐specific factors not only influenced the species present but also the time lag between loss of vegetation and loss of the seed bank. Seed banks in these impacted and fragmented sites do not recover quickly.

Seed banks in sandy beach‐ridges were less affected by degradation due to the greater proportion of ruderals present in the original vegetation and the absence of the high soil salinities that are characteristic of degraded salt‐marsh soils.
Resprouting and growth dynamics after fire of the clonal shrub Andira legalis (Leguminosae) in a sandy coastal plain in south‐eastern Brazil
Authors: Cirne Paulo , Scarano Fabio R.
Published: March 2003

Survival, resprouting and growth dynamics of the clonal shrub Andira legalis were studied for 2 years after fire, on a sandy spit on the coastal plain of Brazil. We examined the importance of resprouting for post‐fire persistence, the relationship between resprouting patterns and injury suffered and size of individuals, and whether ramet growth was determined by competition and self‐thinning.

 Post‐fire resprouting was responsible for production of new ramets and led to an increase in the mean number of ramets per A. legalis individual.

 There was a negative association between resprouting from overground vs. underground. Highly injured individuals showed a significant tendency to sprout new ramets from underground organs whereas less damaged plants produced new branches and leaves from stem buds. Ramet production was related to an individual’s prefire size (basal area), but to a lesser extent than to injury.

 Immediately after fire, the G(t,x) function (mean of absolute growth rates of shoots of size x at time t) was size‐independent, suggesting an absence of competition. G(t,x) then became size‐dependent, while D(t,x) (variance of absolute growth rates of shoots of size x at time t) remained size‐independent, indicating that any competition between ramets was symmetric.

 Size‐dependent mortality and a negative linear relationship between mean ramet size and density indicated self‐thinning. However, the low ramet mortality (7.7%) and the absence of size hierarchies (coefficients of variation remained constant) suggest that competition and self‐thinning were not intense.
Clonal variation in morphological and physiological responses to irradiance and photoperiod for the aquatic angiosperm Potamogeton pectinatus
Authors: Pilon Jörn , Santamaría Luis
Published: March 2003

Widely distributed plants are exposed to contrasting gradients in irradiance and photoperiod across latitude. We investigated the relative contribution of local specialization and phenotypic plasticity to variation in plant growth for three clones of the aquatic angiosperm Potamogeton pectinatus L., originating from 42.5 to 68° N. Plants were grown at a factorial combination of two irradiances (50 and 350 µmol m−2 s−1) and three photoperiods (13, 16 and 22 h) and morphology, gas‐exchange rate and biomass accumulation were recorded.

The overall response to variation in irradiance and photoperiod was similar for all three clones.

Differences in irradiance resulted in strong acclimative changes in morphological and physiological characteristics. At low irradiance, pronounced vertical shoot extension compensated for the limited plasticity in leaf area production, while photosynthetic capacity, apparent quantum yield and total chlorophyll concentration increased. As a result, biomass yield at the end of the experimental period was similar in both treatments.

A decrease in photoperiod also resulted in plastic changes in morphology (increase of leaf biomass per unit plant biomass) and physiology (increase of photosynthetic capacity). However, these acclimative responses did not fully compensate for differences in photoperiod, since biomass was significantly lower under 13 and 16 h photoperiods than at 22 h.

P. pectinatus is therefore phenotypically plastic, rather than locally specialized to differences in irradiance and photoperiod.
The relationship of impending death and age category to treatment intensity in the elderly
Authors: Long Michael J. , Marshall Brenda Stevenson
Published: March 2003

The purpose of this study was to isolate and quantify the age‐related treatment intensity differential in elderly clients (n = 278) with functional disability in one managed care setting. For those who died during the study, treatment intensity changes for the last year and month of life were examined. The subjects were categorized into four age groups: 75–79 years; 80–84 years; 85–89 years and 90 + years, and a treatment intensity index was calculated for each group using a ratio of actual to expected costs. Indices of overall costs and cost per day for all clients, and also indices for the year and month prior to death for the deceased clients were calculated. The results clearly show that for all clients, the oldest age group was treated less intensively than the youngest age group. For the deceased clients, the older age group was treated less intensively than the youngest age group in the last year and month of life but, for all age groups, the intensity of treatment increased during the last month of life.
Treating individuals according to evidence: why do primary care practitioners do what they do?
Authors: Oswald Nigel , Bateman Hilarie
Published: March 2003

Research evidence does not necessarily translate into changed management for individual patients, but that may not mean that the evidence has been ignored. Drawing on accounts from general practitioners, we use a study of non‐rheumatic atrial fibrillation (NRAF) to illuminate the processes by which practitioners became aware of and assimilated research evidence. We follow that with an account of how the evidence was incorporated into practice protocols for anticoagulation and then applied to a review of individual patients’ records. Practitioners used a range of sources of evidence. They reported difficulties arising from their own skills and circumstances and from the perceived quality of the evidence. Creating a protocol involved overcoming problems of scheduling, resources and managing judgements about the value of the review process. In applying the protocol practitioners drew on their knowledge of the patients’ preferences, circumstances and previous specialist consultations. As a result, practitioners made judgements that evidence, combined with prior experience, did not support the initiation of anticoagulation in 52% of an unselected primary care population with NRAF. Our findings have implications for evidence‐based practice and for practitioner education.
Why are investigations not recommended by practice guidelines ordered at the periodic health examination?
Authors: Walraven Carl van , Goel Vivek , Austin Peter
Published: March 2003

Evidence‐based guidelines recommend few routine investigations for healthy adults at the periodic health examination (PHE). However, small studies indicate that laboratory tests are commonly ordered at the PHE. This study examined PHE laboratory testing that is not recommended by recognized guidelines (‘discretionary’). Using administrative data from the universal health care system in Ontario, Canada, we studied 792 844 adults having a PHE in 1996 and the 3727 physicians who administered them. We measured the number of discretionary laboratory tests per PHE along with the patient and physician factors potentially influencing laboratory testing. A multilevel, multivariate model was used to examine the association between the number of discretionary laboratory tests at the PHE with patient and physician characteristics. A mean of 7.1 discretionary tests (SD 7.1) was ordered per PHE. Renal, haematological, glucose and lipid tests each were conducted in more than a third of PHEs. Testing varied extensively between physicians and was more common in healthy patients. With the exception of age, patient factors had little effect on discretionary testing. However, each physician factor we examined was independently associated with the number of discretionary tests. Physician specialty, practice volume and previous testing patterns had the strongest influence on discretionary testing. Discretionary investigations are common at the PHE. Testing varies extensively between physicians and seems to be driven more by physician than by patient factors. Interventions to modify discretionary test utilization at the PHE should consider these physician factors.
Towards an optimal model for community‐based diabetes care: design and baseline data from the Mayo Health System Diabetes Translation Project
Authors: Dinneen Sean F. , Bjornsen Susan S. , Bryant Sandra C. , Zimmerman Bruce R. , Gorman Colum A. , Knudsen Jens B. , Rizza Robert A. , Smith Steven A.
Published: March 2003

The objective of the Mayo Health System Diabetes Translation Project is to assess the impact of three different models of care on the overall quality of diabetes care in the community. The unit of study is the primary care practice with a different model of care implemented at each of three sites. The design incorporates a comparison of a diabetes guideline implementation team initiative (Practice model A), a guideline initiative combined with clinical use of a Diabetes Electronic Management System (DEMS) by primary care providers (Practice model B) and a guideline initiative combined with DEMS utilization combined with electronic review of DEMS patient encounters by an endocrinologist (Practice model C). Administrative data sets were used to define the patient population at each practice. Patients were designated as new, attending or non‐attending based on their pattern of visits over the preceding 12 months. A random sample of 200 charts from attending patients at each site was audited at baseline for diabetes‐related process and outcome measures. This audit will be repeated yearly during the 2 years of the project. Baseline data revealed significant differences across sites in adherence to certain key indicators of the quality of diabetes care including: frequency of documentation of eye examinations (19, 39 and 37% for sites A, B and C, respectively), haemoglobin A1c monitoring (64, 89 and 77%) and microalbumin monitoring (3, 15 and 6%). The interventions being assessed in this study include traditional (diabetes education; guideline implementation) and modern (DEMS; telemedicine specialist review) methods for improving the quality of diabetes care. In spite of variation in baseline quality indicators, the setting and design should lead to broad applicability of the results and help determine an optimal model of diabetes care in the community.
Use of marketing to disseminate brief alcohol intervention to general practitioners: promoting health care interventions to health promoters
Authors: Lock Catherine A. , Kaner Eileen F. S.
Published: March 2003

Health research findings are of little benefit to patients or society if they do not reach the audience they are intended to influence. Thus, a dissemination strategy is needed to target new findings at its user group and encourage a process of consideration and adoption or rejection. Social marketing techniques can be utilized to aid successful dissemination of research findings and to speed the process by which new information reaches practice. Principles of social marketing include manipulating the marketing mix of product, price, place and promotion. This paper describes the development of a marketing approach and the outcomes from a trial evaluating the effectiveness and cost‐effectiveness of manipulating promotional strategies to disseminate actively a screening and brief alcohol intervention (SBI) programme to general practitioners (GPs). The promotional strategies consisted of postal marketing, telemarketing and personal marketing. The study took place in general practices across the Northern and Yorkshire Regional Health Authority. Of the 614 GPs eligible for the study, one per practice, 321 (52%) took the programme and of those available to use it for 3 months (315), 128 (41%) actively considered doing so, 73 (23%) actually went on to use it. Analysis of the specific impact of the three different promotional strategies revealed that while personal marketing was the most effective overall dissemination and implementation strategy, telemarketing was more cost‐effective. The findings of our work show that using a marketing approach is promising for conveying research findings to GPs and in particular a focus on promotional strategies can facilitate high levels of uptake and consideration in this target group.
Exploring the pathology of quality failings: measuring quality is not the problem – changing it is†
Authors: Davies Huw Talfryn Oakley
Published: March 2003

The USA can boast a long history of investigation into quality failings in health care. From Ernest Codman and Abraham Flexner in the opening decades of this century through to the intense activity of the 1980s and 1990s, much careful study has exposed extraordinary and at times scandalous deficiencies in the quality of care (Millenson 1997;Chassin & Galvin 1998;Schusteret al.1998). Yet we are still far from developing ‘industrial strength’ quality in health care: in all but a few isolated areas, such as general anaesthesia, ‘six sigma quality’ (i.e. a handful of errors per million) seems wishful thinking (Chassin 1998). Pockets of excellence and innovation notwithstanding, the dominant experience of the past two decades has been an increasing ability to document quality failings and a seeming inability to mobilize effective action (Coye & Detmer 1998). The rich literature on health‐care quality that has sprung up over the past few decades has largely failed to provide a clear direction for quality improvement activity. This paper analyses some of the reasons why this might be so. Contrasting the relative absence of progress on health‐care quality with the relative success of disease epidemiology provides some illuminating parallels. In essence, study of the quality of care has focused largely on providing a ‘descriptive epidemiology’. Much more work is needed yet to unravel the underlying pathology of quality failings, in order to empower development of an ‘aetiological epidemiology’ of quality in health care. Such understanding is essential as a precursor to targeted and effective preventative and remedial action.
Evidence‐based medicine in general practice: beliefs and barriers among Australian GPs
Authors: Young Jane M. , Ward Jeanette E.
Published: March 2003

If implemented, evidence‐based medicine (EBM) in general practice will improve health outcomes for patients. This paper examines the views of 60 Australian general practitioners about EBM. While 57% of respondents had a computer in their surgery, 15% had Internet access and only 3% had access to the Cochrane Library at work. The most commonly cited barrier to EBM was ‘patient demand for treatment despite lack of evidence for effectiveness’ (45%). The next three most highly rated barriers related to lack of time. For each of three tasks of EBM, namely searching for evidence, appraising evidence and discussing the implications of evidence with patients, lack of time was rated as a ‘very important barrier’ by significantly more participants than lack of skills (McNemar’s tests: χ21 = 7.1, P = 0.008, χ21 = 14.0, P = 0.001 and χ21 = 9.0, P = 0.003, respectively). Preferred resources for EBM included clinical practice guidelines (rated as ‘very useful’ by 55%) and journals that summarize research evidence, for example Evidence‐based Medicine (52%). Systematic reviews were considered ‘very useful’ by only 15% of respondents, consistent with our finding that 30% did not understand the term ‘systematic review’. Furthermore, 43% did not understand ‘meta‐analysis’. A minority indicated they understood the terms ‘relative risk’ (23%), ‘absolute risk’ (28%) and ‘number needed to treat’ (15%) sufficiently to explain to others. Skills development is crucial to achieve EBM in general practice.
Clinical evaluation: constructing a new model for post‐normal medicine
Authors: FRCGP Kieran Sweeney MA MPhil , MRCGP David Kernick MD
Published: March 2003

The current paradigm in medicine is served by an explanatory model based on scientific positivism. We argue that there are inherent weaknesses in this model: its basis on reductionism, its reliance on linear thinking and its failure to incorporate human values invite a revision of our thinking about knowledge in medicine. We propose that a fresh explanatory model should be based on complexity theory, and argue that this better suits the new era of post‐normal medicine, where analytical and predictive power are obtained by stepping back and looking at the relationships and overall context of a system rather than forcing reality into a preferred disciplinary framework. Better at times to be vaguely right, we argue, rather than precisely wrong.