bluuebunny/crossref_metadata_2025 huggingface dataset:
Endocrine disrupters and human puberty
Authors: DEN HOND E. , SCHOETERS G.
Published: February 2006

In this overview of the literature, epidemiological research studying the effect of endocrine disrupters on the onset of puberty is summarized. In girls, earlier age at menarche was reported after exposure to polychlorinated biphenyls (PCBs), polybrominated biphenyls (PBBs), persistent pesticides [dichlorodiphenyltrichloroethane (DDT)] and phthalate esters. However, several other studies found no effect of these compounds on age at menarche or pubertal Tanner stages. One study reported a delaying effect of dioxin‐like compounds on breast development. In boys, exposure to PCBs, PCDFs or the pesticide endosulfan was associated with delayed puberty or decreased penile length. Much of the results found in population studies are in accordance with experimental studies in animals. However, the mixture of different components with antagonistic effects (oestrogenic, anti‐oestrogenic, anti‐androgenic) and the limited knowledge about the most critical window for exposure (prenatal, peri‐natal and pubertal) may hamper the interpretation of results.
Di(2‐ethylhexyl)phthalate (DEHP): human metabolism and internal exposure – an update and latest results1
Authors: Koch H. M. , Preuss R. , Angerer J.
Published: February 2006

Di(2‐ethylhexyl)phthalate (DEHP) is a reproductive and developmental toxicant in animals and a suspected endocrine modulator in humans. There is widespread exposure to DEHP in the general population. Patients can be additionally exposed through DEHP‐containing medical devices. Toxicokinetic and metabolic knowledge on DEHP in humans is vital not only for the toxicological evaluation of DEHP but also for exposure assessments based on human biomonitoring data. Secondary oxidized DEHP metabolites like mono‐(2‐ethyl‐5‐hydroxyhexyl)phthalate (5OH‐MEHP), mono‐(2‐ethyl‐5‐oxohexyl)phthalate (5oxo‐MEHP), mono‐(2‐ethyl‐5‐carboxypentyl)phthalate (5cx‐MEPP) and mono‐[2‐(carboxymethyl)hexyl]phthalate (2cx‐MMHP) are most valuable biomarkers of DEHP exposure. They represent the major share of DEHP metabolites excreted in urine (about 70% for these four oxidized metabolites vs. about 6% for MEHP); they are immune to external contamination and possibly the ultimate developmental toxicants. Long half‐times of elimination make 5cx‐MEPP and 2cx‐MMHP excellent parameters to measure the time‐weighted body burden to DEHP. 5OH‐MEHP and 5oxo‐MEHP more reflect the short‐term exposure. We calculated the daily DEHP intake for the general population (n = 85) and for children (n = 254). Children were significantly higher exposed to DEHP than adults. Exposures at the 95th percentile (21 and 25 μg/kg/day, respectively) scooped out limit values like the Reference Dose (RfD, 20 μg/kg/day) and the Tolerable Daily Intake (TDI, 20–48 μg/kg/day) to a considerable degree. Up to 20‐fold oversteppings for some children give cause for concern. We also detected significant DEHP exposures for voluntary platelet donors (n = 12, 38 μg/kg/apheresis, dual‐needle technique). Premature neonates (n = 45) were exposed to DEHP up to 100 times above the limit values depending on the intensity of medical care (median: 42 μg/kg/day; 95th percentile: 1780 μg/kg/day).
Breast cancer, oestrogens and environmental pollutants: a re‐evaluation from a mixture perspective
Authors: Kortenkamp Andreas
Published: February 2006

The continuing rise in breast cancer incidence rates in almost all Western countries cannot be explained entirely in terms of known risk factors of the disease process. Additional determinants need to be examined, among them exposure to environmental pollutants. With the demonstration that elevated levels of endogenous sex hormones and the use of hormones for the relief of menopausal symptoms are associated with the disease, the oestrogen hypothesis of breast cancer has received further empirical support. This has led to heightened concerns about the possible involvement of oestrogen‐like pollutants, such as p,p′‐Dichlorodiphenyldichloroethane (DDE). Case–control studies assessing whether women with breast cancer have elevated burdens of p,p′‐DDE have produced results not suggestive of a link with cancer risks. However, possible effects of p,p′‐DDE and other pollutants cannot be seen in isolation from sex hormones also present in serum. In view of the low potency of p,p′‐DDE, and its low levels in serum, it seems unlikely that the chemical on its own will add significantly to the action of sex hormones. However, chemical analyses show that numerous pollutants with oestrogen‐like effect profiles can be found in human tissues. Thus, the oestrogen hypothesis of breast cancer should be extended to encompass the multitude of these agents. Viewed from such a perspective, a putative role of organochlorines and other agents in breast cancer should not be dismissed prematurely. Instead, breast cancer epidemiology should face the reality of combined exposures and should take account of recent evidence from in vitro models demonstrating that a large number of oestrogen‐like pollutants, all present at low levels, can act together to add to the internal oestrogenic load.
Semen quality in fertile US men in relation to geographical area and pesticide exposure
Authors: Swan Shanna H.
Published: February 2006

We conducted the first US study to compare semen quality among study centres using standardized methods and strict quality control. We present data on semen quality in partners of 493 pregnant women recruited through prenatal clinics in four US cities during 1999–2001. Sperm concentration, semen volume and motility were determined at the centres and morphology was assessed at a central laboratory. While between‐centre differences in sperm morphology and sample volume were small, sperm concentration and motility were significantly reduced in Columbia, MO (MO) relative to men in New York, NY, Minneapolis, MN and Los Angeles, CA; total number of motile sperm was 113 × 106 in MO and 162, 201 and 196 × 106 in CA, MN and NY respectively. Differences among centres remained significant in multivariate models that controlled for abstinence time, semen analysis time, age, race, smoking, history of sexually transmitted disease and recent fever (all p‐values <0.01). We hypothesized that poorer sperm concentration and motility in MO men relative to other centres might be related to agricultural pesticides that are commonly used in the mid‐west. We investigated this hypothesis by conducting a nested case–control study within the MO cohort. We selected 25 men in this cohort for whom all semen parameters (concentration, % normal morphology and % motile) were low as cases and an equal number of men for whom all semen parameters were within normal limits as controls. We measured metabolites of eight non‐persistent, current‐use pesticides in urine samples the men had provided at the time of semen collection. Pesticide metabolite levels were elevated in cases compared with controls for the herbicides alachlor and atrazine, and for the insecticide diazinon (2‐isopropoxy‐4‐methyl‐pyrimidinol) (p‐values for Wilcoxon rank test = 0.0007, 0.012, and 0.0004 for alachlor, atrazine and diazinon respectively). Men with higher levels of alachlor or diazinon were significantly more likely to be cases than men with low levels [odds ratios (OR) = 30.0, 16.7 for alachlor and diazinon respectively], as were men with atrazine over the limit of detection (OR = 11.3). These associations between current‐use pesticides and reduced semen quality suggest that agricultural chemicals may have contributed to the reduced semen quality seen in fertile men from mid‐Missouri.
Ethnic differences in occurrence of TDS – genetics and/or environment?
Authors: Giwercman Aleksander , Rylander Lars , Hagmar Lars , Giwercman Yvonne Lundberg
Published: February 2006

It has been hypothesized that poor semen quality, testis cancer, undescended testis and hypospadias are symptoms of one underlying entity, the so‐called testicular dysgenesis syndrome (TDS). TDS was suggested to be a result of disruption of embryonal programming and gonadal development during foetal life and as aetiological factor, an impact of adverse environmental factors such as hormone disrupters, probably acting upon a susceptible genetic background, was suggested. Extensive studies considering the risk of TDS‐related diseases in Denmark compared with Finland, showed higher sperm counts and lower risk of cryptorchidism and testicular cancer among Finns. However, when comparing these two populations, the question arises, to which degree this difference might be due to discrepancy in genetic background. A more obvious example of the impact of genetic factors on the risk of TDS concerns Afro‐Americans having significantly lower incidence of testicular cancer when compared with Caucasians living in the USA. A yet unexplored scenario is a possible interaction between genetic and environmental/lifestyle‐related factors, certain genotypes making individuals more susceptible to adverse exogenous exposures. Studying such interactions has biological, epidemiological and public health‐related implications. It will help us to understand the background for the defects in male reproductive organs, facilitate proper design of epidemiological studies and add to identifying individuals susceptible to certain environmental and lifestyle‐related hazards. Such ‘susceptibility genes’ need to be identified, those involved in the synthesis, action and metabolism of sex steroids being strong candidates.
Effects of the plant growth regulator, chlormequat, on mammalian fertility
Authors: Sørensen Martin T. , Danielsen Viggo
Published: February 2006

This paper summarizes the consequences of exposure to chlormequat, a plant growth regulator, on reproduction in mammals. Plant growth regulators are chemicals used to manipulate plant growth, flowering and fruit yield. In grain crops, plant growth regulators are applied to promote sturdier growth and reduce the risk of lodging. Chlormequat is the most common plant growth regulator. Maximum residue limits of chlormequat in food products are 10 mg/kg in oat and pear, 3 mg/kg in wheat and rye, and 0.5 mg/kg in milk. In Denmark, results from experiments with pigs in the late 1980s showed sows that display impaired reproduction, mainly impaired oestrus, when fed grain from crop treated with chlormequat. Subsequently, the advisory body to the Danish pig industry recommended limiting the use of grain (maximum 30% of diet energy) from crop treated with chlormequat given to breeding stock due to the risk of reproduction problems. More recently, experiments have been conducted to evaluate the influence of chlormequat‐treated wheat crop on reproductive function in male and female mice. These experiments showed that epididymal spermatozoa from mice on feed or water containing chlormequat had compromised fertilizing competence in vitro, while reproduction in female mice was not compromised. The estimated intake of chlormequat in the pig (0.0023 mg/kg bw/day) and the mouse (0.024 mg/kg bw/day) experiments was below the acceptable daily intake of 0.05 mg/kg bw/day. Reports from the industry do not show any effects at these low levels.
Reproductive dysgenesis in wildlife: a comparative view
Authors: Edwards Thea M. , Moore Brandon C. , Guillette Louis J.
Published: February 2006

Abnormal reproductive development in males has been linked to environmental contaminant exposure in a wide variety of vertebrates. These include humans, rodent models, and a large number of comparative wildlife species. In human males, abnormal reproductive development can manifest as a suite of symptoms, described collectively as testicular dysgenesis syndrome (TDS). TDS is also described as demasculinization or feminization of the male phenotype. The suite includes cryptorchidism, in situ germ cell carcinoma of the testis and overt testicular cancer, reduced semen quality, and hypospadias. In this paper, we review examples of TDS among comparative species. Wildlife exposed to environmental contaminants are susceptible to some of the same developmental abnormalities and subsequent symptoms as those seen in human males with TDS. There are additional end points, which are also discussed. In some cases, the symptoms are more severe than those normally seen in humans with TDS (i.e. oocytes developing within the testis) because some non‐mammalian species exhibit greater innate reproductive plasticity, and are thus more easily feminized. Based on our review, we present an approach regarding the ontogeny of TDS. Namely, we suggest that male susceptibility to the androgynizing influences of environmental contaminants originates in the sexually undifferentiated embryo, which, in almost all species, including humans, consists of bipotential reproductive tissues. These tissues can develop as either male or female and their ultimate direction depends on the environment in which they develop.
Coordinated European investigations of semen quality: results from studies of Scandinavian young men is a matter of concern
Authors: Jørgensen Niels , Asklund Camilla , Carlsen Elisabeth , Skakkebæk Niels E.
Published: February 2006

For many years it has been acknowledged that Danish and Norwegian men have one of the highest risks in the world for testicular cancer in sharp contrast to neighbouring Baltic men from Finland, Estonia and Lithuania. As an association between poor semen quality and testicular cancer has been established, it was suggested that men from high‐risk testicular cancer areas would be more likely to have poor semen quality. However, previous studies were not able to elucidate this question due to their retrospective nature. In prospectively designed and strictly controlled studies of fertile men, the existence of regional differences in semen quality was confirmed. In addition, studies of men from the general populations were undertaken and a similar regional difference in semen quality was detected. Men from the eastern part of the Nordic–Baltic area had better semen quality than men from the western part. These findings parallel the incidence of testicular cancer in these regions. Approximately 20% of young men from Norway and Denmark had sperm concentrations below the World Health Organization reference level of 20 × 106 spermatozoa/mL, and approximately 40% had <40 × 106 spermatozoa/mL which, according to recent publications, may be the ‘threshold’ below which fecundity declines. In Denmark, the situation is of concern and a continued surveillance of semen quality in young men was established in 2001 by a government‐supported programme.
Adverse effects of environmental antiandrogens and androgens on reproductive development in mammals1
Authors: Earl Gray L. , Wilson Vickie S. , Stoker Tammy , Lambright Christy , Furr Johnathan , Noriega Nigel , Howdeshell Kembra , Ankley Gerald T. , Guillette Louis
Published: February 2006

Within the last decade, several classes of chemicals have been shown in laboratory studies to disrupt reproductive development by acting as androgen receptor (AR) antagonists and/or inhibitors of fetal Leydig cell testosterone production. Some phthalate esters alter gubernacular differentiation by reducing insulin‐like 3 (insl3) mRNA levels. We have found that AR antagonists and inhibitors of fetal testis hormone production generally induce cumulative, apparently dose‐additive adverse effects when administered in mixtures. New research has also revealed the presence of androgens in the environment. Effluents from pulp and paper mills display androgenic activity of sufficient potency to masculinize and/or sex‐reverse female fish. Effluent from beef cattle concentrated animal feedlot operations from the United States also displays androgenic activity in vitro, due, in part, to the presence of a steroid used to promote growth in beef cattle. In summary, we are only beginning to identify the classes of chemicals that have the potential to alter the androgen signalling pathway in utero. This review will (i) present information on the classes of environmental chemicals that display antiandrogenic and androgenic activities in vitro and in vivo, and (ii) provide an insight into how exposure to mixtures these chemicals might behave in utero.
Y chromosome variants and male reproductive function
Authors: McElreavey Ken , Ravel Celia , Chantot‐Bastaraud Sandra , Siffroi Jean‐Pierre
Published: February 2006

The detailed analysis of the Y chromosome in men with azoospermia or severe oligozoospermia has resulted in the identification of three regions of the long arm of the human Y chromosome, termed AZFa, AZFb and AZFc, (AZF: AZoospermia Factor) that are currently deleted in men with otherwise unexplained spermatogenic failure. Screening for these deletions is now common in many infertility centres and in some instances they have a prognostic relevance. Recently, attention has turned to partial deletions of the AZFc region. At first sight some of these deletions appear to have little effect on fertility, whilst others appear to be associated with significant risk for developing spermatogenic failure. However, the relationship between these partial AZFc deletions, reduced sperm counts and infertility is the subject of a continuing intense debate. There is a pressing need to clarify the impact of partial AZFc deletions on human spermatogenesis. This requires large‐scale studies on well‐characterized normospermic and oligo/azoospermic individuals of different ethnic origins with multiple informative AZFc markers if the correlation between these deletions and the phenotype is finally to be resolved. The definition of Y chromosome variants (haplotypes) in cases of partial AZFc deletions is likely to play an essential role in understanding the contribution of the deletion to reduced sperm counts.
Fertility and abortion rates in the United States, 1960–2002
Authors: Hamilton Brady E. , Ventura Stephanie J.
Published: February 2006

This paper provides a general overview of trends in the United States (US) birth, fertility and abortion data from 1960 to 2002. Rates by age, race and Hispanic origin are also discussed. Data presented in this paper are derived primarily from published reports of the US government's Centers for Disease Control and Prevention's National Center for Health Statistics. In 2002, there were 4 021 726 births in the US. The general fertility rate was 64.8 births per 1000 women aged 15–44 years, the total fertility rate was 2013.0 children per 1000 women, and the net reproduction rate was 968 daughters per 1000 women. These rates have declined in the US since 1960, down by at least 44% for all rates. While these rates have been declining, there are substantial differences in fertility patterns by age and race and Hispanic origin. Rates for women, 30 years of age and over, increased between 1980 and 2002. In contrast, rates for women under 25 years of age rose considerably during the late 1980s, and then decreased sharply since 1991. Rates for women in their late twenties (25–29 years of age), the principal childbearing ages, have fluctuated within a narrow range throughout this period (1980–2002). As a result of the increase in births to older women, the mean age of mother at first birth increased by nearly 4 years from 1968 to 2002. In 2000, the latest year for which data are available, there were 21.3 induced abortions per 1000 women aged 15–44 years, down from 27.4 in 1990. The total abortion rate, average number of legally induced abortions that would occur to a hypothetical cohort of 1000 women, was 672.0 abortions per 1000 women in 2000, down from 785.5 in 1980. The abortion rate has declined fairly steadily since 1980. Like the birth and fertility rates, substantial differences in abortion rates exist by age and race and Hispanic origin. The rates of induced abortion increased for women in their thirties between 1980 and 2000, whereas rates for women under 25 years of age and women 40 years of age and over decreased since 1980. The rate for women 25–29 years of age changed little. The rate of induced abortion was considerably higher for non‐Hispanic black women (57.4) in 2000 than for non‐Hispanic white women (11.7). The rate for Hispanic women (30.6) was intermediate. The total abortion rate was also much higher for non‐Hispanic black women than non‐Hispanic white and Hispanic women.
From embryonic stem cells to testicular germ cell cancer – should we be concerned?
Authors: Almstrup Kristian , Sonne Si Brask , Hoei‐Hansen Christina E. , Ottesen Anne Marie , Nielsen John E. , Skakkebæk Niels E. , Leffers Henrik , Meyts Ewa Rajpert‐De
Published: February 2006

Since the discovery of testicular carcinoma in situ (CIS) – the precursor cell for the vast majority of germ cell tumours – it has been proposed that CIS cells could be derived from transformed primordial germ cells or gonocytes. Here, we review recent discoveries not only substantiating that initial hypothesis but also indicating that CIS cells have a striking phenotypic similarity to embryonic stem cells (ESC). Many cancers have been proposed to originate from tissue‐specific stem cells [so‐called ‘cancer stem cells’ (CSC)] and we argue that CIS may be a very good example of a CSC, but with exceptional features due to the retention of embryonic pluripotency. In addition, considering the fact that pre‐invasive CIS cells are transformed from early fetal cells, possibly due to environmentally induced alterations of the niche, we discuss potential risks linked to the uncontrolled therapeutic use of ESC.
Proteolysis and lipolysis in White cheeses manufactured by two different production methods
Authors: Cinbas Tulay , Kilic Meral
Published: February 2006

The effect of the production method on the proteolysis and lipolysis in White cheese was investigated during 3 months of storage. Two types of White cheese were manufactured with different production methods: (i) the traditional, applying mild heat treatment to milk (65 °C/5 min) and (ii) the industrial, using milk heat‐treated at a high temperature (75 °C/5 min) and starter culture. Lower moisture, higher water‐soluble N, lower trichloroacetic acid‐soluble N and higher free fatty acids levels were found in the cheese produced by the traditional method compared with the cheese produced using the industrial method. The amount of 2,4,6‐trinitrobenzenesulphonic acid‐reactive free amino groups was not significantly different between the cheeses.
Patterns and frequency of anxiety in women undergoing gynaecological surgery
Authors: Carr Eloise , Brockbank Katrina , Allen Sandra , Strike Paul
Published: February 2006

Aims.  Within a gynaecological surgical setting to identify the patterns and frequency of anxiety pre‐ and postoperatively; to identify any correlation between raised anxiety levels and postoperative pain; to identify events, from the patients’ perspective, that may increase or decrease anxiety in the pre‐ and postoperative periods.

Background.  It is well documented that surgery is associated with increased anxiety, which has an adverse impact on patient outcomes. Few studies have been conducted to obtain the patient's perspective on the experience of anxiety and the events and situations that aggravate and ameliorate it.

Method.  The study used a mixed method approach. The sample consisted of women undergoing planned gynaecological surgery. Anxiety was assessed using the State Trait Anxiety Inventory. Trait anxiety was measured at the time of recruitment. State anxiety was then assessed at six time points during the pre‐ and postoperative periods. Postoperative pain was also measured using a 10 cm visual analogue scale. Taped semi‐structured telephone interviews were conducted approximately a week after discharge.

Results.  State anxiety rose steadily from the night before surgery to the point of leaving the ward to go to theatre. Anxiety then increased sharply prior to the anaesthetic decreasing sharply afterwards. Patients with higher levels of trait anxiety were more likely to experience higher levels of anxiety throughout their admission. Elevated levels of pre‐ and postoperative anxiety were associated with increased levels of postoperative pain. Telephone interviews revealed a range of events/situations that patients recalled distressing them and many were related to inadequate information.

Conclusion.  This study found higher rates of anxiety than previously reported and anxiety levels appeared raised before admission to hospital. This has important clinical and research implications.

Relevance to clinical practice.  Patients with high levels of anxiety may be identified preoperatively and interventions designed to reduce anxiety could be targeted to this vulnerable group. Patient experiences can inform the delivery of services to meet their health needs better.
‘The intruder’: spouses’ narratives about life with a chronically ill partner
Authors: Eriksson Monica , Svedlund Marianne
Published: February 2006

Aim. The aim of this study was to illuminate the meaning of middle‐aged spouse's experiences of living with a chronically ill partner. A purposive sample of four female spouses was selected for interviews using a narrative approach.

Background. When someone is diagnosed with a chronic illness, it is easy to understand that a considerable number of devastating consequences follow, both for the afflicted as well as for the family. Families often feel neglected and that their problems and needs are underestimated, if they do not personally draw attention to this fact.

Methods. A phenomenological hermeneutic method, inspired by the philosophy of Ricoeur, was used when interpreting the interview text.

Results. The experiences of spouses living with a chronically ill partner often brought a feeling of detachment from their partner's lives. The women experienced changes in their relationships because of their partners’ disabilities; they had emotions of loneliness, despite living together as a couple. Through their actions, the women sought reassurance and support in order to maintain a meaningful partnership with their spouses and this is expressed in three themes: feelings of limitation, the struggle of everyday life and a striving for normalization.

Conclusions. Middle‐aged women living with a chronically sick partner are still of an active disposition and regard themselves as still being in mid‐life. They wish to be loved as a wife and not as a care provider.

Relevance to clinical practice.The findings from this study can help increase the knowledge and understanding of the problems and concerns encountered by middle‐aged spouses living with chronically ill partners and can be useful in the education and supervision of nurses and in relationship with relatives.
The health‐promoting school: what role for nursing?
Authors: Whitehead Dean
Published: February 2006

Aim.  To review the existing literature on health‐promoting schools and put forward recommendations for continuing progress.

Background.  The World Health Organisation's Ottawa Charter for Health Promotion in 1986 sought to create a framework for health promotion action that conveyed the notion of capacity building as it related to specific settings. It provided the catalyst from which the health‐promoting school movement emerged, against the backdrop of health professionals adapting to the changing needs and demands of clients and the evolving social context of the communities in which they live. Since then, the international health‐promoting school movement has been one of the most successful of the settings‐based projects and has expanded considerably over recent years.

Method.  An extensive review of available health‐promoting school‐related literature provides the basis for critical discussion and recommendations.

Findings.  Traditionally, the school nursing movement has provided the backbone of nursing‐related health promotion activity in the school setting. The literature, however, is generally critical of its contribution over the years – especially as its role is mainly confined to a ‘conventional’ health education function and has little to do with health‐promoting school projects. There are more and more calls now for the school nursing service to either re‐evaluate its function and processes or be devolved back into a broader primary health care practitioner role.

Conclusion.  Nurses should view the health‐promoting school movement as another opportunity to embrace evolving broad‐based health promotion concepts truly, as a means to forge and own their own health agenda and also as a means to move beyond a traditional reliance on a limited health education role. Schools also need to adapt and expand their efforts to focus on health promotion activities, in collaboration with the ever‐widening community networks of health and social agencies. This requires the commitment of all healthcare professional groups. Nurses who practice in all settings, and not just school nurses, should be aiming to initiate and promote radical health promotion reform as set out in the health‐promoting school movement.

Relevance to clinical practice.  If health professionals wish to be at the forefront of current health‐promoting school strategies they must embrace the radical health promotion reforms that are emerging from the current literature and put forward in this article. Building such group capacity, through developing social interaction, cohesion, participation and political action can only benefit the community at large and further emphasize the health promotion role of nursing. The health‐promoting school movement is truly an international concept and, as such, deserves a concerted nursing representation and resourcing well beyond its current commitment.
Documenting the cognitive status of hip fracture patients using the Short Portable Mental Status Questionnaire
Authors: Söderqvist Anita , Strömberg Lars , Ponzer Sari , Tidermark Jan
Published: February 2006

Aims and objectives.  The aim of this study was to describe how nurses document their subjective assessment of the patients’ cognitive status in the patients’ records and to compare this documentation with an assessment made using a validated evaluation instrument in older patients with a hip fracture.

Background.  There are indications that older people with a hip fracture and impaired cognitive ability do not receive optimal care and that they suffer from a disproportionately high number of complications. Preventing and rapidly detecting confusion is probably an effective strategy for improving care for these patients. To be able to prevent care‐related complications and plan for future nursing and medical care, it is necessary to identify patients with impaired cognitive ability.

Design.  Clinical trial including 362 patients.

Methods.  The patients’ cognitive function was assessed by a research nurse using a validated instrument, the Short Portable Mental Status Questionnaire, and an independent subjective assessment was made by a ward nurse. The agreement between these assessments was analysed.

Results.  An assessment of cognitive function by the ward nurse was lacking in 12% of the patients. The assessment made by the nurses did not correspond to the level of orientation according to Short Portable Mental Status Questionnaire in 24% of the patients. In the vast of majority of these cases, the patients were documented as being cognitively alert although they were cognitively impaired according to the Short Portable Mental Status Questionnaire. Among the patients who were cognitively oriented according to the Short Portable Mental Status Questionnaire, the nurses’ assessment identified 97% as oriented, but among the patients with impaired cognitive ability according to the Short Portable Mental Status Questionnaire, only 58% were identified as being cognitively impaired by the ward nurses.

Conclusions.  An assessment of cognitive function is still lacking in nursing records for a substantial number of older people with a hip fracture and cognitive dysfunction is frequently underdiagnosed in routine health care.

Relevance to clinical practice. Patient care could be improved if the patients’ cognitive function was assessed regularly and objectively by means of a validated evaluation instrument.
Comparison between direct humidification and nebulization of the respiratory tract at mechanical ventilation: distribution of saline solution studied by gamma camera
Authors: Klockare Maria , Dufva Ann , Danielsson Anne‐Marie , Hatherly Robert , Larsson Stig , Jacobsson Hans , Mure Margareta
Published: February 2006

Aim.  To study the effectiveness of this procedure, an intra‐individual pilot study comparing the distribution of an instilled radiolabelled saline solution and an inhaled nebulized radiolabelled saline solution was performed using a scintigraphic technique.

Background.  In patients treated with mechanical ventilation, we have routinely used instillation of saline solution in the endotracheal tube before suctioning with the aim of softening mucus and facilitating removal of secretions. In our experience, the effectiveness of this procedure is doubtful. It may also have adverse effects.

Methods.  Nine patients on mechanical ventilation were examined with Single Photon Emission Computed Tomography on the same occasion using both humidification methods. The entire examination was carried out with the patient kept in a constant position in relation to the gamma camera, thereby allowing subtraction of the first registration from the second registration and subsequent evaluation and digital comparison of the two humidification methods.

Results.  Most of the instilled fluid goes to the posterior portion of the right lower pulmonary lobe. Compared with direct instillation, nebulized solution is more uniformly distributed between and within the lungs. With nebulization, distribution is less influenced by gravitation than with instillation. The aerosol reaches the periphery of the lung to a larger extent.

Conclusions.  Through the use of an aerosol with specific size characteristics, it may be possible to optimize the distribution of a fluid in the respiratory tract and achieve a more homogenous humidification. It is recommended to replicate the study using 25 subjects.

Relevance to clinical practice.  Direct instillation of saline should not be used with mechanical ventilation.
Psychological approaches to chronic pain management: part 1
Authors: Adams Nicola , Poole Helen , Richardson Clifford
Published: February 2006

Aims and objectives.  The aim of this paper is to provide an overview of the theoretical basis and application of psychological interventions used in the management of chronic pain. In doing this, psychological factors mediating pain and disability will also be reviewed.

Background.  A biopsychosocial model of chronic pain is widely purported and pain management is often based upon cognitive–behavioural principles as psychological factors meditating pain and disability have been found to include emotional, cognitive and behavioural components.

Conclusions.  This paper provides support for a biopsychosocial model of and for the effectiveness and efficacy of psychological interventions for the management of chronic pain conditions.

Relevance to clinical practice.  The application of psychological approaches to chronic pain management is reviewed and discussed. The way in which psychological approaches may be integrated specifically into nursing management of chronic pain is discussed in a later paper.
The Acute Care Nurse Practitioner: challenging existing boundaries of emergency nurses in the United Kingdom
Authors: Norris Tracey , Melby Vidar
Published: February 2006

Aim.  This study explored the opinions of nurses and doctors working in emergency departments towards the development of the Acute Care Nurse Practitioner service in the United Kingdom.

Background.  Studies carried out in the United States and Canada suggest that the Acute Care Nurse Practitioner can have a positive impact on the critically ill or injured patients’ experiences in the emergency department. This role is well developed in the United States and Canada, but is still in its infancy in the United Kingdom.

Design and methods.  A descriptive, exploratory design incorporating questionnaires (n = 98) and semi‐structured interviews (n = 6) was employed. The sample included nurses and doctors from seven emergency departments and minor injury units.

Results.  Respondents felt it was important for the Acute Care Nurse Practitioner to have obtained a specialist nurse practitioner qualification and that the Acute Care Nurse Practitioner should retain a clinical remit. While participants seemed comfortable with nurses undertaking traditional advanced skills such as suturing, reluctance was displayed with other advanced skills such as needle thoracocentesis. Three main themes were identified from the interviews: inter‐professional conflict, autonomy and the need for the Acute Care Nurse Practitioner.

Discussions.  Doctors were reluctant to allow nurses to practise certain additional advanced skills and difficulties appear to be centred on the autonomy and other associated inter‐professional conflicts with the role of the Acute Care Nurse Practitioner.

Conclusion.  Nurses and doctors identified a need for the Acute Care Nurse Practitioner, but the blurring of boundaries between doctors and nurses can result in inter‐professional conflict unless this is addressed prior to the introduction of such advanced practitioners.

Relevance to clinical practice.  As the role of the emergency nurse diversifies and expands, this study re‐affirms the importance of inter‐professional collaboration when seeking approval for role expansions in nursing.
Teamwork in the operating theatre: cohesion or confusion?
Authors: Undre Shabnam , Sevdalis Nick , Healey Andrew N. , Darzi Sir Ara , Vincent Charles A.
Published: February 2006

Rationale  The aim of the research that we report here was to empirically assess the cohesiveness of the multidisciplinary operating theatre (OT) team.

Method  We used concepts from the team performance and team mental models literature to assess OT professionals’ perceptions of their teamwork, the structure of their teams and their respective roles within them and their teams’ performance.

Results  Team structure: OT professionals would welcome a change from the current structure of the team, although there was no agreement on what that structure is. Nurses perceived the team as unitary, surgeons and anaesthetists perceived it as comprising multiple subteams. Team roles: OT professionals tended to overrate their own understanding of their colleagues’ role in the OT relative to the role understanding that the colleagues attributed to them. This tendency was especially marked for the surgeons. Team communication and team performance: OT professionals agreed on the relative importance of the various communicating pairs in the OT. Moreover, they were satisfied with the quality of communication among them, except for the communication between the surgeon and the anaesthetist, which received lower ratings. Finally, the quality of the teamwork in the OT was deemed acceptable, although there is room for improvement.

Conclusions  The OT environment need not be as cohesive as previously assumed – a finding that carries implications for the effectiveness of team training interventions. Further research is needed in order to fully comprehend the dynamics of the OT as a working environment and, most importantly, their relation to patient safety.
Evaluating disease management programme effectiveness: an introduction to instrumental variables
Authors: Linden Ariel , Adams John L.
Published: February 2006

This paper introduces the concept of instrumental variables (IVs) as a means of providing an unbiased estimate of treatment effects in evaluating disease management (DM) programme effectiveness. Model development is described using zip codes as the IV. Three diabetes DM outcomes were evaluated: annual diabetes costs, emergency department (ED) visits and hospital days. Both ordinary least squares (OLS) and IV estimates showed a significant treatment effect for diabetes costs (P = 0.011) but neither model produced a significant treatment effect for ED visits. However, the IV estimate showed a significant treatment effect for hospital days (P = 0.006) whereas the OLS model did not. These results illustrate the utility of IV estimation when the OLS model is sensitive to the confounding effect of hidden bias.
The impact of implantable cardiac defibrillators for primary prophylaxis in the community: baseline risk and clinically meaningful benefits
Authors: Jolly S. , Dorian P. , Alter D. A.
Published: February 2006

Objective  To estimate the baseline risk of arrhythmic death required for prophylactic implantable cardiac defibrillators (ICDs) to result in clinically meaningful survival benefits in the population.

Background  While proven efficacious, the absolute survival impact of ICDs for the primary prevention of sudden cardiac death among patients with left ventricular (LV) dysfunction is highly dependent upon patient's baseline risk of arrhythmic death.

Methods  Using echocardiographic data from a random sample of patients identified from community echocardiographic laboratories, patients with moderate or severe LV dysfunction (ejection fraction < 35%) were linked to administrative databases to characterize baseline mortality risk (median follow‐up duration of 4.85 years). Relative efficacy was ascertained from meta‐analysis and clinical trial data. The baseline annual risk of arrhythmic death required for prophylactic ICDs to result in clinically meaningful survival benefits in the population was estimated at different ranges of relative efficacy and numbers needed to treat (NNTs) thresholds.

Results  LV dysfunction was a significant independent predictor of adverse outcomes. In total, 35.4% of the patients with moderate to severe LV dysfunction died during the follow‐up period. Assuming a base‐case relative efficacy of 66%, we estimated that the baseline risk for arrhythmic death required to exert a clinically meaningful NNT threshold of 50 in order to prevent one death (from any cause) was 3% per year or higher.

Conclusions  The survival impact and cost‐effectiveness of prophylactic ICDs in the population will depend upon the ability to risk‐stratify and identify patients whose baseline risk for sudden cardiac death exceed 3% per year.
Compliance to surgical and radiation treatment guidelines in relation to patient outcome in early stage endometrial cancer
Authors: Lankveld Marieke AL van , Koot Nicole CM , Peeters Petra HM , Schagen van Leeuwen Jules , Jürgenliemk‐Schulz Ina M , Eijkeren Marion A van
Published: February 2006

Rationale, aims and objectives  We evaluated the adherence to treatment guidelines in early stage endometrial cancer and the influence of adherence to guidelines on overall survival.

Method  Patients were identified in the central region in the Netherlands from 1990 till 1995. Patient and tumour characteristics, surgical findings, radiation and follow‐up data were abstracted from medical records. Endpoint was overall survival. Kaplan‐Meier method was used to perform time‐to‐event analysis. Hazard ratios for overall survival were estimated with a Cox Proportional Hazards model.

Results  359 patients were eligible for analysis. 335 patients presented with a clinical stage I cancer. 333 patients underwent a Total Abdominal Hysterectomy with Bilateral Salpingo Oophorectomy (TAH/BSO), of which 301 were staged as International Federation of Gynaecology and Obstetrics (FIGO) stage I, whereas 34 (10.2%) as FIGO stage II. Of the 24 patients with a clinical stage II cancer, 12 underwent a Radical Hysterectomy with Pelvic Lymph Node Dissection (RH/PLND), of which seven were diagnosed with FIGO stage II. In 72.1% of the patients adjuvant radiation was given or not in adherence to the guidelines. Whether treatment was given according to the guidelines or not did not affect 5 years overall survival.

Conclusion  This suggests that extensive surgical procedures are redundant in the treatment of occult stage II endometrial cancer.
Evaluation of a national quality use of medicines service in Australia: an evolving model
Authors: Beilby Justin , Wutzke Sonia E. , Bowman Jenny , Mackson Judith M , Weekes Lynn M.
Published: February 2006

Rationale  To describe the first phase of a global evaluation framework for the National Prescribing Service (NPS), with a focus on services for health professionals, and in particular highlight the lessons learnt from evaluation around the establishment and implementation of this national pragram.

Methods  The agreed evaluation framework used mixed methods focused around a series of evaluation questions, aimed at measuring the overall effect of this new organization as well as the individual pragrams within it. The evaluation questions were determined a priori and were based on the objectives established by the organization in its first year of operation. A detailed analyses has been completed of: the process, scope and reach of pragram delivery using both quantitative and qualitative measures; changes in attitudes and knowledge measured through key informant interviews and surveys of professional groups and consumers; and changes in prescribing behaviour and savings to the Pharmaceutical Benefits Scheme (PBS) through analysis of prescription data. The evaluation period for this report was mid‐1998 to mid‐2004.

Results  The NPS has successfully implemented a complex, multi‐facted pragram across Australia. From 1998 to 2004, in addition to print material provided to all general practitioners (GPs) and pharmacists, 90% of all GPs have been actively involved in one or more educational activity; 116 of 120 divisions of general practice have coordinated local NPS pragrams; and 9% of pharmacists have actively participated in at least one educational activity. Sixty per cent of GPs and pharmacists rated the printed educational materials as good or very good. In the last three years, the NPS activities have generated savings in the range of $121–163 million to the PBS, owing to changes in prescribing practices.

Conclusion  The national evaluation framework has informed pragram delivery and ongoing design and development. Continued refinement of existing evaluation methods and further exploration of new techniques will remain a priority for the organization.
Professional approaches to stroke treatment in Japan: a relationship‐centred model
Authors: Slingsby Brian Taylor
Published: February 2006

Rationale  To examine how stroke professionals in Japan approach rehabilitation therapy.

Methods  This qualitative study was based on Grounded Theory. Data collection included (1) non‐participatory observation, (2) non‐structured interviews, and (3) semi‐structured interviews. A national hospital located in an urban area of the prefecture of Kanagawa in Japan specializing in the treatment of stroke and other neurological disorders. Stroke professionals (doctors, nurses, clinical psychologists, physiotherapists, occupational therapists and speech therapists), patients and patients’ families.

Results  (1) Professionals recognized patient motivation as a factor related to rehabilitation outcome, but believed it to be a direct product of fostered fiduciary relationships and effective patient interaction. (2) Professionals regarded fiduciary relationships as the most important determinant of rehabilitation outcome. (3) Professionals adapted their behaviour and communication style in aims of fostering fiduciary relationships. These findings informed a three‐component model of care: the Relationship‐centred Model.

Conclusions  The Relationship‐centred Model describes how stroke professionals in Japan approach rehabilitative therapy. This model of care may be preferred by patients in other countries who also favour a family‐centred approach to decision making.