Outcomes for Pressure Ulcer Trials (OUTPUTs) project: review and classification of outcomes reported in pressure ulcer prevention research.

In order to overcome inconsistencies in the reporting of outcomes in clinical trials, core outcome sets (COSs) have been developed in many clinical areas and the awareness of this concept is growing steadily. The Outcomes for Pressure Ulcer Trials (OUTPUTs) project aims to improve the quality of evidence from pressure ulcer prevention trials by developing a COS. As an initial step in the COS process we aimed to identify and classify both outcomes and concepts that represent potential outcomes for future trials that have been reported in pressure ulcer prevention research. A review was conducted in 12 major databases covering the literature indexed until 2016. Outcomes and relevant concepts reported in primary studies and/or reviews on pressure ulcer prevention in adult patients were extracted as presented in the articles, and afterwards inductively grouped into outcome domains. The domains were then categorized according to the outcome domain taxonomy recently proposed by the COMET group. In total 332 studies were included and 68 outcome domains were identified, covering multiple aspects of pressure ulcer prevention. Pressure ulcer occurrence was reported in 71% of all included studies, representing the most frequent outcome, followed by costs (22% of all studies) and acceptability of intervention and comfort (18% of all studies). A plethora of different outcomes are applied in pressure ulcer prevention research and substantial variations in definitions and reporting of similar outcomes were observed. A COS for pressure ulcer prevention trials is needed to overcome the noncomparability of outcomes.

Silicone adhesive multilayer foam dressings as adjuvant prophylactic therapy to prevent hospital-acquired pressure ulcers: a pragmatic noncommercial multicentre randomized open-label parallel-group medical device trial.

BACKGROUND: Silicone adhesive multilayer foam dressings are used as adjuvant therapy to prevent hospital-acquired pressure ulcers (PUs). OBJECTIVES: To determine whether silicone foam dressings in addition to standard prevention reduce the incidence of PUs of category 2 or worse compared with standard prevention alone. METHODS: This was a multicentre, randomized controlled medical device trial conducted in eight Belgian hospitals. At-risk adult patients were centrally randomized (n = 1633) to study groups based on a 1 : 1 : 1 allocation: experimental groups 1 (n = 542) and 2 (n = 545) - pooled as the treatment group - and the control group (n = 546). The experimental groups received PU prevention according to hospital protocol, and a silicone foam dressing on the relevant body sites. The control group received standard of care. The primary endpoint was the incidence of a new PU of category 2 or worse at the studied body sites. RESULTS: In the intention-to-treat population (n = 1605), PUs of category 2 or worse occurred in 4·0% of patients in the treatment group and 6·3% in the control group [relative risk (RR) 0·64, 95% confidence interval (CI) 0·41-0·99, P = 0·04]. Sacral PUs were observed in 2·8% and 4·8% of the patients in the treatment group and the control group, respectively (RR 0·59, 95% CI 0·35-0·98, P = 0·04). Heel PUs occurred in 1·4% and 1·9% of patients in the treatment and control groups, respectively (RR 0·76, 95% CI 0·34-1·68, P = 0·49). CONCLUSIONS: Silicone foam dressings reduce the incidence of PUs of category 2 or worse in hospitalized at-risk patients when used in addition to standard of care. The results show a decrease for the sacrum, but no statistical difference for the heel and trochanter areas.

Standardizing the classification of skin tears: validity and reliability testing of the International Skin Tear Advisory Panel Classification System in 44 countries.

BACKGROUND: Skin tears are acute wounds that are frequently misdiagnosed and under-reported. A standardized and globally adopted skin tear classification system with supporting evidence for diagnostic validity and reliability is required to allow assessment and reporting in a consistent way. OBJECTIVES: To measure the validity and reliability of the International Skin Tear Advisory Panel (ISTAP) Classification System internationally. METHODS: A multicountry study was set up to validate the content of the ISTAP Classification System through expert consultation in a two-round Delphi procedure involving 17 experts from 11 countries. An online survey including 24 skin tear photographs was conducted in a convenience sample of 1601 healthcare professionals from 44 countries to measure diagnostic accuracy, agreement, inter-rater reliability and intrarater reliability of the instrument. RESULTS: A definition for the concept of a 'skin flap' in the area of skin tears was developed and added to the initial ISTAP Classification System consisting of three skin tear types. The overall agreement with the reference standard was 0·79 [95% confidence interval (CI) 0·79-0·80] and sensitivity ranged from 0·74 (95% CI 0·73-0·75) to 0·88 (95% CI 0·87-0·88). The inter-rater reliability was 0·57 (95% CI 0·57-0·57). The Cohen's Kappa measuring intrarater reliability was 0·74 (95% CI 0·73-0·75). CONCLUSIONS: The ISTAP Classification System is supported by evidence for validity and reliability. The ISTAP Classification System should be used for systematic assessment and reporting of skin tears in clinical practice and research globally. What's already known about this topic? Skin tears are common acute wounds that are misdiagnosed and under-reported too often. A skin tear classification system is needed to standardize documentation and description for clinical practice, audit and research. What does this study add? The International Skin Tear Advisory Panel Classification System was psychometrically tested in 1601 healthcare professionals from 44 countries. Diagnostic accuracy was high when differentiating between type 1, 2 and 3 skin tears using a set of validated photographs.

Core elements of the interpersonal care relationship between nurses and older patients without cognitive impairment during their stay at the hospital: A mixed-methods systematic review.

BACKGROUND: The fundamental importance of establishing an interpersonal care relationship for quality nursing care has been highlighted. However specific elements of the interpersonal care relationship of importance to older patients in the hospital have not been identified. OBJECTIVES: The aim of this review was to explore and synthesise research findings regarding the elements of the interpersonal care relationship concept from the perspectives of older patients. DESIGN: A systematic mixed-methods review. DATA SOURCES: An extensive search was conducted up until October 2018 for articles without any publication date time limit in PubMed, Web of Science, Cochrane Database of Systematic Reviews and CINAHL. REVIEW METHODS: Primary studies were included if they concerned patients aged 65 years or older and their perspectives on the elements of the interpersonal care relationship with nurses. Inclusion was limited to patients without cognitive impairment who were admitted to an acute hospital setting. The methodological quality of each study was assessed using the Critical Appraisal Skills Programme for qualitative studies, the Quality Assessment Tool for Quantitative Studies and the Mixed-Methods Appraisal Tool. Thematic analysis was used to structure the results of the included studies. RESULTS: Of the 7596 studies found, 24 were included in this review. Twenty articles had a qualitative, three a quantitative and one a mixed methods design. Older patients consider dignity and respect as core values that need to be met in the interpersonal care relationship. Five core elements of the interpersonal care relationship were identified to meet these core values: elements related to caring behaviour and attitude, person-centred care, patient participation, communication and situational aspects. These core elements were structured according to three categories, identified in the literature, that determine the quality of the interpersonal care relationship: nurse-, older-patient-related elements and situational aspects. CONCLUSIONS: The elements identified in this review can guide efforts to define the interpersonal care relationship between older patients and nurses. Nurses should be supported and motivated by education and practice to adapt their behaviour, attitudes and communication to meet older patients' expectations. Hospital management can also encourage nurses to communicate well. Investment in the current organisation of care is needed to improve nurses' work overload and presence. Further research is needed to clarify the underlying processes influencing the experience of the interpersonal care relationship from the perspectives of older patients, nurses, informal caregivers and hospital management.

Core outcome sets in dermatology: report from the second meeting of the International Cochrane Skin Group Core Outcome Set Initiative.

Results of clinical trials are the most important information source for generating external clinical evidence. The use of different outcomes across trials, which investigate similar interventions for similar patient groups, significantly limits the interpretation, comparability and clinical application of trial results. Core outcome sets (COSs) aim to overcome this limitation. A COS is an agreed standardized collection of outcomes that should be measured and reported in all clinical trials for a specific clinical condition. The Core Outcome Set Initiative within the Cochrane Skin Group (CSG-COUSIN) supports the development of core outcomes in dermatology. In the second CSG-COUSIN meeting held in 2017, 11 COS development groups working on skin diseases presented their current work. The presentations and discussions identified the following overarching methodological challenges for COS development in dermatology: it is not always easy to define the disease focus of a COS; the optimal method for outcome domain identification and level of detail needed to specify such domains is challenging to many; decision rules within Delphi surveys need to be improved; appropriate ways of patient involvement are not always clear. In addition, there appear to be outcome domains that may be relevant as potential core outcome domains for the majority of skin diseases. The close collaboration between methodologists in the Core Outcome Set Initiative and the international Cochrane Skin Group has major advantages for trialists, systematic reviewers and COS developers.

Towards an international language for incontinence-associated dermatitis (IAD): design and evaluation of psychometric properties of the Ghent Global IAD Categorization Tool (GLOBIAD) in 30 countries.

BACKGROUND: Incontinence-associated dermatitis (IAD) is a specific type of irritant contact dermatitis with different severity levels. An internationally accepted instrument to assess the severity of IAD in adults, with established diagnostic accuracy, agreement and reliability, is needed to support clinical practice and research. OBJECTIVES: To design the Ghent Global IAD Categorization Tool (GLOBIAD) and evaluate its psychometric properties. METHODS: The design was based on expert consultation using a three-round Delphi procedure with 34 experts from 13 countries. The instrument was tested using IAD photographs, which reflected different severity levels, in a sample of 823 healthcare professionals from 30 countries. Measures for diagnostic accuracy (sensitivity and specificity), agreement, interrater reliability (multirater Fleiss kappa) and intrarater reliability (Cohen's kappa) were assessed. RESULTS: The GLOBIAD consists of two categories based on the presence of persistent redness (category 1) and skin loss (category 2), both of which are subdivided based on the presence of clinical signs of infection. The agreement for differentiating between category 1 and category 2 was 0·86 [95% confidence interval (CI) 0·86-0·87], with a sensitivity of 90% and a specificity of 84%. The overall agreement was 0·55 (95% CI 0·55-0·56). The Fleiss kappa for differentiating between category 1 and category 2 was 0·65 (95% CI 0·65-0·65). The overall Fleiss kappa was 0·41 (95% CI 0·41-0·41). The Cohen's kappa for differentiating between category 1 and category 2 was 0·76 (95% CI 0·75-0·77). The overall Cohen's kappa was 0·61 (95% CI 0·59-0·62). CONCLUSIONS: The development of the GLOBIAD is a major step towards a better systematic assessment of IAD in clinical practice and research worldwide. However, further validation is needed.

The prevalence of unplanned pregnancy ending in birth, associated factors, and health outcomes.

STUDY QUESTION: What are associated factors of unplanned pregnancies ending in birth? SUMMARY ANSWER: Pregnancies that were less planned were associated with women of lower socio-economic status (SES), an unhealthier lifestyle before and during the pregnancy, more stress, and less social support. WHAT IS KNOWN ALREADY: In Europe, the prevalence of unplanned pregnancy leading to birth varies. Unplanned pregnancy is more common among socially disadvantaged women, and associated with adverse pregnancy outcomes. STUDY DESIGN, SIZE, DURATION: In a cross-sectional study, 517 women were recruited from May through September 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women were recruited from six hospitals in Flanders, Belgium. Data from self-report and medical records were collected during the first 5 days postpartum. The validated London Measure of Unplanned Pregnancy was used to collect data regarding pregnancy planning. Data were analysed with Mann-Whitney U tests, Kruskal-Wallis tests, and multiple linear regression analysis. MAIN RESULTS AND THE ROLE OF CHANCE: The majority of the pregnancies (83%) ending in birth were planned, 15% were ambivalent, and 2% unplanned. Women who are multigravida (95% CI -0.30 to -0.02), less well educated (95% CI 0.07-0.85), single or having a non-cohabiting relationship (95% CI 0.01-2.53), having history of drug abuse (95% CI -2.07 to -0.35), and experiencing intimate partner violence (95% CI -3.82 to -1.59) tended to have a significantly higher risk of a less planned pregnancy. Less planned pregnancies were significantly associated with initially unwanted pregnancies (P < 0.001), no folic acid or vitamin use before pregnancy (P < 0.001), lower number of prenatal visits (P = 0.03), smoking during pregnancy (P < 0.001), more stress (P = 0.002), lower relationship satisfaction (P = 0.001), and less social support (P < 0.001). Less planned pregnancies were also significantly associated with hyperemesis (P < 0.001) and shorter duration of delivery (P = 0.03). No differences were found in neonatal outcomes. LIMITATIONS, REASONS FOR CAUTION: The prevalence of unplanned pregnancies is probably underestimated due to overrepresentation of women with higher SES in this study. Women's emotions may have influenced the answer to certain questions. Owing to the cross-sectional design, no causal relationships could be established. WIDER IMPLICATIONS OF THE FINDINGS: This study emphasizes the importance of targeting socially disadvantaged women in the prevention of unplanned pregnancies. STUDY FUNDING/COMPETING INTERESTS: This study was funded by the Research Foundation - Flanders (FWO). The authors have no conflict of interests. TRIAL REGISTRATION NUMBER: Not applicable.

Development of a Quality of Meals and Meal Service Set of Indicators for Residential Facilities for Elderly.

OBJECTIVES: To develop a content validated set of indicators to evaluate the quality of meals and meal service in residential facilities for elderly. Inadequate food intake is an important risk factor for malnutrition in residential facilities for elderly. Through better meeting the needs and preferences of residents and optimization of meals and meal service, residents' food intake can improve. No indicators were available which could help to guide strategies to improve the quality of meals and meal service. DESIGN: The indicator set was developed according to the Indicator Development Manual of the Dutch Institute for Health Care Improvement (CBO). The working group consisted of three nurse researchers and one expert in gastrology and had expertise in elderly care, malnutrition, indicator development, and food quality. A preliminary list of potential indicators was compiled using the literature and the working group's expertise. Criteria necessary to measure the indicator in practice were developed for each potential indicator. In a double Delphi procedure, the list of potential indicators and respective criteria were analyzed for content validity, using a multidisciplinary expert panel of 11 experts in elderly meal care. RESULTS: A preliminary list of 20 quality indicators, including 45 criteria, was submitted to the expert panel in a double Delphi procedure. After the second Delphi round, 13 indicators and 25 criteria were accepted as having content validity. The content validity index (CVI) ranged from 0.83 to 1. The indicator set consisted of six structural, four result, and three outcome indicators covering the quality domains food, service and choice, as well as nutritional screening. The criteria measure diverse aspects of meal care which are part of the responsibility of kitchen staff and health care professionals. CONCLUSION: The 'quality of meals and meal service' set of indicators is a resource to map meal quality in residential facilities for elderly. As soon as feasibility tests in practice are completed, the indicator set can be used to guide meal and meal service quality improvement projects in collaboration with kitchen staff and health care professionals. These improvement projects will help to improve food intake and reduce the risk of malnutrition among elders living in residential facilities.

Incontinence-associated dermatitis and pressure ulcers in geriatric patients.

The key characteristics of geriatric patients are advanced age, multimorbidity, a decrease of psychical performance and care dependency. In addition, advanced age, chronic and acute diseases and treatments (e.g. polypharmacy) lead, either directly or indirectly, to a wide range of skin and tissue problems. Incontinence-associated dermatitis and pressure ulcers (PUs) belong to the most prevalent in geriatric settings. Prolonged exposure of the skin to urine and/or stool can cause an irritant contact dermatitis. Skin surface 'wetness', increased skin surface pH, digestive intestinal enzymes, repeated skin cleansing activities, and a possible occlusive environment contribute to irritation and inflammation. Prevention and treatment includes activities to maintain and to enhance continence and to limit, to reduce exposure of the skin to urine and stool, and to promote healing and reepithelialisation. In frail aged skin, it is recommended to use incontinence products with smooth and breathable materials with maximum absorption capacity. Immediate skin cleansing after soiling using mild cleansers and protective and caring leave-on products are recommended. PUs are localized injuries to the skin and/or underlying tissue caused by sustained deformations of skin and underlying soft tissues. PUs management includes risk assessment, repositioning and mobilization, and the use of appropriate support surfaces. Patients must be never positioned directly on an existing PU. Especially at end of life, the PU closure and wound healing may not be the primary therapeutic goal.

Determinants and associated factors influencing medication adherence and persistence to oral anticancer drugs: a systematic review.

BACKGROUND AND AIMS: The use of oral anticancer drugs has increased in modern oncology treatment. The move from intravenous treatments towards oral anticancer drugs has increased the patients' own responsibility to take oral anticancer drugs as being prescribed. High rates of non-adherence to oral anticancer drugs have been reported. A systematic literature review was conducted to gain insight into determinants and associated factors of non-adherence and non-persistence in patients taking oral anticancer therapy. REVIEW METHODS: PubMed, Cochrane, Web of Science and Cinahl were systematically searched for studies focusing on determinants and associated factors of medication non-adherence and non-persistence to oral anticancer drugs. The methodological quality of the included studies was assessed by two independent reviewers. No studies were excluded based on the quality assessment. RESULTS: Twenty-five studies were included and systematically reviewed. The quality of the studies was moderate. Associated factors influencing medication non-adherence and non-persistence to oral anticancer drugs are multifactorial and interrelated. Older and younger age, and the influence of therapy related side effects were found to be predominant factors. CONCLUSION: Non-adherence and non-persistence to oral anticancer drug therapy are complex phenomena. More qualitative research is needed to facilitate the development of patient tailored complex interventions by exploring patients' needs and underlying processes influencing medication non-adherence and non-persistence to oral anticancer drugs.

Multi-stage versus single-stage inflation and deflation cycle for alternating low pressure air mattresses to prevent pressure ulcers in hospitalised patients: a randomised-controlled clinical trial.

INTRODUCTION: The duration and the amount of pressure and shear must be reduced in order to minimize the risk of pressure ulcer development. Alternating low pressure air mattresses with multi-stage inflation and deflation cycle of the air cells have been developed to relieve pressure by sequentially inflating and deflating the air cells. Evidence about the effectiveness of this type of mattress in clinical practice is lacking. AIM: This study aimed to compare the effectiveness of an alternating low pressure air mattress that has a standard single-stage inflation and deflation cycle of the air cells with an alternating low pressure air mattress with multi-stage inflation and deflation cycle of the air cells. METHODS AND MATERIALS: A randomised controlled trial was performed in a convenience sample of 25 wards in five hospitals in Belgium. In total, 610 patients were included and randomly assigned to the experimental group (n=298) or the control group (n=312). In the experimental group, patients were allocated to an alternating low pressure air mattress with multi-stage inflation and deflation cycle of the air cells. In the control group, patients were allocated to an alternating low pressure air mattress with a standard single-stage inflation and deflation cycle of the air cells. The outcome was defined as cumulative pressure ulcer incidence (Grade II-IV). An intention-to-treat analysis was performed. RESULTS: There was no significant difference in cumulative pressure ulcer incidence (Grade II-IV) between both groups (Exp.=5.7%, Contr.=5.8%, p=0.97). When patients developed a pressure ulcer, the median time was 5.0 days in the experimental group (IQR=3.0-8.5) and 8.0 days in the control group (IQR=3.0-8.5) (Mann-Whitney U-test=113, p=0.182). The probability to remain pressure ulcer free during the observation period in this trial did not differ significantly between the experimental group and the control group (log-rank χ(2)=0.013, df=1, p=0.911). CONCLUSION: An alternating low pressure air mattress with multi-stage inflation and deflation of the air cells does not result in a significantly lower pressure ulcer incidence compared to an alternating low pressure air mattress with a standard single-stage inflation and deflation cycle of the air cells. Both alternating mattress types are equally effective to prevent pressure ulcer development.

Protection of pigs against Chlamydia trachomatis challenge by administration of a MOMP-based DNA vaccine in the vaginal mucosa.

Plasmid DNA (pWRG7079::MOMP) expressing the major outer membrane protein of a human Chlamydia trachomatis serovar E strain was tested for the ability to induce an immune response and protect against experimental genital infection with the same serovar. The vaccine was tested in pigs, as they are genetically and physiologically related to humans and suitable for studying C. trachomatis infection of the genital system. To increase the immune response, GM-CSF, LTA and B and CpG motives were used as adjuvants. GM-CSF was administered seven days before immunization, while the other adjuvants were administered together with the vaccine. Ten pigs were randomly divided into two groups. One group received an intravaginal primo-vaccination and a booster of 500 µg pWRG7079::MOMP, while the other group received the placebo vaccine pWRG7079. All animals were challenged with 10(8) TCID(50) of C. trachomatis serovar E. Pigs immunized with the DNA vaccine showed significantly less macroscopic lesions, vaginal excretion and chlamydial replication in the genital tract, as compared to placebo-vaccinated controls. However, infection could not be completely cleared.

Chlamydophila psittaci in homing and feral pigeons and zoonotic transmission.

Chlamydiosis is a zoonotic disease in birds caused by Chlamydophila psittaci, an obligate intracellular bacterium. There are seven known avian outer-membrane protein A genotypes, A-F and E/B. The importance of genotyping lies in the fact that certain genotypes tend to be associated with certain hosts and a difference in virulence. Genotype B is the most prevalent in pigeons, but the more virulent genotypes A and D have also been discovered. The current study assessed the prevalence of C. psittaci in 32 Belgian homing-pigeon facilities and in 61 feral pigeons captured in the city of Ghent, Belgium. Additionally, zoonotic transmission of C. psittaci was investigated in the homing-pigeon facilities. Homing pigeons were often infected, as at least one of the lofts was positive in 13 of the 32 (40.6 %) pigeon breeding facilities. Genotypes B, C and D were detected. Zoonotic transmission was discovered in 4 of the 32 (12.5 %) pigeon fanciers, revealing genotype D in two of them, whilst genotyping was unsuccessful for the other two human pharyngeal swabs. This study clearly demonstrates the possible risk of C. psittaci zoonotic transmission from homing pigeons. Pigeon fanciers often (37.5 %) used antibiotics for prevention of respiratory disease. Because of the risk of developing drug-resistant strains, regular use of antimicrobial drugs must be avoided. This study is believed to be the first to detect C. psittaci in Belgian feral pigeons. The prevalence rate in the city of Ghent was extremely low, which is beneficial for public health.

Chlamydophila psittaci zoonotic risk assessment in a chicken and turkey slaughterhouse.

Chlamydophila psittaci causes respiratory disease in poultry and can be transmitted to humans. We conducted a C. psittaci zoonotic risk assessment study of a chicken and turkey slaughterhouse. Eighty-five percent of the slaughtered chicken flocks tested positive by PCR and culture. Genotype D was discovered. Fifty-seven percent of the slaughtered turkey flocks tested positive by PCR and culture. Genotype D was present. For the chicken slaughterhouse employees, 7.5% and 6% tested positive for C. psittaci by PCR and culture, respectively. In the turkey slaughterhouse, 87% and 61% of the employees tested positive by PCR and culture, respectively. All genotyped human samples contained genotype D. Using stationary bioaerosol monitoring by means of an MAS-100 ecosampler and ChlamyTrap collection medium, chlamydial DNA, and viable organisms were detected in both the chicken and turkey slaughterhouses. Positive air samples were most frequently found in the animal reception area and evisceration room. Zoonotic transmissions were very common, especially from processed turkeys. Accurate diagnostic monitoring and reporting of C. psittaci infections should be promoted in poultry workers.

Pressure ulcers: development and psychometric evaluation of the attitude towards pressure ulcer prevention instrument (APuP).

BACKGROUND: Pressure ulcers continue to be a significant problem in hospitals, nursing homes and community care settings. Pressure ulcer incidence is widely accepted as an indicator for the quality of care. Negative attitudes towards pressure ulcer prevention may result in suboptimal preventive care. A reliable and valid instrument to assess attitudes towards pressure ulcer prevention is lacking. AIMS AND OBJECTIVES: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP). DESIGN: Prospective psychometric instrument validation study. METHODS: A literature review was performed to design the instrument. Content validity was evaluated by nine European pressure ulcer experts and five experts in psychometric instrument validation in a double Delphi procedure. A convenience sample of 258 nurses and 291 nursing students from Belgium and The Netherlands participated in order to evaluate construct validity and stability reliability of the instrument. The data were collected between February and May 2008. RESULTS: A factor analysis indicated the construct of a 13 item instrument in a five factor solution: (1) attitude towards personal competency to prevent pressure ulcers (three items); (2) attitude towards the priority of pressure ulcer prevention (three items); (3) attitude towards the impact of pressure ulcers (three items); (4) attitude towards personal responsibility in pressure ulcer prevention (two items); and (5) attitude towards confidence in the effectiveness of prevention (two items). This five factor solution accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. All items demonstrated factor loadings over 0.60. The instrument produced similar results during stability testing [ICC=0.88 (95% CI=0.84-0.91, P<0.001)]. For the total instrument, the internal consistency (Cronbachs alpha) was 0.79. CONCLUSION: The APuP is a psychometrically sound instrument that can be used to effectively assess attitudes towards pressure ulcer prevention in patient care, education, and research. In further research, the association between attitude, knowledge and clinical performance should be explored.

Possible pathogenic interplay between Chlamydia suis, Chlamydophila abortus and PCV-2 on a pig production farm.

A concurrent outbreak of chlamydial disease in boars, sows and gilts and postweaning multisystemic wasting syndrome (PMWS) in weaned piglets was investigated on a large pig production farm in Estonia. Chlamydia suis DNA was detected in conjunctival swabs from boars, sows and gilts, but also in the faeces of boars and sows. Chlamydophila abortus DNA was found in semen, and in conjunctival swabs from sows; DNA was demonstrated by microarrays. Serum samples from boars were examined using a Chlamydiaceae-specific recombinant ELISA. All 10 serum samples examined were positive (1:960 to 1:3840). Chlamydiosis was characterised by reproductive failure and conjunctivitis. Piglets were not examined for Chlamydiaceae, as eye problems were not observed. Piglets showed wasting, respiratory signs, diarrhoea, enlargement of lymph nodes and increased mortality (10 per cent). Porcine circovirus type 2 (PCV-2) was detected in the lymph nodes of piglets by immunohistochemistry, and PCV-2 antibodies were demonstrated in all 10 serum samples from sows examined using an immunoperoxidase monolayer assay.

Pressure ulcer prevention: development and psychometric validation of a knowledge assessment instrument.

BACKGROUND: Profound knowledge of pressure ulcers is important to enable good prevention. Validity and reliability of instruments assessing pressure ulcer knowledge are limited evaluated in previous research. AIMS AND OBJECTIVES: To develop a valid and reliable instrument to assess knowledge of pressure ulcer prevention. DESIGN: Prospective psychometric instrument validation study. METHODS: An extensive literature review was performed to develop an instrument to assess knowledge of pressure ulcer prevention. Face and content validity were evaluated in a double Delphi procedure by an expert panel of nine trustees of the European Pressure Ulcer Advisory Panel (EPUAP) who each have extensive experience in pressure ulcer care and research (PhD level). A convenience sample of 608 nurses and nursing students from Belgium and The Netherlands participated to evaluate validity of the multiple-choice test items (item difficulty, discriminating index, quality of the response alternatives), construct validity, internal consistency, and stability of the instrument. The data were collected between February and May 2008. RESULTS: A 26-item instrument was developed, reflecting 6 themes expressing the most relevant aspects of pressure ulcer prevention. The content validity was excellent (CVI=0.78-1.00). Group scores of nurses with a (theoretically expected) high level of expertise were found to be statistically significantly higher than those of participants with (theoretically expected) less expertise (P<0.001). The item difficulty index of the questions ranged from 0.27 to 0.87, while values for item discrimination ranged from 0.29 to 0.65. The quality of the response alternatives was found to be good. The overall internal consistency reliability (Cronbach's alpha) was 0.77. The 1-week test-retest intraclass correlation coefficient (stability) was 0.88. CONCLUSION: The instrument demonstrated acceptable psychometric properties and can be applied in both research and practice for evaluating knowledge about pressure ulcer prevention.

Zoonotic Chlamydophila psittaci infections from a clinical perspective.

Human psittacosis is a zoonotic infectious disease which is caused by the obligate intracellular bacterium Chlamydophila psittaci. Transmission of the disease usually originates from close contact with infected birds, most frequently in the context of the poultry industry, and from contact with Psittaciformes (cockatoos, parrots, parakeets and lories). Due to a low awareness of the disease and a variable clinical presentation psittacosis is often not recognised as such by general practitioners. This review therefore gives an overview of the epidemiology, symptoms, diagnosis and possible treatments for psittacosis in humans. The current case definition for epidemiological surveillance, as issued by the CDC, is discussed, as well as the possible emergence of Cp. psittaci antibiotic-resistant strains. There is an urgent need for information and for awareness campaigns directed at professional health care workers and the general public. In addition, a broader use of new diagnostic methods in medical laboratories and the development of prophylactics are called for.

Evaluation of proposed methods to update human testing of self-contained breathing apparatus.

The current Man Test protocols used by the National Institute for Occupational Safety and Health for the certification testing of self-contained breathing apparatus (SCBA) do not provide continuous real-time information on the performance of these devices during actual use. In addition, current protocols do not test human subjects at the same absolute work rates but at rates that vary according to the subjects' body weights. This study was conducted to evaluate revised "Use Test" protocols proposed by the U.S. Bureau of Mines, which are normalized to subjects' body weights. No differences in duration were observed among the three body weight categories for the multiple work rate. Use Test 2. It was concluded that the proposed Use Test protocols could form the basis for eventual recommendations to revise the current Man Tests for SCBA performance evaluation.