Vitamin D enhances reactive oxygen intermediates production in phagocytic cells in term and preterm infants.

BACKGROUND: Newborn infants are endotoxin tolerant which may be responsible for their increased susceptibility to bacterial sepsis. Vitamin D has an immunomodulatory effect and newborn infants are at risk of vitamin D deficiency. We examined the in vitro effect of 1, 25-dihydroxyvitamin D (1,25OHD) on whole blood phagocytic toll-like receptor 4 (TLR4), CD11b, and reactive oxygen intermediates (ROIs) in newborn infants during sepsis. METHODS: Whole blood from preterm infants <32-wk gestation, control term neonates, and adults were sampled for phagocytic expression of ROI, TLR4, CD11b in response to lipopolysaccharide (LPS), and 1,25OHD using flow cytometer. RESULTS: ROI production from newborn phagocytes incubated with LPS alone was decreased. Pretreatment with 1,25OHD demonstrated increased (P = 0.001) phagocytic ROI production in newborns but not in adults. 1,25OHD did not have any effect on TLR4 and CD11b in both newborns and adults. Pretreatment with ROI inhibitors (apocynin (APO) and diphenyleneiodonium), phosphoinositide 3-kinase (PI3K) inhibitor, and p38 inhibitor blocked neutrophil ROI production. CONCLUSION: Neonatal phagocytic cells had diminished ROI production in the presence of LPS, however, pretreatment with 1,25OHD reversed this hyporesponsiveness. This action by 1,25OHD was mediated by activation of nicotinamide adenine dinucleotide phosphate oxidase system through PI3K signaling enzymes.

Illumination system for corneal collagen crosslinking.

PURPOSE: We have designed and constructed an ultraviolet (UV) illumination system for use in corneal collagen crosslinking (CXL) procedures. CXL is a recently developed procedure to treat Keratectasia such as Keratoconus and Pellucid Marginal Degeneration. The role of the illumination system is to safely provide UV light at the absorption peak of the Riboflavin photosensitizer, which generates reactive oxygen species and subsequently increases the number of covalent bonds between collagen fibrils. METHODS: Raytracing simulations were used to compare various optical designs for the illumination system. Alternative layouts are presented and design compromises between competing goals are discussed in reference to safety and practical considerations for clinical use. The mechanical mounting system and the beam output power and beam diameter testing system are briefly described. RESULTS: The illumination system has several features that help provide uniform effectivity of the applied treatment over the desired treatment diameter, assuming Riboflavin has uniform absorption in the treatment zone. The optical design offers substantially greater beam control and safety than rudimentary devices relying on direct illumination. The prototype was relatively inexpensive to construct and includes a mounting system and beam testing setup. CONCLUSIONS: The UV illumination system was found to be successful in providing a balanced solution regarding clinical use and the eye safety issues relevant to CXL.

William Howard Guest Rees.

A distinguished vet who became the UK's chief veterinary officer, dealing with issues such as salmonella in eggs and bovine spongiform encephalopathy. His passions were his family and rugby.

Assessing the Registered Nursing Care Contribution for older people in care homes: issues of reliability and validity.

The present paper reports on a study designed to investigate the validity and reliability of the Registered Nursing Care Contribution (RNCC) tool for assessing the level of nursing care required by care home residents. Care plan data from 186 residents in participating care homes were assessed by multiple assessors using the RNCC tool (i.e. care home registered nurses, a nurse researcher, an external care home expert and a nurses consultant). The Minimum Data Set (MDS) rating was used as a validated comparison. The findings from the study indicated that there were disparities between the RNCC and MDS bandings, and between different raters, with the external care home expert achieving the closest agreement with the MDS. This suggests that the use of the RNCC tool varies considerably according to the assessor, which also suggests that training of users is needed to ensure consistency and reliability. However, the difference between the outcomes of using the RNCC tool and the MDS suggests that assessment of nursing need may need to be re-examined to ensure validity.

Using randomised controlled trials (RCTs) to test service interventions: issues of standardisation, selection and generalisability.

The commissioning of healthcare services is increasingly linked to the availability of rigorous evidence of clinical and cost effectiveness. In the current climate, 'rigorous evidence' is synonymous with the randomised controlled trial (RCT). Consequently, health technologies are often funded in preference to service developments due to an imbalance in the availability of strong evidence to support service developments. Simultaneously, there is an increasing policy emphasis on patient choice and individualized care in the NHS. In this paper Bill Watson, Susan Procter and Wendy Cochrane discuss the implications of using experimental methods in service development research, with reference to an ongoing RCT evaluating the component parts of pulmonary rehabilitation in people with chronic obstructive pulmonary disease (COPD).

A community outreach service for people with COPD.

This paper describes the development and evaluation of a nurse-led interagency community outreach service for patients with chronic obstructive pulmonary disease. The service improved the quality of life of the patients who accessed it. However, difficulties in maintaining the service arose from the historical structure of care delivery and policy frameworks.

Understanding distress in people with severe communication difficulties: developing and assessing the Disability Distress Assessment Tool (DisDAT).

BACKGROUND: Meaningful communication with people with profound communication difficulties depends on the ability of carers to recognize and translate many different verbal cues. Carers appear to be intuitively skilled at identifying distress cues, but have little confidence in their observations. To help in this process, a number of pain tools have been developed, but this sits uncomfortably with the lack of evidence that pain has any specific signs or behaviours. A palliative care team working with people with intellectual disabilities developed the Disability Distress Assessment Tool (DisDAT) to document a wide range of signs and behaviours of distress and when an individual is content. METHOD: The tool was piloted with 16 carers and 8 patients. It was then assessed using quantitative and qualitative methods, employing 56 carers in routine clinical situations with 25 patients, most with severe communication difficulties. Carers of 10 patients participated in semi-structured interviews exploring the signs and behaviours demonstrated by patients when distressed and when content. These same 10 patients were observed for distress cues during different activities. RESULTS: It became clear that distress did not have a common meaning among carers, but there was a clear understanding that distress did not just cover physical pain. The range of distress cues was wide, with no evidence that any cues were specific to particular causes. Although some distress cues were common between patients, each patient had a distinct pattern of distress cues. In addition, different carers identified a different range of distress cues, while the length of the relationship did not influence the number of cues identified. Most distress cues were a change from the norm, but some patients demonstrated distress as an absence of content cues. Carers found the DisDAT simple to use and useful, and several felt that DisDAT would have helped advocate for the patients in previous conflicts with clinical teams. CONCLUSIONS: There was no evidence that pain has any specific signs or behaviours. The preliminary and assessment phases showed that distress was a useful clinical construct in providing care. The DisDAT reflected patients' distress communication identified by a range of carers, and provided carers with evidence for their intuitive observations of distress.

The SEIQoL and functional status: how do they relate?

Over recent years, an emphasis has emerged in the UK and international policy documents, over the involvement of people in the delivery of health care. However, evaluations of health services still largely rest on outcome measures that reflect professional concerns. As new health services are being developed, new patient-centred outcome measures are needed to evaluate them. This paper aims at exploring the possibility of individual quality of life as an outcome measure for health services. As a first step, it aims to elucidate the relationship of functional outcome measures to the Schedule for the Evaluation of Individual Quality of Life (SEIQoL) in groups of people whose age or medical diagnosis serve as the basis for health service design. Its objectives are to study the relation of SEIQoL scores and life areas to functional status in an older population and in a group of people with chronic obstructive pulmonary disease (COPD). Older people selected their health most frequently as one of the most important areas in their life (9.9%, vs. 8.6% for people with COPD) and were more satisfied with it (U = 2,512, p = 0.007). People's health status did not impact on the way they defined their quality of life, but on their level of satisfaction with discrete life areas. The weights attributed to health were significantly negatively correlated to people's overall quality of life score in the overall sample (rho = -0.34, p < 0.001). In the light of recent national and international policy documents advocating for the development of new, more person-centred health services, our results support the proposition of the authors of SEIQoL, that individual quality of life measures have the potential to bring a significant contribution to the evaluation of health services.

Exploratory factor analysis of the Research and Development Culture Index among qualified nurses.

AIMS AND OBJECTIVES: This paper presents the exploratory factor analysis of a rating instrument for assessing the strength of organizational Research and Development (R&D) culture. BACKGROUND: Despite nursing's limited research capacity, the discipline is capitalizing upon opportunities to become involved in research and is making strong progress. Within the context of the debate on nursing research capacity, the R&D Culture Index was developed as a means of appraising R&D culture within health care organizations. DESIGN: Factor analysis was carried out on data collected from 485 nursing staff. The method of extraction was Principal Components Analysis with oblique rotation. METHODS: The Index was developed from the findings of qualitative research conducted with NHS staff. Eighteen items, encompassing the main themes from the data, were initially included in the Index. This pilot instrument was distributed to nursing staff within three different types of NHS Trust. Factor analysis resulted in rejection of two items and the analysis was repeated using the remaining 16 items. RESULTS: Three latent factors were extracted accounting for 58.0% of the variance in the data. The factors were: R&D Support, describing the perceived support within the working environment for R&D activity; Personal R&D Skills and Aptitude, describing an individual's perception of their ability towards R&D activity; and Personal R&D Intention, describing an individual's willingness to engage in R&D activity. Each factor had good internal reliability, as did the overall index. CONCLUSION: The R&D Culture Index provides an efficient means of assessing the strength of an organization's R&D culture in a way that captures the role of the individual practitioner and the organizational environment. RELEVANCE TO PRACTICE: These findings suggest that the continuing promotion of R&D within health care organizations is dependent upon a multi-faceted approach that addresses the learning needs of the organization as well as those of the individual practitioners.