Structural chemistry of polycyclic heteroaromatic compounds. Part 13. Photoelectron spectra and electronic structures of tricyclic hetarenes of the anthracene type.

The ultraviolet photoelectron spectra of two tricyclic heteroaromatic compounds (2,3) that are pi-isoelectronic with anthracene (1) have been recorded and analysed making use of semi-empirical AM1 and PM3, as well as density functional theory (DFT) B3LYP calculations. In compounds 2 and 3, one peripheral benzene ring of compound 1 is substituted by a thiophene ring that is either [b]- or [c]-annellated. In compounds 2 and 3, only small shifts are found for most of the ionization potentials of pi electrons. Since the ionization energies of all occupied pi molecular orbitals of compounds 1-3 could be assigned, a direct comparison of their pi electron energy is possible. Compared with compound 1, the pi-electron system of naphtho[2,3-b]thiophene (2) is stabilized by 0.6 eV, while that of naphtho[2,3-c]thiophene (3) is destabilized by 0.2 eV. [b]-Annellation of the thiophene ring is thus favourable while [c]-annellation is unfavourable.

Structural chemistry of polycyclic heteroaromatic compounds. Part XI. Photoelectron spectra and electronic structures of tetracyclic hetarenes of the triphenylene type.

The UV photoelectron spectra of several tetracyclic heteroaromatic compounds (2-9) which are pi-isoelectronic with triphenylene (1) have been recorded and analysed making use of semiempirical AM1 and PM3 as well as ab initio/DFT B3LYP calculations. In one series of compounds (2-7), the peripheral benzene rings of 1 are successively substituted by thiophene rings that are either [b]- or [c]-annellated with the central benzene unit. In 2-7 only marginal shifts are found for most of the IPs of electrons. In the benzotrithiophenes 5-7, a systematic variation is displayed by IP(pi7). Compared to 1, the pi electron system of benzo[c]trithiophene (7) is approximately two times as much destabilized as in the isomers 5 and 6 with [b]annellated thiophene rings. The IP[n(S)] values of the thiophene derivatives 2-7 indicate that these orbitals are clearly destabilized relative to thiophene. The same holds for the n(O) orbital of the furane derivative 9 in comparison with that of furane. In 9, only the higher pi MOs (pi7-pi9) are destabilized whereas the lower levels (pi1-pi4) are stabilized, and those in between (pi5-pi6) remain essentially unshifted. In the pyrrole derivative 8, all pi MOs are substantially destabilized by about 0.5-1.6 eV relative to 1.

Through the eye of the beholder: multiple perspectives on quality in women's health care.

Quality is an illusive concept with different meanings to different people. Providers often define quality in terms of patient outcomes, professional standards of practice, predetermined criteria used to measure quality, and even subjective opinion. Patients describe quality in terms of the interpersonal aspects of care, how well they were treated, and the responsiveness of the provider to their needs. This qualitative study using a semi-structured interview defined quality from the perspectives of patients, physicians, nurses, and payers associated with a hospital-based women's service line, and how the attributes of quality varied among the multiple groups. The study also described how stakeholders become aware of quality and how they determined a hospital's quality. From the findings of the study, a conceptual framework of quality in women's health was developed.

A comparison of temperature measurements using three ear thermometers.

Following anecdotal and research-based reports of inaccuracies encountered with the use of ear thermometers in patient care settings, this two-phase study was designed to compare the accuracy of three ear thermometers when used in a multioperator environment. The within-subject variation (limits of agreement) in ear temperature measurements obtained with the three ear thermometers in a multioperator condition by using an oral temperature reference standard ranged from +/- 1.25 degrees F to 1.85 degrees F. In multioperator, multisubject patient care environments using a pulmonary artery catheter core temperature as the reference standard, the limits of agreement for ear temperature measurements obtained with the three different ear thermometers ranged from +/- 2.19 degrees F to 2.85 degrees F. These results suggest that there is substantial variation in ear measurements and raise questions about the use of ear thermometers when there are multiple personnel taking temperatures, as occurs in hospital-based clinical practice environments. Handedness of the operator, position of the patient, and the ear used for measurement did not produce clinically significant variability in ear temperature measurements.

Automated, eight-cage indirect calorimetry in rats.

We have constructed an automated, eight-cage indirect calorimeter (AIC) for the measurement of energy expenditure in rats. We compared the measurements of resting energy expenditure (REE) in rats during a 30-h fast obtained with the AIC with those obtained with a manual indirect calorimetry (MIC) system. There was both a high degree of correlation between the two techniques during the initial 18 h of the fast (r = 0.90, P < 0.05) and strong intertechnique agreement. REE (AIC) decreased during the final 12 h of the 30-h fast (79.6 +/- 2.7-72.0 +/- 4.4 kcal.kg-0.75.d-1 [mean +/- SD, P < 0.01]). REE (MIC) did not show a significant decrease during this part of the fast (79.7 +/- 2.6 - 75.2 +/- 4.7 kcal.kg-0.75.d-1 [P = NS]). During the final 12 h of the fast agreement between the two systems gradually dissipated and correlation was poor (r = 0.375, P < 0.05). The frequency of animal handling necessitated by MIC may have resulted in a stress-induced increase in metabolic work that would mask the animals' adaptive response to starvation. This investigation demonstrates the advantages of the AIC and calls into question the accuracy of manual methods under long-term starvation conditions.

Case management as a tool for clinical integration.

Case management has evolved to meet the challenges of contemporary health care. As an effective strategy to promote clinical integration within health care systems, case management brings together population and individual approaches to development and coordination of evidence-based, outcome-focused health, disease, and illness management programs and services. A three-level prevention-focused model for health care management across the continuum of care is presented.

A controlled trial of immunotherapy for asthma in allergic children.

BACKGROUND: Injections of allergens are widely prescribed for patients with asthma, but little is known about the effectiveness of immunotherapy. METHODS: We conducted a double-blind, placebo-controlled trial of multiple-allergen immunotherapy in 121 allergic children with moderate-to-severe, perennial asthma. The children, who required daily medication for their asthma, were randomly assigned to receive subcutaneous injections of either a mixture of up to seven aeroallergen extracts or a placebo. Maintenance injections were continued for 18 months or longer. Medications were adjusted every two to three weeks on the basis of peak flow rates and symptoms. The principal outcome was the daily medication score. Bronchial sensitivity to methacholine (the concentration provoking a 20 percent decrease in the forced expiratory volume in one second [PC20]) was measured twice yearly. RESULTS: The median medication score declined from 5.4 to 4.9 in the immunotherapy group (P<0.001) and from 5.2 to 5.0 in the placebo group (P<0.001), but there was no significant difference between the groups (P>0.6). The number of days on which oral corticosteroids were used was similar in the two groups. Partial or complete remission of asthma occurred in 31 percent of the immunotherapy group and in 28 percent of the placebo group (P>0.5). There was no difference between the groups in the use of medical care, symptoms, or peak flow rates. The median PC20 increased significantly in both groups, but again with no difference between the two groups. CONCLUSIONS: Immunotherapy with injections of allergens for over two years was of no discernible benefit in allergic children with perennial asthma who were receiving appropriate medical treatment.

Telephonic nursing: empowering patients at risk for preterm birth.

Telephonic nursing is an innovative approach to providing prevention-focused care to patients at risk for preterm birth. Telephonic nursing includes case management and direct care services. A focus on health promotion supports client empowerment in self-care and decision making during the high-risk pregnancy.

Accuracy of electronic axillary temperature measurement in term and preterm neonates.

The accuracy of axillary temperature measurement using an electronic thermometer in the predictive mode was investigated in term and preterm infants. Predictive mode measurements were compared to axillary monitoring mode measurements and to rectal temperature recordings. Fifty temperature recordings were obtained in each of four groups of neonates (full-term/radiant warmer, full-term/open crib, preterm/radiant warmer, preterm/incubator). Correlation of axillary predictive and monitoring mode temperatures ranged from r = 0.83 to 0.90. Correlations between axillary monitoring mode and rectal measurements were r = 0.69 to 0.80, and between predictive mode and rectal measurements were r = 0.59 to 0.80. Small, statistically significant differences were found between predictive and monitoring mode axillary temperatures in preterm neonates (0.1 to 0.2 degrees F). Rectal temperatures were higher than axillary predictive temperatures by 0.5 degrees F and higher than axillary monitoring mode temperatures by 0.7 degrees F. Ranges of variation of +/- 0.8 to 1.1 degrees F were similar in comparisons of rectal with axillary predictive and monitoring mode measurements. The results of this study support the use of axillary measurement in the predictive mode for clinical measurement of temperature in neonates. Clinicians should be aware of the expected differences between measurements at axillary and rectal sites and the potential for variation in measurements across measurement modes and sites.

Infrared tympanic thermometry for neonatal temperature assessment.

OBJECTIVE: To investigate the accuracy and precision of infrared tympanic thermometer use with neonates by comparing with axillary and rectal measurements. DESIGN: Descriptive, comparative study. SETTING: Newborn nursery of a tertiary-level perinatal center. SUBJECTS: Thirty-four full-term newborns. INSTRUMENTS: Infrared thermometers were used to collect tympanic temperatures. An electronic thermometer was used to collect axillary and rectal temperatures. RESULTS: There was no significant difference between tympanic and axillary temperatures. The range of variation (95% CI) was +/- 0.7-.9 degrees C. The mean difference between tympanic and rectal measurements was 0.4 degrees C. The range of variation was +/- 0.7-0.75 degrees C. Right ear measurements produced the best approximation of axillary temperature, and protected ear measurements produced the best approximation of rectal temperature. The protected ear was 0.2-0.3 degrees C higher than the exposed ear. CONCLUSIONS: There was more variation between tympanic versus axillary and tympanic versus rectal measurements than between axillary and rectal measurements. Tympanic thermometry may be useful for rapid screening of neonatal temperature, but its usefulness for monitoring unstable neonates remains in question.

Peak flow variation in childhood asthma: a three-year analysis.

Measuring peak expiratory flow (PEF) variation has been suggested as a indicator of asthma disease severity and also of nonspecific bronchial hyperreactivity. To test these assumptions, we examined the relationships between PEF variation, methacholine reactivity, symptom scores, and medication requirements in 74 children with tightly controlled allergic asthma. The level of mean diurnal variation (MDV) for the group was 7.1%, which is generally regarded as normal. We found statistically significant correlations between MDV and both methacholine reactivity (r = 0.43, p = 0.0001) and symptom scores (r = 0.28, p = 0.016). These asthma variables were analyzed longitudinally in 33 children who were followed up at 6-month intervals for at least 36 months. Visit-to-visit changes in MDV were generally not reflective of changes in other variables. However, group levels of MDV gradually decreased over time, especially in children with initial MDV of more than 8%. This reduction in group MDV coincided with similar reductions in group medication requirements and methacholine reactivity. We conclude that children with moderately severe asthma that is tightly controlled may have normal levels of PEF variation. The correlation between PEF variation and other asthma variables is statistically significant but too weak to be useful in the treatment of individual patients. In contrast, measurement of MDV may be a useful indicator of disease severity in group studies of asthma.

Using Roy's adaptation model in practice: nurses' perspectives.

Using a qualitative research methodology, the utility of the Roy adaptation model as a framework for nursing practice within a hospital setting was investigated. The level of integration of the model into practice varied among nurses. The model was generally found to be useful in focusing, organizing, and directing nurses' thoughts and actions regarding patient care, resulting in a perception of improved quality of nursing process and patient outcomes. Prior education on the Roy model and participation in professional advancement activities facilitated model integration, while lack of education and resistance to change inhibited implementation of model-based practice.

Drug allergy.

Although allergic drug reactions are just one type of adverse reaction to medications, they are clinically very important because of the morbidity and mortality they cause. An ever-expanding pharmacopeia increases the potential for allergic drug reactions. An understanding of the types of allergic drug reactions, their immunopathologic mechanisms, and the most likely medications involved; an approach to determine the drug responsible for the reaction; and ways to prevent future allergic drug reactions are important features in minimizing patient morbidity.

Postpartum mothers' preferences for nighttime care of the neonate.

This study, conducted in response to issues raised during implementation of a dyad care delivery system, investigated preferences of postpartum mothers for nighttime care of the neonate. For dyad as well as traditional care subjects, the availability of individual care options emerged as a theme in both personal preference and preference based on available hospital accommodation. Significant differences existed between dyad and traditional care subjects on second choices for nighttime care and on environmental variables.