Assessing Meaningful Improvement: Focus on the Tinnitus Functional Index.

Many studies have attempted to determine methodology for interpreting change on outcome instruments that result from an intervention. The objective of these studies has been to devise methods to identify the minimal level of change that would be consistent with actual benefit perceived by the patient, and not just statistically significant change. With respect to intervention for bothersome tinnitus, the authors of the original study to develop and validate the Tinnitus Functional Index (TFI) suggested that a minimum 13-point reduction in the TFI score was likely to reflect a change perceived as meaningful to an individual. The 13-point estimation of meaningful change for an individual is appropriate for use with any adult seeking care for tinnitus. However, it cannot be relied upon in isolation to determine if an individual believes that there has been a noticeable, or meaningful improvement in their quality of life. It is important to use subjective impressions elicited from the patient to assist in interpreting the meaning of TFI data for an individual. For clinicians engaging in care for tinnitus, we recommend using the TFI and pairing it with the patient's belief/impression as to whether they are doing better than they were before care for tinnitus was provided. Ideally, the outcome assessment would be conducted by someone other than the clinician who provided the intervention.

Assessment of tinnitus: measurement of treatment outcomes.

There is a wide range of assessment techniques for tinnitus, but no consensus has developed concerning how best to measure either the presenting features of tinnitus or the effects of tinnitus treatments. Standardization of reliable and valid tinnitus measures would provide many advantages including improving the uniformity of diagnostic and screening criteria between clinics and facilitating comparison of treatment outcomes obtained at different sites. This chapter attempts to clarify issues involved in developing self-report questionnaires for the assessment of tinnitus. While the tinnitus questionnaires that are currently available provide valuable information on which to base diagnostic and screening decisions, they were not originally developed in such a way as to maximize their sensitivity to treatment-related changes in tinnitus. As a result, their construct validity for measuring treatment benefit has not received appropriate attention. In this paper, special emphasis is devoted to the use of effect sizes as an estimate of the ability of questionnaires (and their individual items) to measure changes associated with treatment. We discuss the criteria relevant to evaluating the effectiveness of a questionnaire for diagnostic purposes vs. for treatment-evaluation purposes, and we present a detailed illustration of how the various criteria have been applied in a recent questionnaire development effort.

Reduction in Staphylococcus aureus bacteraemia rates in patients receiving haemodialysis following alteration of skin antisepsis procedures.

This study examined all cases of Staphylococcus aureus bacteraemia (SAB) in the haemodialysis cohort at the Royal Darwin Hospital, Australia over a seven-year period. Midway through this period, antisepsis for arteriovenous fistulae (AVF) and central venous catheters (CVC) changed from 0.5% chlorhexidine solution to 2% chlorhexidine solution. Rates of SAB episodes were calculated using registry data. Trends in SAB over time were analysed using an interrupted regression analysis. Following the change to 2% chlorhexidine, average SAB rates decreased by 68%, and it is estimated that 0.111 cases of SAB/patient-year were prevented. CVC-related SAB rates remained low throughout. These results support the use of 2% chlorhexidine in skin antisepsis for patients with AVF.

Indels and imperfect duplication have driven the evolution of human Complement Receptor 1 (CR1) and CR1-like from their precursor CR1 alpha: importance of functional sets.

This study examines the effects of duplication and insertions-deletions (indels) by comparing human complement receptor 1 (CR1) and human CR1-like (CR1L) with syntenic genes from four other vertebrates (chimpanzee, baboon, rat, and mouse). By phylogenetic analysis, the domains of these genes can be classified into 10 distinct subfamilies (a, b, c, d, e, f, g(-like), h, j, and k), which have been largely conserved throughout vertebrate and invertebrate evolution. In spite of many complex and diverse duplications and indels, the subfamily order of domains (a, j, e, f, b, k, d, g(-like)) has been maintained. The number of domain sets has increased progressively, thereby expanding the functional repertoire.

Development of a radioimmunoassay method for ethynylestradiol in plasma using a monoclonal antibody.

An ethynylestradiol (EE2) radioimmunoassay method (RIA) using a monoclonal antibody (MAB) reagent is described. 76 plasma and 67 buffer blanks spiked with known concentrations of EE2 were used as positive samples. The steroid was extracted using dichloromethane method with an extraction efficiency of 78 +/- 2.6%. The plasma extracts were not purified. Separation of the free from bound tritiated EE2 was by centrifugation with dextran-coated charcoal suspension in phosphate-gelatin buffer. Within 95% confidence limits, the sensitivity of the assay was 10 pg/ml in buffer samples, and 43 pg/ml in unpurified plasma samples. The accuracy and precision of the method were lower for the plasma samples than for the buffer solutions but within accepted limits (i.e., 80-120% for accuracy, and up to 20% for precision). The mean recovery accuracy (R) of the method for measuring 38 pg/ml EE2 in buffer was 101 +/- 0.9% (n = 67), while for 2.39 pg/ml to 18.0 pg/ml EE2 in plasma was 97 +/- 12% (n = 76). The buffer solutions and plasma samples containing 600 pg/ml EE2 had a mean R of 102% (n = 18) and 90% (n = 16), respectively. The average interassay variation (%CV) between buffer samples was 14 +/- 1.2%, and between plasma samples was 19 +/- 8%. Plasma samples with 18 pg/ml and 2.39 pg/ml EE2, together with the blank negative plasma samples showed high interassay variations (CV > 20%). Except for the above samples, however, the precision of the method in all sample groups was within accepted limits. The intra-assay variation of replicate assays of a single plasma sample containing 1.2 ng/ml EE2 and 4 ng/ml levonorgestrel was 13% (n = 7). In the presence of very high concentration of closely related levonorgestrel, the R of the method was 106%. The increase in average variability (%CV) between results for the plasma samples (CV 19 +/- 8%) over that of the spiked buffer solutions (CV 14 +/- 1.2%) suggest some possible interference by co-extracted materials from plasma, for example lipids, which interfered in the ligand-antibody reactions. Further investigation may prove that a pre-assay purification of the sample, e.g., HPLC, would eliminate this interference. Nevertheless, the immunoassay described above completely eliminates the problem of cross-reactivity caused by the natural estrogens in plasma with the conventional polyclonal antibodies. It possesses an acceptable intra- and interassay variation with very high specificity to EE2.(ABSTRACT TRUNCATED AT 400 WORDS)

Resin-process methods for improved isolation of organisms from blood and other body fluids.

Two resin-based processes and conventional culturing methods were compared in isolating organisms from blood specimens of patients given antimicrobial agents. Of 20 patients whose specimens were found to contain clinically relevant organisms, one or both of the resin-process methods isolated organisms in eight after conventional culturing was unsuccessful. Conventional cultures were successful in five cases in which the resin-process methods did not work, and both resin-process and conventional culturing were successful in seven cases. In eight cases in which other body fluids were cultured, only a resin-process method was successful in four, although they are intended for use only with blood specimens. Data indicate that resin-process methods should be used along with conventional culturing methods when patients have already been given an antimicrobial. A review of the literature shows that the devices improve the recovery of organisms but does not establish that detection time is decreased.

Central administration of corticotrophin releasing hormone but not arginine vasopressin stimulates the secretion of luteinizing hormone in rams in the presence and absence of testosterone.

This study tested the hypothesis that central administration of corticotrophin-releasing hormone (CRH) and/or arginine vasopressin (AVP) will affect the secretion of LH in rams and that testosterone is necessary for these actions to occur. Plasma LH levels were measured in castrated rams during 1 h infusion of either 100 microliter vehicle/mock cerebrospinal fluid (CSF) or mock CSF containing 25 microgram CRH, 25 microgram AVP or 25 microgram of each peptide through guide cannulae into the third cerebral ventricle. These intracerebroventricular (i.c.v.) infusions were given to the castrated rams following injections (i.m.) each 12 h of oil or 8 mg testosterone propionate for 7 days. Blood samples were collected every 10 min for 4 h before i.c.v. infusion, during infusion and for 4 h following the infusion. Infusion of vehicle did not affect any endocrine parameters. In contrast, the plasma concentrations of LH and the amplitude of LH pulses were increased significantly during and following infusion of CRH, and this effect was not influenced by whether the castrated rams were treated with testosterone propionate or whether the CRH was administered in combination with AVP. Infusion of AVP alone did not affect LH secretion. The frequency of LH pulses and the plasma concentrations of FSH did not change with any of the i.c.v. treatments. The plasma concentrations of cortisol were significantly increased by CRH and AVP infusions. The plasma concentrations of cortisol achieved during and following i.c.v. infusion of CRH and AVP combined were greater than the concentrations achieved as a result of treatment with AVP alone but were similar to those with CRH. There was no effect of testosterone propionate on cortisol levels. These results show that CRH, but not AVP, is capable of acting either centrally or at the pituitary level to increase the secretion of LH in rams and these actions are not affected by testosterone. The stimulatory effects of CRH on LH secretion are to increase the amplitude of GnRH pulses and/or the responsiveness of the pituitary to the actions of GnRH with no effect on the frequency of GnRH pulses. The secretion of FSH in rams is not influenced by either CRH or AVP. The effect of CRH to increase LH pulse amplitude occurs in the face of increased cortisol levels, further reinforcing our belief that this adrenal steroid does not affect the reproductive axis in this species.

A reliable test for differentiation and presumptive identification of certain clinically significant anaerobes.

A modification of the slide catalase test was evaluated to determine its reliability for the presumptive identification of certain anaerobic gram-negative and gram-positive organisms isolated from clinical specimens. A total of 650 fresh isolates was evaluated. Growth from a trypticase blood agar plate or Schaedler's agar with laked blood was transferred to a slide and a drop of 15% H2O2 with Tween 80 added. Veillonella alcalescens, Proprionibacterium species, Peptococcus species, and Bacteroides fragilis, B. thetaiotaomicron, B. distasonis, B. ovatus, and B. vulgatus were positive by this method. Comparative slide and tube catalase tests were performed with the above-mentioned bacteroides species by growing each isolate on trypticase soy agar, Brucella agar, brain-heart infusion agar, each with and without added hemin, and on Schaedler's agar. Four solutions of H2O2 were used, 3 and 15%, and 3 and 15% with Tween 80. The addition of Tween 80 to H2O2 increased the sensitivity of the reaction with both slide and tube methods. The 15% H2O2 with Tween 80 consistently gave the most rapid and persistent positive reaction. A slide catalase test in combination with a Gram stain should be performed on each anaerobic isolate; this would significantly decrease the time required for presumptive identification of many anaerobic organisms.

Enterotoxigenic bacteria in the sudden infant death syndrome.

Faecal samples from 123 infants who died with sudden infant death syndrome (SIDS) and from a comparative group of 52 age-matched babies were analysed for toxigenic bacteria and their toxins. Serum samples from the SIDS infants were also analysed for these toxins. A significantly higher proportion of toxigenic bacteria and their toxins were found in faecal samples of SIDS babies than in samples from the comparative group. These toxins were also found in serum from the SIDS babies. Clostridium perfringens was found in 54 (45.4%) of 119 SIDS cases compared with 10 (19.6%) of 51 healthy babies (chi 2 = 10.1, p < 0.01); C. difficile in 33 (27.7%) of 119 SIDS cases compared with 8 (14.8%) of 54 healthy babies (chi 2 = 3.43ns, p < 0.1); Staphylococcus aureus in 12 (27.3%; 66.7% enterotoxigenic) of 44 SIDS cases compared with 12 (85.7%; non-enterotoxigenic) of 14 healthy babies (chi 2 = 14.9, p < 0.001); C. botulinum in 6 (5.0%) of 120 SIDS cases compared with 0 of 53 healthy babies (chi 2 = 2.74, p < 0.1). Campylobacter jejuni, Yersinia enterocolitica, Vibrio parahaemolyticus, salmonellae and Bacillus cereus were not detected. Heat-labile toxin, lethal to mice (HLML) was found in 32 (27.1%) of 118 SIDS faecal samples compared with 5 (10.6%) of 47 healthy babies (chi 2 = 5.24, p < 0.05); cytotoxins in 38 (30.9%) of 123 SIDS faecal samples compared with 0 of 21 of healthy babies (chi 2 = 8.8, p < 0.01) and 24 (27.6%) of 87 SIDS serum samples. C. perfringens enterotoxin was detected in 33 (34.4%) of 96 SIDS faecal extracts compared with 0 of 23 of healthy babies (chi 2 = 10.94, p < 0.001), and in 27 (24.5%) of 110 SIDS serum samples. C. perfringens alpha-toxin (presumptive) was detected in 14 (17.5%) of 80 SIDS faecal extracts compared with 0 of 17 from healthy babies (chi 2 = 3.5ns, p congruent to 0.05) and in 2 (2.3%) of 87 SIDS serum samples. C. difficile toxin was detected in four SIDS faecal samples and two serum samples. C. botulinum toxin was detected in only one of 120 SIDS faecal samples compared with none of 49 from healthy babies. Staphylococcal enterotoxins were detected in 8 (19.5%) of 41 SIDS faecal samples compared with 0 of 19 from healthy babies (chi 2 = 4.278, p < 0.05), and in 4 (10.8%) of 37 SIDS serum samples.(ABSTRACT TRUNCATED AT 400 WORDS)

A sensitive direct radioimmunoassay for assessing D-norgestrel levels in human plasma.

A direct radioimmunoassay was developed for assessing the levonorgestrel levels in human plasma without the need for heat, chromatographic or extraction pretreatment. D-norgestrel-3 (0-carboxymethyl)-oximino-BSA conjugate was used to raise antibodies having a low binding affinity towards other endogenous steroids. The rivanol-purified antiserum after dilution was used as the binding protein. The direct assay of levonorgestrel in human plasma was then compared to an extraction procedure. Lower intra-assay variability was shown by the direct assay when compared to the extraction method used at a sensitivity level of 0.15 nmol/L. The performance of the direct assay in quality control tests was more than favourable when compared with the extraction procedure. An examination of the effects of protein concentration on extraction efficiency was carried out together with an assessment of levonorgestrel levels in plasma in eight normal healthy women currently taking oral contraceptives and eight women who were not, at 0-24 h after the ingestion of 150 micrograms of D-NG and 30 micrograms of ethynyl oestradiol.

pH and concentrations of pepsin and trypsin in feeding tube aspirates as predictors of tube placement.

BACKGROUND: The purpose of this study was to determine the extent to which pepsin and trypsin concentrations in feeding tube aspirates, in addition to pH, contribute to predicting feeding tube position. METHODS: Aspirates from 742 feeding tubes (nasogastric, n = 343; nasointestinal, n = 399) were tested for pH and enzyme concentrations. Also tested were aspirates from two feeding tubes inadvertently positioned into the lung (one in the pleural space and one in the tracheobronchial tree) and 146 samples of tracheobronchial and pleural fluids collected by other methods. Enzyme assays were conducted in a research laboratory. Results of the pH and enzyme tests were compared with radiologic reports of tube location. RESULTS: Gastric fluid had a mean low pH (4.06), a high mean pepsin concentration (349.1 micrograms/mL), and a low mean trypsin concentration (19.3 micrograms/mL). In contrast, intestinal fluid had a mean high pH (7.40), a high mean trypsin concentration (143.0 micrograms/mL), and a low mean pepsin concentration (24.2 micrograms/mL). Respiratory samples also had a high mean pH (7.89) but contained little or no pepsin or trypsin. Using a logistic regression equation with all three variables to differentiate between respiratory and gastrointestinal placement, it was possible to correctly classify 100% of the respiratory cases and 93.4% of the gastrointestinal cases. Another equation used to differentiate between gastric and intestinal sites was able to classify correctly 91.2% of the gastric cases and 91.5% of the intestinal cases. CONCLUSIONS: The results clearly indicate that laboratory-determined enzyme concentrations in feeding tube aspirates are helpful in predicting tube location. Thus, it is desirable that inexpensive, simple bedside tests be developed so that they can be used in conjunction with pH measurements to help predict tube position.

Enrichment processes in family caregiving to frail elders.

Interview and observational data obtained from caregiver-care recipient dyads were analyzed in developing a theory of enrichment that explains how some families use pleasurable or meaningful experiences in their caregiving to frail elders. The personal history and frailty trajectory of both caregiver and care recipient, the quality of the dyadic relationship, and the caregiving situation are antecedents to enrichment processes. Core elements influencing the nature of enriching events include acquiring symbolic meaning, performing activity, and fine tuning. Categories of enrichment events are customary routines and innovative routine breakers. Consequences of enrichment are relationship and identity sustenance for both caregiver and care recipient, comfort for the care recipient, and rewards of meaning for the caregiver.

Evaluating teaching effectiveness.

Major reform in nursing education is underway, with increased emphasis being placed on the importance of the teacher-student relationship. An instrument for evaluation of teaching effectiveness, developed at the Oregon Health Sciences University School of Nursing, attempts to capture the student's perception of the quality of the teacher-student relationship as well as other salient aspects of teaching practices. The evaluation tool contains 26 items evaluating teaching effectiveness and 14 items that evaluate the course. The teaching effectiveness items yield five scales including: knowledge and expertise, facilitative teaching methods, communication style, use of own experiences, and feedback. Psychometric testing has been completed and there is evidence of construct validity in relation to teaching effectiveness and internal consistency reliability for the five scales.

Establishing partnerships with family caregivers. Local and cosmopolitan knowledge.

1. The concepts of local and cosmopolitan knowledge may be used by gerontological nurses in creating partnerships with family caregivers to frail older people. 2. Local knowledge is the understanding and skills that the family brings to the caregiving situation; cosmopolitan knowledge is the understanding and skills that the gerontological nurse brings to the situation. 3. Four nursing interventions are guided by the conceptualization of local and cosmopolitan knowledge: acknowledging and affirming local knowledge when it is adequate; developing or enhancing local knowledge when it is inadequate; assisting family caregivers to apply local knowledge to problem solving; and blending local and cosmopolitan knowledge.

Type C botulism in young dogs.

A diffuse lower motor neurone paralysis developed in a 6-month-old male Australian cattle dog pup 4 days after it had eaten the carcase of a rotting duck in Centennial Park, Sydney. Two other dogs which ate smaller portions of the same carcase were less severely affected. Clostridium botulinum type C was isolated from and C. botulinum type C toxin was detected in faeces from the severely affected dog. The serum contained 25 LD50 of toxin/ml. The high C. botulinum count and toxin level in the faeces declined progressively during the ensuing weeks, but 114 days after ingesting the carcase C. botulinum type C was still present in faeces and a low toxin titre persisted. Soil, mud and water samples in the area of the duck ponds in the park contained C. botulinum type C spores. Spores and high toxin titres were also found in the intestine of the carcases of 2 birds in the area.

Detection of neonatal hypoglycemia--a comparison of three reagent strips.

This article reports two studies that replicate previous investigations of the effectiveness of Chemstrip bG, Dextrostix and Visidex for making nursing assessments of hypoglycemia in the newborn. The article also describes a third study that combines results of the first two studies with results of previous studies in the literature in an attempt to improve the reliability and validity of the findings. In the first study, 102 blood samples were tested using either Chemstrip bG or Dextrostix and then compared with laboratory blood glucose levels. Because of the small number of hypoglycemic samples, a second study was devised in which six samples of cord blood were artificially titrated to known levels of glucose. In this study, Visidex as well as Chemstrip bG and Dextrostix were used. Eighty-five percent, 50 percent and 90.4 percent of the hypoglycemic samples were detected by Chemstrip bG, Dextrostix and Visidex, respectively. Data available in the literature from previous studies investigating the same question were then compiled and analyzed. The composite sample of 402 infants for Dextrostix and 484 for Chemstrip bG resulted in the finding that less than half of the hypoglycemic infants tested with Dextrostix were detected whereas Chemstrip bG detected 90 percent of them. The conclusion reached is that both Chemstrip bG and Visidex can be considered adequate screening techniques for nursing assessment of hypoglycemia in the newborn, while visually read Dextrostix is unacceptable in clinical practice.

Establishing partnerships with family caregivers. Local and cosmopolitan knowledge.

Families now provide most of the care received by older people in the United States. Proposed changes in the health care system will mean that families must take an even greater role in delivering health care. It is crucial that nurses practicing in a variety of settings be prepared to establish partnerships with family caregivers in order to attend to the long-term care needs of older people.