Morphogens: how big is the big picture?

Morphogens are in the front line just now. Here I trace how the concept of a morphogen has evolved over the past 100 years and step a little beyond what we already know.

Alarm limit settings for early warning systems to identify at-risk patients.

AIM: This paper is a report of a study conducted to provide objective data to assist with setting alarm limits for early warning systems. BACKGROUND: Early warning systems are used to provide timely detection of patient deterioration outside of critical care areas, but with little data from the general ward population to guide alarm limit settings. Monitoring systems used in critical care areas are known for excellent sensitivity in detecting signs of deterioration, but give high false positive alarm rates, which are managed with nurses caring for two or fewer patients. On general wards, nurses caring for four or more patients will be unable to manage a high number of false alarms. Physiological data from a general ward population would help to guide alarm limit settings. METHODS: A dataset of continuous heart rate and respiratory rate data from a general ward population, previously collected from July 2003-January 2006, was analyzed for adult patients with no severe adverse events. Dataset modeling was constructed to analyze alarm frequency at varying heart rate and respiratory rate alarm limits. RESULTS: A total of 317 patients satisfied the inclusion criteria, with 780.71 days of total monitoring. Sample alarm settings appeared to optimize false positive alarm rates for the following settings: heart rate high 130-135, low 40-45; respiratory rate high 30-35, low 7-8. Rates for each selected limit can be added to calculate the total alarm frequency, which can be used to judge the impact on nurse workflow. CONCLUSION: Alarm frequency data will assist with evidence-based configuration of alarm limits for early warning systems.

Impact of continuous vigilance monitoring on nursing workflow.

BACKGROUND: Increasing nursing time in patient care is beneficial in improving patient outcomes, but this is proving increasingly difficult with the nursing shortage, budgetary constraints, and higher patient acuity. OBJECTIVE: Nursing workflow was evaluated after the implementation of a continuous vigilance monitoring system to determine if the system enhanced patient-centric nursing care. METHODS: Work sampling observations were conducted at 3 hospitals for 6 categories of nursing activities (direct and indirect nursing, documentation, administrative, housekeeping, and miscellaneous) at baseline and at 3 and 9 months. RESULTS: Statistically significant increases in direct (3 months) and indirect nursing care (3 and 9 months) were found, with variability between sites. Statistically significant increases at 3 and 9 months for documentation of patient care activities and decreases in administrative activities were the most consistent findings for all sites. CONCLUSION: Continuous vigilance monitoring enhanced patient-centric care with increases in direct and indirect nursing care and documentation of those activities.

Should mentoring be routinely introduced into general dental practice to reduce the risk of occupational stress?

Introduction Occupational stress within general dental practice can potentially have an adverse impact on a practitioner's wellbeing and the quality of healthcare provided by that individual. Mentoring has routinely been utilised in other professions for stress management, however, there is little in the dental literature discussing the benefits of mentorship on the reduction of occupational stress for dental practitioners.Aim The aim of this study was to explore the perceptions of experienced foundation dental trainers within the Health Education, Kent, Surrey and Sussex postgraduate deanery as to the usefulness of routine mentoring as a tool to reduce occupational stress.Methods Using a qualitative approach, six individual semi-structured interviews were undertaken. Recorded interviews were transcribed and transcriptions were analysed using thematic coding to identify overarching themes.Results Both similarities and differences with the existing literature on routine mentoring within professional settings were identified. Foundation dental trainers were positive towards the concept of routine mentoring, although there was also a degree of scepticism regarding the potential uptake among colleagues. There was a perception that mentoring might more practically be used as a reactionary tool. Multiple potential barriers to routine mentoring were identified, included funding, scheduling and a lack of training.Conclusions The analysis identified that currently, experienced foundation dental practitioners do not consider routine mentoring as a practical option in the prevention of occupational stress. The results would suggest that further education is required as to the benefits of routine mentoring as a strategy for occupational stress management. However, with additional resources buying time, a hybrid model of mentoring and coaching has significant potential in general dental practice.

Wingless signalling: more about the Wingless morphogen.

Recent work on pattern formation in the Drosophila embryo reveals a new mechanism which shapes the gradient of the secreted morphogen, Wingless: Wingless protein is degraded more rapidly on one side of its source than on the other.

An attempt to hybridize Drosophila species using pole cell transplantation.

We have made hybrid embryos in Drosophila by pole cell transplants, by transferring pole cells from two species, D. rajasekari and D. eugracilis, into sterile D. melanogaster hosts. These females were then mated to melanogaster males and the older these females were, the further their hybrid offspring developed. In the case of the rajasekari/melanogaster hybrids, the embryos form cuticle but had defective heads, while the eugracilis/melanogaster hatched as larvae that grew but did not moult to the second instar. Hybrid pole cells could be transferred to melanogaster hosts but they failed to make eggs.

Deterioration of diabetic patients' knowledge and management skills as determined during outpatient visits.

A checklist of 22 items that diabetic persons need to perform correctly in order to carry out adequate home management was analyzed for 30 patients in an outpatient clinic. Both a recording of correct performance (baseline assessment) and a reassessment 3--17 mo later were obtained for each item included in the study. An 8 1/2% error rate occurred on reassessment. Approximately one-third of the patients had an error rate of 10% or more. No significant relationship was found between the percentage of error and age, interval between assessments, years of diabetes, or past performance on the checklist. Nor did a majority of the errors occur on items that showed an error immediately before the correct baseline assessment. This error rate is less than in reports not including a correct baseline performance. However, it is high enough to indicate that reassessment is needed more frequently than is generally done.

Accuracy of nurses in performing capillary blood glucose monitoring.

The accuracy and outcome of capillary blood glucose (CBG) monitoring as routinely performed by nursing staff were assessed. The sample consisted of 160 readings conducted by 93 nursing staff members in four hospitals; 19% of the readings deviated from simultaneous laboratory results by greater than 20%, and deviations resulted in altered responses to standing orders in 26 patients (17%). There was no statistically significant difference between the total variation attributed within and between nurses, possibly indicating that all nurses should be given the same intensity of follow-up training rather than targeting those who perform incorrectly on sample tests. Nurses in the one hospital that required certification before CBG monitoring had significantly less deviation from the laboratory standard than the other three hospitals. Although these data do not provide direct evidence that the certification program increased accuracy, this seems a logical conclusion. More study is needed to determine the most cost-effective type of training and follow-up.

Immunolocalization of type III collagen in human articular cartilage prepared by high-pressure cryofixation, freeze-substitution, and low-temperature embedding.

We localized Type III collagen by immunogold electron microscopy in resin sections of intact normal and osteoarthritic human articular cartilage. Comparisons of antibody staining between tissue prepared by high-pressure cryofixation and freeze-substitution without fixatives and that exposed to conventional mild chemical fixation with paraformaldehyde showed that dedicated cryotechniques yielded superior preservation of epitopes that are modified by chemical fixation, and simultaneously provided good ultrastructural preservation. Type III collagen was detected with two polyclonal antibodies, one against the triple-helical domain of the molecule and a second against the more antigenic, globular amino pro-peptide domain, which in this collagen is retained in the extracellular matrix after secretion. Positive labeling was seen in association with the major interstitial fibrils, suggesting co-polymerization of Types III and II collagen in cartilage. Type III collagen could not be detected in aldehyde-fixed normal cartilage. In fixed osteoarthritic cartilage, Type III was detectable only when the antibody to the amino pro-peptide was employed. In contrast, high-pressure cryofixation and freeze-substitution preserved epitopes for both antibodies, permitting immunodetection of Type III collagen in normal and osteoarthritic cartilage. Cryotechniques offer exciting possibilities for significantly improving the immunolocalization of collagens and other fixative-sensitive antigens in situ.

Immunolocalization of collagen types II and III in single fibrils of human articular cartilage.

Type II and III fibrillar collagens were localized by immunogold electron microscopy in resin sections of human femoral articular cartilage taken from the upper radial zone in specimens from patients with osteoarthritis. Tissue samples stabilized by high-pressure cryofixation were processed by freeze-substitution, either in acetone containing osmium or in methanol without chemical fixatives, before embedding in epoxy or Lowicryl resin, respectively. Ultrastructural preservation was superior with osmium-acetone, although it was not possible to localize collagens by this method. In contrast, in tissue prepared by low-temperature methods without chemical fixation, collagens were successfully localized with mono- or polyclonal antibodies to the helical (Types II and III) and amino-propeptide (Type III procollagen) domains of the molecule. Dual localization using secondary antibodies labeled with 5- or 10-nm gold particles demonstrated the presence of Types II and III collagen associated within single periodic banded fibrils. Collagen fibrils in articular cartilage are understood to be heteropolymers mainly of Types II, IX, and XI collagen. Our observations provide further evidence for the complexity of these assemblies, with the potential for interactions between at least 11 distinct collagen types as well as several noncollagenous components of the extracellular matrix.

Aspects of the epidemiology of suicide in England and Wales.

This paper is concerned with the variations in suicide rates in the 161-171 local authorities in England and Wales during the 11-year period 1961-71. Analysis of the overall secular trends shows that the rates for both males and females reached a peak in 1963 and subsequently declined at a steady rate. Virtually the whole of this reduction is associated with the fall in the number of poisonings by domestic gas. Suicide rates were about 50 per cent higher in males than in females and tended to increase with increasing age and, in general, were higher in the county boroughs than in the (more rural) county authorities. There is a marked variation in terms of geographical area, with the highest rates being reported in the London and South-East Region and the lowest rates in the South-East Wales and Northern Regions. There are also systematic differences between the various conurbations, with the highest rates in London and South-East Lancashire and the lowest in Merseyside and the West Midlands. The variations between individual local authorities are then considered and it is shown that as much as 99 per cent of the total variation can be explained in terms of a small number of variables which represent the general characteristics of the the local authority and the population. The most important of these variables is the proportion of single-person housegolds, which accounts for about three-quarters of the variation in the male suicide rates and more than half of the variation in female suicide rates. The significance of these results is discussed, with particular reference to the effect of the detoxification of the domestic gas supply during the period of study.

Neurotransmitters regulating acid secretion in the proventriculus of the Houbara bustard (Chlamydotis undulata): a morphological viewpoint.

Endocrine cells containing somatostatin (Som), gastrin-releasing peptide (GRP), and neuronal nitric oxide synthase (nNOS) and nerve fibers containing choline acetyl transferase (ChAT), tyrosine hydroxylase (TH), galanin (Gal), substance P (SP), and vasoactive intestinal polypeptide (VIP) were immunolocalized in the proventriculus of the Houbara bustard, Chlamydotis undulata. While GRP-immunoreactive (GRP-IR) cells occur in the inner zone, somatostatin (Som-IR) and polyclonal nNOS (nNOS-IR) immunoreactive cells were localized mainly in the peripheral zone of submucosal glands. GRP-IR, Som-IR, and nNOS-IR cells were occasionally observed in the walls of the gastric glands. Endocrine cells are of the closed variety and usually possess apical processes extending along the basal surfaces of adjacent nonreactive cells. Ultrastructural features of these cells are typical. ChAT, Gal, SP, VIP, and TH were immunolocalized in nerve fibers and terminals in the walls of arterioles and capillaries at the periphery of submucosal glands. Immunoreactivity to monoclonal nNOS occurred mainly in neuronal cell bodies in ganglia located around the submucosal glands. ChAT and TH immunoreactive cell bodies were also occasionally seen around the submucosal glands in the peripheral region. Immunoreactivity to Gal, SP, and VIP, but not ChAT or TH, was discernible around the walls of gastric glands. It was concluded that the distribution of neurotransmitters in neuronal structures is similar, but that of the endocrine cells varies from that of some avian species. The roles of these neurotransmitters in the regulation of acid secretion are discussed.

Telemedicine: teleproctored endoscopic sinus surgery.

OBJECTIVE/HYPOTHESIS: Teleproctored surgery projects a surgeon's expertise to remote locations. The objective of the present study was to evaluate the safety and feasibility of this technique as compared with the current standard of care. STUDY DESIGN: Prospective. METHODS: A study was conducted in a residency training program comparing conventionally proctored endoscopic sinus surgery cases with teleproctored cases, with the faculty surgeon supervising through audiovisual teleconferencing (VTC) in a control room 15 seconds from the operating room. RESULTS: Forty-two control patients (83 sides) and 45 teleproctored patients (83 sides) were evaluated. There were no internal differences between groups regarding extent of polypoid disease, revision status, procedures per case, degree of difficulty, general or local anesthesia, or microdebrider use. There were no cases of visual disturbance, orbital ecchymosis or hematoma, or cerebrospinal fluid leak. Orbital fat herniation and blood loss were equal between groups. Three teleproctored cases required faculty intervention: two for surgical difficulty, one for VTC problems. Teleproctored cases took 3.87 minutes longer per side (28.54 vs. 24.67 min, P <.024), a 16% increase. This was thought to be a result of nuances of VTC proctoring. Residents had a positive learning experience, with nearly full control of the operating suite combined with remote supervision through telepresence. Faculty thought such supervision was safe but had concerns regarding personal skills maintenance. CONCLUSIONS: Teleproctored endoscopic sinus surgery can be safely performed on selected cases with an acceptable increase in time. Teleproctored surgery with remote sites may continue to be safely investigated. Incorporating remote supervision through telepresence into the curriculum of surgical residency training requires further study.

Effects of acidic gases and mists on the reproductive capability of three fern species.

The effects of exposure to 40 nl litre(-1) SO2 + 40 nl litre(-1) NO2 on the reproductive biology of Polypodium interjectum (Shivas), Dryopteris affinis (Lowe) Fraser-Jenkins and Phyllitis scolopendrium (L.) Newman were investigated after 14 weeks exposure in a closed chamber fumigation system. The numbers of sori per pinna were reduced in response to SO2 and NO2 for D. affinis but were unaffected for the other species. Numbers of sporangia in sori and spore viability were reduced in P. interjectum and P. scolopendrium but not in D. affinis in response to the SO2 and NO2 treatment. Spore size was not affected by the pollution treatment. A separate experiment tested viabilities of spores collected from the three species in response to daily spraying with simulated mists at pHs of 2.5, 3.5, 4.5 and 5.6. For all three species, there was little or no spore germination in the pH 2.5 treatment and significantly reduced germination in response to the pH 3.5 as compared to the pH 4.5 and pH 5.6 treatments.

Telemedicine in otolaryngology.

More research is needed in otolaryngology telemedicine, but it would be a mistake to stop at only determining if telemedicine is as good as an in-person exam. The digital image recorded in a telemedicine encounter can be manipulated to increase diagnostic information not currently available. Radiologists currently take a chest radiograph in which a chest mass or the tip of an nasogastric tube is difficult to visualize, and by inverting the gray scale or viewing other digital manipulations of that image, the mass or tube tip becomes obvious. Examples in otolaryngology might include images of the larynx manipulated to better demonstrate the inflamed tissue of reflux, or images of the tympanic membrane manipulated to better demonstrate early retraction. Despite dramatic and likely continued decreases, equipment cost is still an issue. Current research points to good consumer acceptance, and certainly with each new generation the technology is more readily accepted. As Nesbitt [4] points out, it is certainly not difficult to look to the future and see ubiquitous broadband with video as common as telephone, or even extreme broadband enabling robotics and virtual reality TV with three-dimensional touch. Robotics and genomics will eventually play a greater role in telemedicine and our lives in general. Applications for remote diagnosis in biologic warfare defense and homeland security are currently raising interest in telemedicine. Telemedicine will be combined with new technological advances such as virtual "fly-through" computerized axial tomography examinations. Instead of performing an exploratory tympanotomy, surgeons will use computer programs to "fly through" and examine all aspects of a patient's middle or even inner ear. Spectral imaging of the eardrum, larynx, or oropharynx will immediately identify bacteria without cultures, or gram stain, and potential malignancy without biopsy. By measuring fluorescence emitted from an oropharynx illuminated with a specific visible or nonvisible light spectrum, spectral imaging will be able to provide instant identification of bacteria or evidence of malignant changes. The underlying principles of a successful business model must continue to be applied, with the most critical ingredient for telemedicine's success being the filling of specific health care needs. As long as the need is there, telemedicine in otolaryngology will advance.

Telehealth: voice therapy using telecommunications technology.

Telehealth offers the potential to meet the needs of underserved populations in remote regions. The purpose of this study was a proof-of-concept to determine whether voice therapy can be delivered effectively remotely. Treatment outcomes were evaluated for a vocal rehabilitation protocol delivered under 2 conditions: with the patient and clinician interacting within the same room (conventional group) and with the patient and clinician in separate rooms, interacting in real time via a hard-wired video camera and monitor (video teleconference group). Seventy-two patients with voice disorders served as participants. Based on evaluation by otolaryngologists, 31 participants were diagnosed with vocal nodules, 29 were diagnosed with edema, 9 were diagnosed with unilateral vocal fold paralysis, and 3 presented with vocal hyperfunction with no laryngeal pathology. Fifty-one participants (71%) completed the vocal rehabilitation protocol. Outcome measures included perceptual judgments of voice quality, acoustic analyses of voice, patient satisfaction ratings, and fiber-optic laryngoscopy. There were no differences in outcome measures between the conventional group and the remote video teleconference group. Participants in both groups showed positive changes on all outcome measures after completing the vocal rehabilitation protocol. Reasons for participants discontinuing therapy prematurely provided support for the telehealth model of service delivery.

Distance learning on the Internet: web-based archived curriculum.

Web-based education through archived educational modules offers a significant opportunity to provide didactic education. By archiving lectures and teaching materials, it reduces the educators' time of preparation, especially when many students will need to take the same curriculum over a long period of time. The site can package educational material in multiple formats including audio, video, and readable text, allowing the student to tailor the educational experience to his/her learning preferences. This can be a stand-alone program, or integrated into a program combining distance and in-person education. Assessment through on-line tests can also be conducted, but these must be considered open-book assessments where collaboration cannot be prevented. As such, this vehicle can be utilized effectively for continuing education programs in health care, where open book is permitted and credits are generally awarded on the honor system. However, tests for certificate courses should only be given with a proctor in attendance. In this instance, on-line tests can be used as pre-tests for the student, while being structured to enhance further learning.