How practice nurses engage with parents during their consultations about the MMR vaccine: a qualitative study.

AIM: We aimed to understand practice nurses' perceptions about how they engage with parents during consultations concerning the measles, mumps and rubella (MMR) vaccine. BACKGROUND: The incidence of measles is increasing globally. Immunisation is recognised as the most significant intervention to influence global health in modern times, although many factors are known to adversely affect immunisation uptake. Practice nurses are a key member of the primary care team responsible for delivering immunisation. However, little is known how practice nurses perceive this role. METHODS: Semi-structured interviews were undertaken with 15 practice nurses in England using a qualitative descriptive approach. Diversity in terms of years of experience and range of geographical practice settings were sought. These interviews were recorded, transcribed verbatim and open-coded using qualitative content analysis to manage, analyse and identify themes. FINDINGS: Three themes were derived from the data: engaging with parents, the informed practice nurse and dealing with parental concerns: strategies to promote MMR uptake. During their consultations, practice nurses encountered parents who held strong opinions about the MMR vaccine and perceived this to be related to the parents' socio-demographic background. Practice nurses sought to provide parents with tailored and accurate sources of information to apprise their immunisation decision-making about the MMR vaccine.

A single baseline ultrasound assessment of fibroid presence and size is strongly predictive of future uterine procedure: 8-year follow-up of randomly sampled premenopausal women aged 35-49 years.

STUDY QUESTION: How well can a single baseline ultrasound assessment of fibroid burden (presence or absence of fibroids and size of largest, if present) predict future probability of having a major uterine procedure? SUMMARY ANSWER: During an 8-year follow-up period, the risk of having a major uterine procedure was 2% for those without fibroids and increased with fibroid size for those with fibroids, reaching 47% for those with fibroids ≥ 4 cm in diameter at baseline. WHAT IS KNOWN ALREADY: Uterine fibroids are a leading indication for hysterectomy. However, when fibroids are found, there are few available data to help clinicians advise patients about disease progression. STUDY DESIGN, SIZE, DURATION: Women who were 35-49 years old were randomly selected from the membership of a large urban health plan; 80% of those determined to be eligible were enrolled and screened with ultrasound for fibroids ≥ 0.5 cm in diameter. African-American and white premenopausal participants who responded to at least one follow-up interview (N = 964, 85% of those eligible) constituted the study cohort. During follow-up (5822 person-years), participants self-reported any major uterine procedure (67% hysterectomies). Life-table analyses and Cox regression (with censoring for menopause) were used to estimate the risk of having a uterine procedure for women with no fibroids, small (<2 cm in diameter), medium (2-3.9 cm), and large fibroids (≥ 4 cm). Differences between African-American and white women, importance of a clinical diagnosis of fibroids prior to study enrollment, and the impact of submucosal fibroids on risk were investigated. PARTICIPANTS/MATERIALS, SETTING, METHODS: There was a greater loss to follow-up for African-Americans than whites (19 versus 11%). For those with follow-up data, 64% had fibroids at baseline, 33% of whom had had a prior diagnosis. Of those with fibroids, 27% had small fibroids (<2 cm in diameter), 46% had medium (largest fibroid 2-3.9 cm in diameter), and 27% had large fibroids (largest ≥ 4 cm in diameter). Twenty-one percent had at least one submucosal fibroid. MAIN RESULTS AND THE ROLE OF CHANCE: Major uterine procedures were reported by 115 women during follow-up. The estimated risk of having a procedure in any given year of follow-up for those with fibroids compared with those without fibroids increased markedly with fibroid-size category (from 4-fold, confidence interval (CI) (1.4-11.1) for the small fibroids to 10-fold, CI (4.4-24.8) for the medium fibroids, to 27-fold, CI (11.5-65.2) for the large fibroids). This influence of fibroid size on risk did not differ between African-Americans and whites (P-value for interaction = 0.88). Once fibroid size at enrollment was accounted for, having a prior diagnosis at the time of ultrasound screening was not predictive of having a procedure. Exclusion of women with a submucosal fibroid had little influence on the results. The 8-year risk of a procedure based on lifetable analyses was 2% for women with no fibroids, 8, 23, and 47%, respectively, for women who had small, medium or large fibroids at enrollment. Given the strong association of fibroid size with subsequent risk of a procedure, these findings are unlikely to be due to chance. LIMITATIONS, REASONS FOR CAUTION: Despite a large sample size, the number of women having procedures during follow-up was relatively small. Thus, covariates such as BMI, which were not important in our analyses, may have associations that were too small to detect with our sample size. Another limitation is that the medical procedures were self-reported. However, we attempted to retrieve medical records when participants agreed, and 77% of the total procedures reported were verified. Our findings are likely to be generalizable to other African-American and white premenopausal women in their late 30s and 40s, but other ethnic groups have not been studied. WIDER IMPLICATIONS OF THE FINDINGS: Though further studies are needed to confirm and extend the results, our findings provide an initial estimate of disease progression that will be helpful to clinicians and their patients.

Testing alternative ground water models using cross-validation and other methods.

Many methods can be used to test alternative ground water models. Of concern in this work are methods able to (1) rank alternative models (also called model discrimination) and (2) identify observations important to parameter estimates and predictions (equivalent to the purpose served by some types of sensitivity analysis). Some of the measures investigated are computationally efficient; others are computationally demanding. The latter are generally needed to account for model nonlinearity. The efficient model discrimination methods investigated include the information criteria: the corrected Akaike information criterion, Bayesian information criterion, and generalized cross-validation. The efficient sensitivity analysis measures used are dimensionless scaled sensitivity (DSS), composite scaled sensitivity, and parameter correlation coefficient (PCC); the other statistics are DFBETAS, Cook's D, and observation-prediction statistic. Acronyms are explained in the introduction. Cross-validation (CV) is a computationally intensive nonlinear method that is used for both model discrimination and sensitivity analysis. The methods are tested using up to five alternative parsimoniously constructed models of the ground water system of the Maggia Valley in southern Switzerland. The alternative models differ in their representation of hydraulic conductivity. A new method for graphically representing CV and sensitivity analysis results for complex models is presented and used to evaluate the utility of the efficient statistics. The results indicate that for model selection, the information criteria produce similar results at much smaller computational cost than CV. For identifying important observations, the only obviously inferior linear measure is DSS; the poor performance was expected because DSS does not include the effects of parameter correlation and PCC reveals large parameter correlations.

The impact of pamidronate on inpatient and outpatient services among metastatic breast cancer patients.

Our goal was to evaluate the impact of pamidronate therapy on medical resource utilization for treatment of bone metastases among patients with breast cancer. In this 12-center retrospective study, inpatient and outpatient resource utilization was abstracted from the medical charts of 295 patients with breast cancer who were diagnosed with bone metastases between July 1996 and April 1999. Data were abstracted from the time of bone metastasis diagnosis (baseline) to the present. The analysis compared non-pamidronate patients against pamidronate patients, who were stratified on the basis of whether their pamidronate therapy had been initiated within 3 months (early pamidronate group) or more than 3 months (late pamidronate group) after diagnosis. Resource utilization was compared among groups using multivariate regression analyses. A total of 101 early pamidronate, 72 late pamidronate, and 122 non-pamidronate patients were included in the analysis. The results showed that the early pamidronate group was roughly one-half as likely to have unplanned office visits attributable to bone metastases as the late pamidronate and non-pamidronate groups. The groups had a similar likelihood of ever being hospitalized for bone-related conditions; however, among those hospitalized, there were roughly one-half as many bone-related hospitalizations in the late pamidronate group as in the non-pamidronate group. Also, the mean length of stay was approximately 50% shorter in both pamidronate groups than in the non-pamidronate group. We conclude that pamidronate therapy may be associated with less medical resource utilization, particularly among patients hospitalized for bone-related conditions.

A comparison of solute-transport solution techniques and their effect on sensitivity analysis and inverse modeling results.

Five common numerical techniques for solving the advection-dispersion equation (finite difference, predictor corrector, total variation diminishing, method of characteristics, and modified method of characteristics) were tested using simulations of a controlled conservative tracer-test experiment through a heterogeneous, two-dimensional sand tank. The experimental facility was constructed using discrete, randomly distributed, homogeneous blocks of five sand types. This experimental model provides an opportunity to compare the solution techniques: the heterogeneous hydraulic-conductivity distribution of known structure can be accurately represented by a numerical model, and detailed measurements can be compared with simulated concentrations and total flow through the tank. The present work uses this opportunity to investigate how three common types of results--simulated breakthrough curves, sensitivity analysis, and calibrated parameter values--change in this heterogeneous situation given the different methods of simulating solute transport. The breakthrough curves show that simulated peak concentrations, even at very fine grid spacings, varied between the techniques because of different amounts of numerical dispersion. Sensitivity-analysis results revealed: (1) a high correlation between hydraulic conductivity and porosity given the concentration and flow observations used, so that both could not be estimated; and (2) that the breakthrough curve data did not provide enough information to estimate individual values of dispersivity for the five sands. This study demonstrates that the choice of assigned dispersivity and the amount of numerical dispersion present in the solution technique influence estimated hydraulic conductivity values to a surprising degree.

An exploratory study of nurses' perceptions of their role in neurological rehabilitation.

The role of the nursing profession in the multidisciplinary specialty of neurological rehabilitation has not been clearly defined in the United Kingdom. A qualitative exploratory study was performed in a highly specialized neurological rehabilitation unit. Nine registered nurses having at least 1 year of experience in this setting were interviewed in a semistructured manner. Transcripts of the interviews were subjected to a theme analysis. Three main themes emerged in relation to the role of the nurse. The first theme referred to actions directly related to patient care. This theme included four concepts: the promotion of patient independence, routine tasks, the management of patient care, and counseling. The second theme involved the organizational issues that influence practice. Nurse opinions and views of their roles formed the third theme. The subjects' views identified skills specific to neurological rehabilitation nursing and areas for further exploration.

Comparison of magnetic resonance imaging and transvaginal ultrasonography with hysterosalpingography in the evaluation of women exposed to diethylstilbestrol.

OBJECTIVE: To compare the ability of magnetic resonance imaging (MRI) and transvaginal ultrasound (TV-US) with that of hysterosalpingography (HSG) in detecting uterine abnormalities caused by in utero diethylstilbestrol (DES) exposure. STUDY DESIGN: The study was a prospective MRI and TV-US blind comparison of DES-exposed and nonexposed subjects who had had previous HSG for infertility evaluation. RESULTS: MRI identified uterine constrictions in 60% of patients and T-shaped uteri in 25% of DES-exposed patients with HSG-confirmed abnormalities. TV-US did not identify uterine constrictions or T-shaped uteri in DES-exposed patients. CONCLUSION: HSG must still be considered the preferred method in evaluating DES-related uterine abnormalities. HSG-defined uterine abnormalities associated with in utero DES exposure were variably identified by MRI and not at all by TV-US.

Isolation of telomere junction fragments by anchored polymerase chain reaction.

We describe a simple polymerase chain reaction (PGR)-based method for isolating short stretches of nontelomeric DNA adjacent to arrays of telomere repeat units, in principle applicable to any species for which the telomere repeat sequence is known. Application of this approach to human DNA resulted in the isolation of many candidate telomere junction clones, at least some of which were shown to be derived from telomere-adjacent regions. Most of the isolated clones detect multiple sequences in the human genome which represent one or a few sequence families present at the ends of most or all autosomes and variably truncated before the start of the telomere repeat array. Substantial sequence divergence between different members of these sequence families suggests a low rate of sequence homogenization by telomere exchange processes. The pseudoautosomal telomere junction has also been isolated and contains a shortened version of a recently described family of short interspersed repetitive elements (SINEs), only 14 base pairs (b.p.) from the start of the telomere.

Sonographic manifestations of medical renal disease.

Ultrasound is usually the first imaging procedure used to evaluate the kidneys in a patient presenting with renal failure. It can allow the physician to make a specific diagnosis of bilateral hydronephrosis as the cause of the renal failure and irreversible end-stage renal disease when bilaterally small echogenic kidneys are seen. In the early stages of medical renal disease, the kidneys may appear normal. As parenchymal diseases progress, changes in the echo architecture of the renal parenchyma take place. These changes, however, are nonspecific and ultrasound-guided biopsy may be necessary to determine the exact histological cause of the patient's renal failure.

Peptic ulcer disease: CT evaluation.

The authors retrospectively describe the computed tomographic (CT) findings in 35 patients with peptic ulcer disease. Three of eight patients with gastritis or duodenitis had bowel-wall thickening. Ten of the remaining 27 patients had CT evidence of ulcer perforation (n = 2) or penetration (n = 8), four cases of which were unsuspected clinically. Both patients with acute free perforation had pneumoperitoneum, and one showed free extravasation of orally administered contrast material. The precise site of perforation could not be established in either case with CT. The eight patients with ulcer penetration had CT evidence of bowel-wall thickening (n = 3) and inflammatory changes in adjacent soft tissues and organs (n = 8), including the pancreas (n = 4), liver (n = 1), and lesser omentum (n = 1). Ulcer craters were seen in only two. The CT findings of penetration can mimic other disease processes. CT was not useful in detecting uncomplicated peptic ulcer disease.

Computed tomography and acute pancreatitis.

Computed tomography (CT) is the best overall imaging modality in the clinical management of acute pancreatitis. It can detect complications such as phlegmonous extension outside the gland, abscess and pseudocyst formation, and hemorrhage. Pancreatic necrosis can be diagnosed with the use of dynamic CT scanning after the rapid bolus injection of iodinated contrast media. The information gathered can be used to guide clinical management and provide anatomic detail for percutaneous aspiration and drainage or surgical intervention when indicated.

A clinical evaluation of contrast-detail analysis for ultrasound images.

We report on the reproducibility of human observers' vanishing detection thresholds for visual targets in contrast-detail (C/D) analysis of ultrasound B-mode images. The images used in this study contain visual targets which are circular cross sections of constant-contrast conical structures in the C/D phantom. The vanishing threshold diameters for these targets vary as a function of the perceived size of the imaged target, target-to-background contrast, image noise content, and reproducibility of the decision levels of human observers for repeated observations. Our study indicates that the determination of absolute vanishing threshold diameter values for several targets of different contrast by human observers yields a high degree of error that is not predicted by existing theoretical assumptions based on a static threshold detector. We find that systematic error is introduced by the observers during the course of the experiment and that the levels of sensitivity of the observers differ widely at all times, and increase the amount of total observer error. These results suggest that, due to the large total observer error, C/D analysis may be impractical in a clinical environment, unless there is access to a team of observers specifically and extensively trained in this task. We suggest that a computer-based observer may be more reliable for the objective performance of contrast-detail analysis as a method for evaluating ultrasound image quality and comparison of imaging systems.

Biliary tract dilatation in chronic pancreatitis: CT and sonographic findings.

The authors retrospectively evaluated 44 patients with chronic pancreatitis to determine (a) what features on computed tomographic and sonographic scans were associated with biliary tract dilatation, (b) how these findings and biliary tract dilatation changed at follow-up, and (c) the correlation between the degree of biliary tract dilatation and the laboratory and histologic findings when available. Twenty-four patients had biliary tract dilatation; of this group 88% had pancreatic calcifications and 75% had a focal mass in the pancreatic head. Sixteen of the 24 patients underwent follow-up studies; in 12 there was no change in the degree of biliary tract dilatation or appearance of the pancreas. The levels of serum alkaline phosphatase and bilirubin were elevated in most of the 24 patients; at follow-up, however, there was no consistent relationship between these values and radiologic findings. Biopsy is recommended for those patients in whom the serum alkaline phosphatase level remains persistently elevated. Four of seven such patients in this study underwent biliary-enteric bypass procedures due to pathologic evidence of cholestasis.

Prenatal diagnosis of fetal anomalies using ultrasound and MRI.

In conclusion, it is unlikely that MRI will replace ultrasound as the primary obstetric imaging modality in the near future. Ultrasound has a proven record of accuracy and safety in addition to its easy access and low cost. MRI has promise, however, in providing crucial information in patients with underlying medical or surgical conditions that would ordinarily require ionizing radiation for evaluation. Currently, MRI is helpful in evaluating gross fetal anomalies and disturbances of fetal growth and development when ultrasound is limited by oligohydramnios or maternal obesity. Further experience is required to determine the value of spectroscopy and quantitative relaxation times regarding fetal metabolism and fetal well-being. Technologic improvements and software updates will reduce imaging time and increase spatial resolution, thus rendering MRI more competitive with existing imaging techniques. The ultimate role, however, that MRI will have in the evaluation of the fetus is currently undefined.

Adnexal and cul-de-sac abnormalities: transvaginal sonography.

Sixty-seven patients selectively chosen from 354 undergoing conventional transabdominal (TA) sonography for evaluation of a clinically suspected adnexal mass subsequently underwent transvaginal (TV) sonography either because the TA sonograms were technically suboptimal or because it was not possible to characterize with certainty an abnormality identified with TA sonography. TV sonography added diagnostically useful information in 25 of 28 patients with cystic pathologic changes in the adnexa uteri. Eight of 12 patients with tuboovarian abscess and nonspecific adnexal masses visualized with TA sonography had tube-shaped fluid collections characteristic of pyosalpinx identified with TV sonography. TV sonography added diagnostically useful information in all seven patients with diseases of the cul-de-sac (rectouterine fossa) and allowed differentiation of adnexal from primary uterine disease in three patients with TA sonograms on which findings were equivocal. It also expedited the diagnosis of a tubal pregnancy in ten of 14 patients and was useful in the detection of adhesions and perforated intrauterine devices. These results indicate that adjunctive TV sonography can provide important diagnostic information.