Group-based patient education delivered by nurses to meet a clinical standard for glaucoma information provision: the G-TRAIN feasibility study.

BACKGROUND: Globally, glaucoma is the leading cause of irreversible blindness. However, many patients with glaucoma do not understand their disease which reportedly impacts on their ability to manage their condition successfully. The aim of this feasibility study was to undertake research to inform a future randomised controlled trial of the effectiveness of group-based education for patients to improve adherence to glaucoma eyedrops. METHODS: Key objectives were to understand current provision of information during routine nurse-led glaucoma consultations, to investigate if it is possible to deliver patient information in line with a clinical standard by training nurses to deliver group-based education in multiple hospital sites and to explore the acceptability of group-based education to nurses and patients compared with usual information provision in consultations. This study employed quantitative and qualitative research methods situated in a sequential design across three hospitals in England and Wales. Current provision of information given to 112 patients with glaucoma across the three hospitals was observed and compared to that recommended in a clinical standard. Then, six nurses were trained to deliver group-based education. Following which, the level of information was assessed again in line with the clinical standard as the group-based education programme was delivered in the three hospitals to 16 patients in total. All nurses and six patients were interviewed to explore experiences of the group-based education sessions. RESULTS: The main area of information provided during routine nurse-led consultations concerned the management of glaucoma and that least covered was about prognosis of the disease and information about support services. Nurses were trained to implement group-based education for patients. Information was provided more often by the nurses about all the items of the clinical standard when delivering group based education. However, patients' motivation to attend were negatively impacted mainly by delays in delivering the education for the third phase and because the majority were established patients. Nurses and patients who participated found it useful and comprehensive. CONCLUSION: This feasibility study demonstrates that the proposed intervention for the randomised controlled trial, the group-based education, goes beyond current information provision, is in line with that articulated by a clinical standard and is implementable across several sites. This bodes well for a future randomised trial, but the following needs to be taken into account to ensure success: independent implementation of the research, training and delivery at each site, timely provision of the patient education, inclusion of new patients, and consistently delivered nurse training. TRIAL REGISTRATION: International Standard Randomised Controlled Trial number, ISRCTN91188805.

Holistic assessment of women with hyperemesis gravidarum: A randomised controlled trial.

BACKGROUND: Hyperemesis gravidarum or severe nausea and vomiting of pregnancy affects women's physical, social and psychological wellbeing and often requires frequent hospital admissions. Current standard care may be too medically focussed to meet all of women's complex needs. AIM: The aim of this study is to test where using a validated questionnaire, the Hyperemesis Impact of Symptoms tool, delivered by a nurse to assess the overall effect of hyperemesis on an individual woman's life and to provide advice tailored to her specific needs, will help her cope better with her symptoms and reduce admissions to hospital. DESIGN: This study was a two arm randomised controlled trial in which women with hyperemesis from four hospitals were randomly allocated to one of two groups: (1) usual care and (2) usual care plus assessment with the Hyperemesis Impact of Symptoms questionnaire and a care plan tailored to their responses. PARTICIPANTS AND METHODS: Recruitment was from women who were admitted with hyperemesis gravidarum; diabetic women or those over 14 weeks gestation were excluded. Those who consented completed questionnaires to assess their quality of life and the severity of symptoms at baseline and at three time points over the following 6 weeks. RESULTS: Women's average social functioning, Hyperemesis Impact of Symptom scores and average number of admissions were not significantly different between either group. The average number of days in hospital for the questionnaire and tailored plan group was significantly lower, 4.97, compared with 6.14 in the usual care group. Using the questionnaire to plan individualised care was not associated with significant reduction in health care costs. CONCLUSION: Using the Hyperemesis Impact of Symptoms questionnaire to tailor a care plan to address women's individual needs was not associated with any significant improvements in the quality of life. The cost effectiveness analysis did not indicate that the questionnaire is cost saving. The Hyperemesis Impact of Symptoms questionnaire is a practical tool for nurses and midwives to assess the overall impact of hyperemesis gravidarum on the individual and could be useful for assessing symptoms and evaluating physical, social and psychological changes following treatment in either clinical or research settings.

Analysis of 24-h recovery of transfused stored RBCs in recipient mice of distinct genetic backgrounds.

BACKGROUND AND OBJECTIVES: Human studies have demonstrated substantial donor-to-donor variation in refrigerated RBC storage with respect to several variables, including 24-h post-transfusion RBC recovery. However, the human studies leading to these observations are mostly performed using autologous transfusions of stored RBCs, thereby avoiding issues of infectious disease transmission and alloimmunization. Accordingly, one cannot distinguish whether variability in 24-h RBC recovery is due to alterations in RBC storage, differences in phagocytic activity of the recipient's reticuloendothelial system or both. Similar to humans, genetically distinct inbred mouse strains have substantial differences in RBC storage biology, including 24-h post-transfusion RBC recovery. MATERIALS AND METHODS: In this report, we juxtaposed 24-h recoveries in 15 distinct inbred strains of mice, holding the RBC donor constant to isolate transfusion recipient variation as an independent variable. Strains were chosen for differences in baseline reticulocyte count and haemoglobin, which may correlate to RBC life span and turnover. RESULTS: Unlike large differences observed in storage of RBCs obtained from different strains of mice, only subtle strain-to-strain differences were observed regarding 24-h post-transfusion RBC recoveries. CONCLUSIONS: These findings indicate that the murine strains examined are not likely to be useful in sorting out mechanisms of clearance of stored RBCs, and suggest that such mechanisms may be generally conserved in the strains of mice analysed.

Individualised patient care as an adjunct to standard care for promoting adherence to ocular hypotensive therapy: an exploratory randomised controlled trial.

PURPOSE: To evaluate the impact of individualised patient care, as an adjunct to standard care, on adherence to ocular hypotensive therapy. METHODS: A two-arm, single-masked exploratory randomised controlled trial recruited patients newly prescribed ocular hypotensive therapy. The intervention involved an individual assessment of health-care needs and beliefs and a 1-year follow-up period according to need. The primary outcome was refill adherence, measured by collating prescription and dispensing data for 12 months. Secondary outcomes included self-reported adherence, glaucoma knowledge, beliefs about illness and medicines, quality of care, intraocular pressure (IOP) fluctuation, and changes in clinical management assessed at 12 months. The strength of the intervention was measured following withdrawal by reviewing clinical outcomes for a further 12 months. RESULTS: In all, 127 patients were recruited (91% response rate). Intervention-arm patients collected significantly more prescriptions than control-arm patients. Self-report adherence was significantly better in the intervention-arm for patients who forgot drops and those who intentionally missed drops. The intervention group demonstrated significantly more glaucoma knowledge, expressed a significantly stronger belief in the necessity of eye drops and believed that they had more personal control over managing their condition. Control-arm patients had more IOP fluctuation and changes in clinical management. However, this finding only reached significance at 24 months. CONCLUSION: Modelling patient care according to health-care needs and beliefs about illness and medicines can have a significant impact on improving adherence to therapy for this patient group, with the potential benefit of improving clinical outcomes.

The MOEWAT as a proposed method of evaluating orbital exenteration wounds.

Orbital exenteration is a disfiguring and life-changing surgical procedure that involves the removal of the socket contents, including the eye, surrounding adnexa and, in some cases, the eyelids, orbital bone and sinuses. Wound healing of exenterated sockets can be complex and may take several months to completely heal. In an attempt to provide a framework for continuity of care for patients who undergo orbital exenteration surgery, we propose a socket wound assessment tool, which will allow professionals to track changes in orbital exenteration wounds. The Manchester Orbital Exenteration Wound Assessment tool (MOEWAT) has been developed to facilitate assessment and evaluation of postoperative exenterated sockets at any given time. Consequently, as the first assessment instrument specifically developed for use in orbital exenterated patients, the MOEWAT could provide a basis for wound-care decision-making in relation to clinical findings.

Preliminary survey of educational support for patients prescribed ocular hypotensive therapy.

PURPOSE: to establish the impact of educational support on patients' knowledge of glaucoma and adherence, in preparation for an intervention study. METHODS: structured observation encapsulated the educational support provided during clinical consultations and patient interviews captured the depth of glaucoma knowledge, problems associated with glaucoma therapy, and adherence issues. RESULTS: one hundred and thirty-eight patients completed the study. Education was didactic in nature, limited for many patients and inconsistent across clinics. Patients showed generally poor knowledge of glaucoma with a median score of 6 (range 0-16). A significant association was found between educational support and knowledge for newly prescribed patients (Kendall's tau=0.30, P=0.003), but no association was found for follow-up patients (Kendall's tau=0.11, P=0.174). Only five (6%) patients admitted to a doctor that they did not adhere to their drop regimen, yet 75 (94%) reported at interview that they missed drops. CONCLUSIONS: although important, knowledge alone may not sufficiently improve adherence: a patient-centred approach based on ongoing support according to need may provide a more effective solution for this patient group.

Pain relief during panretinal photocoagulation for diabetic retinopathy: a national survey.

AIMS: Panretinal photocoagulation (PRP) for proliferative retinopathy is known to be painful for some people; however, few studies have explored the effects of pain on the procedure within clinical practice. METHODS: This was a national survey of all Ophthalmic Units within the UK undertaken in late 2006. A questionnaire with 14 questions was developed, piloted, and sent to all NHS units in the UK. RESULTS: A 77% response rate was achieved. The vast majority of responses (96%) were from doctors. A large proportion (79%) of units see up to 20 cases a week and most patients require up to 5 sessions of PRP. Eighty-eight percent said that the procedure is painful. Once present, pain can affect the number and strength of burns delivered and indirectly increases the number of sessions required to complete the therapy. Sub-tenons anaesthesia was the most commonly used analgesic and there is some tentative evidence to support its effect. Few units have a pre-emptive analgesic protocol. Some respondents were using laser with lower exposure and reported reduced pain. CONCLUSIONS: PRP is painful; however, most units do not deliver pain relief pre-emptively. There may be a case to support the routine use of sub-tenons anaesthesia until the full effects of new laser techniques become known.

'Finding the person the disease has'--the case for multisensory environments.

Education about, and exposure to, the utilization of a multisensory environment (MSE) was provided to clinical staff as a response to findings from the problem identification stage of an action research study. Feedback was obtained about their experience and perceptions of its use. Through the auspices of focus groups and one-to-one interviews, respondents commented on the impact that using the MSE had on their perception of their clients and on subsequent care. The case is made that MSEs afford an opportunity to impact on care through their mediating influence on formal carers' perceptions of their clients and, as such represent a significant but as yet unrealized potential for improving the quality of care of older people with dementia.

An evaluation of the administration of sub-Tenon local anaesthesia by a nurse practitioner.

AIM: To evaluate the administration of sub-Tenon local anaesthesia (LA) by a nurse practitioner. METHODS: 106 consecutive patients listed for cataract surgery were given sub-Tenon's anaesthesia by a nurse practitioner. The surgical procedure was performed within 15 minutes of the administration of the LA. Pain, state and adequacy of anaesthesia, appearance of the eye, and patient anxiety were measured. Patients' experiences of this new nursing role were gained through interview. RESULTS: At the beginning of surgery, few patients showed eye movement in any of the four quadrants and the surgeons reported that akinesia was inadequate in only seven (7.1%) cases. Three patients (3.3%) gave a pain score of 3 out of 10 or above during surgery whereas the surgeons assessed the pain relief to be inadequate in eight (8.1%) cases. Five (5.3%) patients required a top up of anaesthesia and 51 (39.8%) patients developed conjunctival chemosis in two or more quadrants. Overall, patients' comments indicate that they were pleased with the new service. CONCLUSION: The results suggest that nurse practitioner delivered sub-Tenon LA is an effective and safe method of LA administration for cataract surgery.

Ethnic variation in fluorescein angiography induced nausea and vomiting.

PURPOSE: A prospective survey was undertaken to investigate ethnic variations in the frequency of nausea and vomiting after fundus fluorescein angiography (FFA). METHOD: Between May and September 1998, 197 adult patients were recruited to the study. A questionnaire containing closed-ended questions was completed by nurses after each FFA and a questionnaire was given to patients to complete 5 hours after the procedure at home. Patients' anxiety level was measured before FFA using a 5-item ordinal response scale. RESULTS: Results indicate that patients from black, Asian, Chino-Asian and mixed ethnic origins are significantly more likely to vomit and feel nauseous immediately after the administration of fluorescein dye. Patients with a history of nausea after FFA are significantly more likely to feel nauseous again after repeat FFA. CONCLUSION: Ethnic origin and a previous history of nausea and vomiting appear to be important factors in FFA-induced nausea and vomiting. The results of this study have led the investigators to develop a protocol for the prophylactic treatment of nausea and vomiting following FFA.

Randomised controlled trial of an integrated versus an optometric low vision rehabilitation service for patients with age-related macular degeneration: study design and methodology.

A number of studies have measured the outcomes of low vision care but these have usually been longitudinal case series, thus constituting very low quality of evidence for effectiveness. To date, there have been no randomised controlled trials (RCTs) which have evaluated the effectiveness and cost effectiveness of different models of care in low vision. The size of the low vision population and the paucity of systematic evaluation have created a pressing need for evidence about cost-effectiveness in order to inform service developments for low vision rehabilitation. This paper describes the study design and methodology of a three-arm RCT currently under way in Manchester. The baseline population recruited is also described. A traditional hospital-based optometric service is being compared with an integrated service (comprising the addition of community-based rehabilitation officer input) and with more generic community input (which is non-integrated and is not vision specific). A wide range of outcome measures are being assessed at recruitment and 12 months post-intervention, including low vision specific and generic quality of life measures, patterns of low vision aid use, and task performance. The rationale for the trial is discussed and the main study outcomes are described.

Molecular mechanisms underlying endocytosis and sorting of ErbB receptor tyrosine kinases.

The major process that regulates the amplitude and kinetics of signal transduction by tyrosine kinase receptors is endocytic removal of active ligand-receptor complexes from the cell surface, and their subsequent sorting to degradation or to recycling. Using the ErbB family of receptor tyrosine kinases we exemplify the diversity of the down regulation process, and concentrate on two sorting steps whose molecular details are emerging. These are the Eps15-mediated sorting to clathrin-coated regions of the plasma membrane and the c-Cbl-mediated targeting of receptors to lysosomal degradation. Like in yeast cells, sorting involves not only protein phosphorylation but also conjugation of ubiquitin molecules. The involvement of other molecules is reviewed and recent observations that challenge the negative regulatory role of endocytosis are described. Finally, we discuss the relevance of receptor down regulation to cancer therapy.

Tumor-inhibitory antibodies to HER-2/ErbB-2 may act by recruiting c-Cbl and enhancing ubiquitination of HER-2.

Overexpression of HER-2/ErbB-2, a homologue of the epidermal growth factor receptor, is associated with poor prognosis, and an ErbB-2-specific antibody is therapeutic when administered to patients with metastatic breast cancer. To understand the mechanism underlying immunotherapy, we concentrated on antibody- and epidermal growth factor-induced degradation of ErbB-2. We show that enhanced degradation is preceded by poly-ubiquitination of ErbB-2. This process necessitates recruitment of the c-Cbl ubiquitin ligase to tyrosine 1112 of ErbB-2. Consequently, mutagenesis of this site retards antibody-induced degradation. Thus, the therapeutic potential of certain antibodies may be due to their ability to direct ErbB-2 to a c-Cbl-regulated proteolytic pathway.

Threonine phosphorylation diverts internalized epidermal growth factor receptors from a degradative pathway to the recycling endosome.

Transregulation of the epidermal growth factor receptor (EGFR) by protein kinase C (PKC) serves as a model for heterologous desensitization of receptor tyrosine kinases, but the underlying mechanism remained unknown. By using c-Cbl-induced ubiquitination of EGFR as a marker for transfer from early to late endosomes, we provide evidence that PKC can inhibit this process. In parallel, receptor down-regulation and degradation are significantly reduced. The inhibitory effects of PKC are mediated by a single threonine residue (threonine 654) of EGFR, which serves as a major PKC phosphorylation site. Biochemical and morphological analyses indicate that threonine-phosphorylated EGFR molecules undergo normal internalization, but instead of sorting to lysosomal degradation, they recycle back to the cell surface. In conclusion, by sorting EGFR to the recycling endosome, heterologous desensitization restrains ligand-induced down-regulation of EGFR.

Molecular requirements for the effect of neuregulin on cell spreading, motility and colony organization.

Neuregulin can trigger morphogenetic signals in cells both in vivo and in culture through the activation of receptors from the ErbB family. We have ectopically expressed various ErbB-receptors in 32D myeloid cells lacking endogenous ErbB-proteins, and in CHO cells, which express only ErbB-2. We show here that activation of ErbB-3/ErbB-2 heterodimeric receptors triggers PI3-kinase-dependent lamellipodia formation and spreading, while individual ErbB-receptor homodimers as well as ErbB-3/ErbB-1 heterodimers are much less effective. CHO cells expressing ErB-3/ErbB-2 together with N-cadherin, an adhesion receptor, form epithelioid colonies. Neuregulin activates cell motility leading to transition of these colonies into ring-shaped multicellular arrays, similar to those induced by neuregulin in epithelial cells of different types (Chausovsky et al., 1998). This process requires both PI3-kinase and MAP kinase kinase activity and depends on coordinated changes in the actin- and microtubule-based cytoskeleton. Transactivation of ErbB-2 is not sufficient for the activation of cell motility and ring formation, and the C-terminal domain of ErbB-3 bearing the docking sites for the p85 subunit of PI3-kinase is essential for these morphogenetic effects. Thus, ErbB-3 in conjunction with ErbB-2 mediates, via its C-terminal domain, cytoskeletal and adhesion alterations which activate cell spreading and motility, leading to the formation of complex structures such as multicellular rings. Oncogene (2000) 19, 878 - 888.

Blood gas analysis: a study of blood loss in intensive care.

This paper describes a quantitative study conducted on an intensive care unit in the north of England. It involved the collection of data from the existing records of 65 patients consecutively sampled from a predetermined date provided that they stayed more than 24 hours and had an arterial line in situ. As patient records were used, ethical approval was not necessary. The objectives of the study were to quantify the mean number of blood gas samples taken per patient and estimate the mean blood loss resulting from this, including discard volume. Limitations include reliance on records and lack of an economic evaluation. The results show that blood loss in this study was greater than that reported elsewhere. Patients who were ventilated for 24 hours or more had a statistically significant greater blood loss when compared to those who were not (P < 0.001). A subgroup of patients undergoing renal replacement therapy had the greatest blood loss (mean 55.18 ml per day). This loss was statistically significant when compared to patients not in acute renal failure (P=0.007). When patients undergoing multiple therapies normally associated with increased sampling were compared to patients not receiving such therapies, there was no statistically significant difference in blood loss. The need to change current nursing practice to reduce iatrogenic anaemia is emphasized.

Trends in ophthalmology services, nursing skill-mix and education: 2nd national survey.

This paper reports on a replication study of the first national survey commissioned by the RCN Ophthalmic Nursing Forum to assess the changing skill-mix of staff caring for ophthalmic patients and the nature of ophthalmic services. After minor modifications to the original questionnaire, it was circulated to the total population of ophthalmic units and hospitals in the United Kingdom (n=181). Following quantitative data analysis, it was found that the numbers of nurses holding ophthalmic nursing qualifications has risen to almost 50%, although this did not reach statistical significance. This increase has occurred alongside a significant rise in numbers of institutions offering ophthalmic nurse education and the expansion of day case surgery. Regional variations exist, however, to the extent that the increase in ophthalmic nurses and provision of ophthalmic nurse education has not been reflected nearly as much in Scotland as the rest of the UK. Overall, it was also found that the proportion of C, G and I grade nurses has fallen significantly, whilst the numbers of nurses graded D and F has risen. The implications of the results are discussed and recommendations for future research made.

The effect of foot massage on patients' perception of care following laparoscopic sterilization as day case patients.

This randomized-controlled study examined the effects of foot massage on patients' perception of care received following surgery. The sample of 59 women who underwent laparoscopic sterilization as day case patients were randomly allocated into two groups. The experimental group received a foot massage and analgesia post-operatively, whilst the control group received only analgesia post-operatively. Each participant was asked to complete a questionnaire on the day following surgery. This examined satisfaction, memory and analgesia taken. The 76% response rate was comparable with other patient satisfaction studies following day-case surgery. Statistical analysis showed no overall significant difference in the pain experienced by the two groups; however, the mean pain scores recorded following surgery showed a significantly different pattern over time, such that the experimental group consistently reported less pain following a foot massage than the control group. This study has attempted to explore the use of foot massage in a systematic way and is therefore a basis for further study.