Barriers and enablers to the use of venous leg ulcer clinical practice guidelines in Australian primary care: A qualitative study using the theoretical domains framework.

BACKGROUND: Venous leg ulcers represent the most common chronic wound problem managed in Australian primary care. Despite the prevalence of the condition, there is an evidence-practice gap in both diagnosis and management of venous leg ulcers. OBJECTIVE: We used the Theoretical Domains Framework to identify barriers and enablers perceived by primary care practitioners in implementing venous leg ulcer guidelines in clinical practice. DESIGN: We collected data to explore the experiences of practice nurses and general practitioners related to their use of clinical practice guidelines in management of venous leg ulcers. SETTING(S): We recruited participants from primary care settings located in metropolitan and rural areas across Victoria, Australia. PARTICIPANTS: We recruited general practitioners (15) and practice nurses (20). METHODS: We conducted 35 semi-structured face-to-face and telephone interviews. Content analysis of health practitioners' statements was performed and barriers to implementing clinical practice guidelines were mapped across the Theoretical Domains Framework theoretical domains. RESULTS: Six main domains from the Theoretical Domains Framework (Environmental context and resources, Knowledge, Skills, Social influences, Social/Professional Role and Identity and Belief about Capabilities) best explained these barriers and enablers. Many participants were not aware of venous leg ulcer clinical practice guidelines. Those that were aware, stated that finding and accessing guidelines was challenging and most participants relied on other sources of information. Venous leg ulcer management was greatly influenced by professional experience and suggestions from colleagues. Other barriers included busy clinical practice, absence of handheld Doppler ultrasonography, insufficient skills and a lack of confidence related to the use of technology to rule out arterial involvement prior to compression application, a particular skill related to venous leg ulcer management that will impact on healing outcomes. CONCLUSIONS: We identified a number of barriers and the lack of enablers that influence the uptake of venous leg ulcer clinical practice guidelines in primary care. This paper adds a theoretically sound, systematic approach for understanding and addressing the behaviour change required to improve translation of venous leg ulcer clinical practice guidelines in clinical practice. Tweetable abstract: The need to optimise venous leg ulcer clinical practice guidelines (CPG) has never been greater as the current estimate of health cost is AUD3billion and increasing due to rising epidemics of diabetes and obesity. We found most primary care health practitioners are unaware of CPG and this will impact on health and healing outcomes in Australian primary care.

Keratoconus and normal cornea: a comparative study of the collagenous fibers of the corneal stroma by image analysis.

Using an automatic image analysis technique, we studied the characteristics of the collagenous fibers of the corneal stroma of keratoconus at different stages of development. The clear portions of keratoconus specimens were studied at three different levels: anterior, middle, and posterior. The parameters obtained were compared with those of a normal adult cornea with the purpose of determining which ultrastructural alterations were caused by the appearance and progression of keratoconus.

Increase of pulmonary density of macrophages in sudden infant death syndrome.

A 1996 cytodensitometric study found increased cellular density in the pulmonary parenchyma of infants who died of sudden infant death syndrome (SIDS). The present study clarifies these results in quantifying the density of immunohistochemical subtyped inflammatory cells. Histomorphometry was used to compare the density of macrophages, granulocytes and T and B lymphocytes in the lungs of two groups of infants. From the post-mortem records of infant deaths between 1983 and 1995, 29 (mean age = 5 months) were randomly selected including 16 cases of SIDS and 13 who died of other non-pulmonary causes. Densities of immunoreactive cells were measured under blind conditions in the parenchyma. The mean density of macrophages was significantly higher in cases of SIDS compared with the controls (P = 0.0318), but there were no differences for the lymphocytes and the granulocytes. These morphometrical results must be interpreted within the methodological limits of this study, especially the non-uniform level of lung inflation between selected subjects. However, the differences in level of inflation are not sufficient to explain the observed increase of macrophage density. Indeed, the mean values of alveolar surface area, which represent an indirect measure of lung inflation, are not significantly different between the two groups. Increase of pulmonary macrophage density in SIDS agrees with three non-exclusive hypotheses: (1) an abnormal inflammatory reaction by expression of Th1 helper cell phenotype activation; (2) consequence of passive smoking; and (3) post-agonal mechanisms. Bacterial superantigens produced by toxigenic bacteria in the respiratory tract could play a role as a trigger factor that initiates a fatal cascade with overproduction of cytokines leading to death. The significant increase of pulmonary macrophage density would be the morphological expression of this potential mechanism of death.

International proficiency testing of analytical laboratories for foods and feeds from 1990 to 1996: the experiences of the United Kingdom Food Analysis Performance Assessment Scheme.

The Food Analysis Performance Assessment Scheme (FAPAS) organized by a Secretariat of the UK Ministry of Agriculture, Fisheries, and Food has checked the proficiency of analytical laboratories for foods and feeds from 1990 to 1996. FAPAS was started for UK laboratories but was expanded worldwide at the request of analysts in other countries who did not have a home-based scheme. Thirteen thousand homogeneity-checked test materials were issued, covering a very wide range of analytes, including pesticides, toxins, veterinary drug residues, trace and nutritional elements, food colors, preservatives, sweeteners, alcohol congeners, fatty acids, nitrate, and proximate analysis. Participants returned 85% of requested data, and 47,000 z-score proficiency assessments were made, of which 81% were satisfactory. Evidence is presented of improvements in overall analytical ability with increased participation in proficiency testing in the areas of proximate analysis; organochlorine pesticide analysis; and lead, mercury, and acesulfame-K analyses. Little improvement was shown in other analytical areas such as calcium analysis. Overall accuracies for analysis of specific pesticides and specific trace elements in the circulated test materials were compared.

Estimation of measurement uncertainty in pesticide residue analysis.

Proficiency test results from 5 countries involving 61 separate interlaboratory proficiency tests for pesticide residues were examined in this study. A total of 24 different matrixes and 869 relative standard deviations of the mean (or median) pesticide residue concentration were statistically evaluated in relation to the Horwitz function. The aim was to determine whether or not the concentration-dependent relationship described by Horwitz would hold for the much narrower range of chemicals and concentrations covered in routine pesticide residue analysis. Although for fatty (animal-derived) matrixes the variability increased as the concentration decreased in line with the Horwitz equation, the between-laboratories relative standard deviations for nonfatty matrixes (fruit, vegetables, and grain) remained at 25% over the entire concentration range of 1 microg/kg to 10 mg/kg for the pesticides studied. Given these findings, the Horwitz equation remains valid for calculating uncertainties involving pesticide residues in fatty matrixes. However, for pesticide residue analyses involving nonfatty matrixes, a constant relative standard deviation of 25% is more appropriate for calculating uncertainties, particularly when a reported result is assessed against a regulatory limit.

[Antiviral agents and cicatrization of the corneal stroma]. / Antiviraux et cicatrisation du stroma cornéen.

Infection of the cornea due to herpes simplex virus continues to be a problem for ophthalmologists despite treatment of the disease with antiviral drugs. These drugs are known to produce some toxic effects and prolonged administration is sometimes necessary. Using tensile strength measurements to assess tissue repair, healing of a 5 mm perforating corneal stromal incision was measured after treatment with different antiviral drugs four times a day for eighteen postoperative days. Results suggest that 3% adenine arabinoside, 3% acycloguanosine, 1% trifluorothymidine, and 1% iododesoxycytidine ointments do not delay (p greater than 0.05) normal stromal healing.

[Sclerocornea. Ultrastructural and morphologic study]. / Sclérocornée. Etude ultrastructurale et morphologique.

A 6 month old white male infant had bilateral congenital diffuse sclerocornea. A penetrating keratoplasty was performed in his left eye. Histologic examination by electron microscopy demonstrated: the presence of vacuoles in the superficial epithelial layer, the absence of Bowman's membrane, a disorganization of collagen fibers and lamellae more prominent in the middle stroma, and an extremely thin Descemet's membrane. A comparison, using an automatized image analysis method, was carried out between the stroma of sclerocornea and a normal cornea. Morphometric analysis of the collagenous fibril's diameter and the interfibrillar distances demonstrated a statistically significant difference (p less than 0.001) between the two corneas examined.

[PHZ-102 (epidermal growth factor) and cicatrization of the corneal epithelium]. / PHZ-102 (epidermal growth factor) et cicatrisation de l'épithélium cornéen.

Epidermal Growth Factor is a polypeptide isolated from mouse submaxillary glands and evaluated by histological studies. The healing of 7.3 mm diameter central corneal epithelial wounds after treatment with epidermal Growth Factor was measured by standardized photography. The results suggest that topically-administrated Epidermal Growth Factor, at a frequency of four (p less than 0.02) and six (p less than 0.001) times daily, significantly increases the corneal epithelial healing rate compared to the vehicle control. Histological examination of the control eyes enucleated after seven days of treatment showed an epithelium four to five layers in thickness. The basal cells had a round shape and round, centrally-positioned nuclei. The Epidermal Growth Factor treated group (six times daily) had an epithelial thickness of five to six layers. The basal cells were taller and more tightly-packed with oval nuclei oriented towards the apex of the cell.

[Morphologic and quantimetric study of the surface of the corneal epithelium]. / Etude morphologique et quantimétrique de la surface de l'épithélium cornéen.

Studies were conducted to attempt to demonstrate the presence of a twofold cell population in the superficial cells of the corneal epithelium as seen on scanning electron microscopy. Transmission electron microscopy was used to compare corneas washed with acetylcysteine with unwashed corneas after staining of surface mucosubstances with ruthenium red. Washing was found to remove some of the mucus film deposited by the tears on the epithelial surface. In contrast, both specimens showed a layer of substance, stained by the ruthenium red and more or less abundant according to the cell, which was thick enough to mask the microvillosities on scanning microscopy. Two distinct layers were observed. One of constant thickness was a thin layer which followed the outline of the microvillosities exactly but did not mask them. This was formed of glycocalix itself, a substance of cellular origin which was visible on developed cell surfaces even before desquamation of adjacent cells occurred. The other layer was more heterogeneous and attached to the cell wall, but it cannot be removed by washing with acetylcysteine. It also appeared on developed cell surfaces before adjacent cells had desquamated. The substance could arise from the lacrimal film or the necrozed remnants of superficial cells. It appears to increase in quantity with aging of the cell, and is capable of infiltrating between the microvillosities giving the appearance of dark cells on scanning microscopy. The different cells noted on scanning microscopy vary only by the amount of this mucin-like substance.(ABSTRACT TRUNCATED AT 250 WORDS)

Determination of aflatoxin levels in peanut butter using HPLC and ELISA procedures: Inter-laboratory comparison.

Six laboratories analyzed portions of the same aqueous acetonitrile extracts of three peanut butters for aflatoxin concentrations by an HPLC procedure (using immunoaffinity column clean - up) and by an ELISA procedure. The extracts were from a nominal "blank" peanut butter, a peanut butter naturally contaminated with aflatoxins (mostly B1), and from a "blank" peanut butter to which equal amounts of aflatoxin B1, B2, G1; and G2 standards had been added. Similar results for the HPLC and ELISA procedures were obtained for the blank (means 2.8 and 4.0µg/kg, respectively) and naturally contaminated (means 26.0 and 25.9µg/kg, respectively) peanut butters. However, the result by ELISA (mean 16.7µg/kg) for the spiked peanut butter was much lower than that obtained by HPLC (mean 28.3 µg/kg).

Quantitative analysis of tight junctions during ciliary epithelium development.

The tight junctions of the ciliary epithelium constitute the main morphological counterpart of the blood-aqueous barrier. Although well-known in the adult, they have only been poorly studied during the morphogenesis of the ciliary processes. We thus analysed them during this period in order to detect whether any changes appear in their general pattern. In the rat, results show that during ciliary body development, the junctional depth and the number of superimposed junctional fibrils decrease, the P-face intramembranous particle density within and outside the junctional domains increase, and particular structures, namely the 'complex strands', are numerous at the early stages and become rare in the adult. Thus, the tight junctions appear as non-stable structures during ciliary-body development and these modifications in their morphology may correspond to changes in barrier properties during the development of this tissue.

Determination of aflatoxin B1 levels in peanut butter using an immunoaffinity column clean-up procedure: inter-laboratory study.

Ten United Kingdom laboratories participated in an evaluation of an immunoaffinity column sample preparation procedure used to prepare aflatoxin B1 containing extracts obtained from peanut butters contaminated by aflatoxins. Each laboratory was sent seven randomly numbered samples of roasted peanut butter which included two sets of undisclosed triplicates. These two peanut butters were naturally contaminated with aflatoxin B1 at levels of about 12 and 35 micrograms/kg. The other sample was a nominal blank peanut butter containing approximately 2 micrograms/kg of aflatoxin B1 which was also employed by participants for recovery experiments. Participating laboratories were instructed to follow a protocol regarding the use of the immunoaffinity columns for extract preparation, but were allowed a free choice of instrumental technique for quantification of aflatoxin levels. Mean recovery for spikes was 72%. Coefficients of variation for the results from the 10 participants for the two contaminated roasted peanut butters were, respectively, 45% (on a mean of 13.6 micrograms/kg) and 36% (on a mean of 37.2 micrograms/kg).

A survey of the occurrence of agaritine in U.K. cultivated mushrooms and processed mushroom products.

The naturally occurring compound agaritine (beta-N-[gamma-L(+)glutamyl]-4-hydroxy-methylphenyl-hydrazine) has been determined in fresh, dried and processed mushrooms. A method was developed involving extraction of the toxin into methanol, clean-up where appropriate (for processed products) by high-performance size exclusion liquid chromatography and determination by reverse-phase HPLC with electrochemical detection. Diode array UV monitoring was used for confirmation. The method had a recovery of 90-98%, a relative standard deviation of 3-5% and a limit of detection of agaritine of 5 mg/kg on a dry-weight basis. Fresh cultivated mushrooms showed agaritine levels of 100-250 mg/kg and 80-190 mg/kg for two different commercial strains. There were slight differences in levels of agaritine between mushrooms of different sizes, and between those of the same size but harvested at different times (different breaks). Retail processed mushrooms products had low agaritine levels in the range 6-33 mg/kg, with the exception of one dried sliced mushroom product found to contain 6520 mg/kg.

Determination of aflatoxin concentrations in peanut butter by enzyme-linked immunosorbent assay (ELISA): study of three commercial ELISA kits.

Sixteen United Kingdom analytical laboratories participated in an evaluation of 3 commercially available enzyme-linked immunosorbent assay (ELISA) kits for analysis of aflatoxin in peanut butter. Each laboratory was sent 3 sets of 10 randomly numbered samples of peanut butter. Each set consisted of 5 pairs of undisclosed duplicates. Four of the sets of duplicates were naturally contaminated butters with "target" aflatoxin values (estimated by liquid chromatography) between 8 and 81 micrograms/kg. The fifth pair was a blank peanut butter containing approximately 3 micrograms/kg of total aflatoxins. A statistical treatment of the results of the study is presented, together with discussion of the relative merits of the different kits.

Liquid chromatographic determination of aflatoxin levels in peanut butters using an immunoaffinity column cleanup method: international collaborative trial.

Thirteen laboratories in 7 different countries participated in a collaborative trial to evaluate the immunoaffinity column cleanup procedure with quantitation by fluorescence liquid chromatography (post-column derivatization) for the determination of aflatoxins in peanut butters. Participants were sent 10 randomly numbered samples of roasted peanut butter for analysis (5 pairs of undisclosed duplicates). Two of the pairs were "blank" peanut butters to which aflatoxin standards had been added; these "spiked" samples were used for recovery purposes. The other 3 pairs of samples were a nominal "blank" and 2 naturally contaminated peanut butters. A full statistical presentation of the results is given. Coefficients of variation (CVs) for the total aflatoxin determinations for mean levels of 4, 15, and 38 microns/kg were between 32 and 44% for the blank and 2 trial samples. Recovery levels for the 2 spiked samples were 51-67%, with aflatoxin B1 recovery of 60%. Relative standard deviations for method repeatability (RSDr) and reproductibility (RSDR) for the 3 trial samples were 15-26% and 33-45%, respectively.

Surveillance and control of aflatoxin contamination of dried figs and fig paste imported into the United Kingdom.

Samples of dried figs and fig pastes from Turkey supplied voluntarily by UK importers and retailers during the period November 1988 to January 1989 showed both a high incidence and high levels of contamination with aflatoxins. In the samples tested, 24% had total aflatoxin concentrations above 10 micrograms/kg, with the highest level being 165 micrograms/kg. More rigorous monitoring of the 1989 fig harvest was undertaken on bulk consignments for all figs from Turkey entering the UK. For whole dried figs 20 kg samples were taken (as 20 sub-samples), and for fig paste 5 kg samples were taken (again as 20 sub-samples). Figs were minced, blended with water and mixed prior to sub-sampling for analysis. Analysis was by immunoaffinity column clean-up with HPLC determination of aflatoxins with fluorescence detection. Examination showed that 11% of 112 consignments of fig paste and 9% of 93 consignments of whole dried figs were contaminated with total alfatoxin concentrations above 10 micrograms/kg, with the highest level of contamination being 40 micrograms/kg. As a result of this surveillance programme 14 consignments of figs were refused entry into the United Kingdom.

A method for the analysis of lincomycin in porcine and bovine kidney.

A method of analysis has been developed for the estimation of lincomycin in porcine and bovine kidney. The method employed high performance liquid chromatography and Sep-Pak clean-up of methanolic tissue extracts and nitrogen specific gas chromatographic detection. Using spiked (0.1 mg kg-1) extracts recoveries in the range 40-50% were obtained. Analysis at the 0.05 mg kg-1 level is possible. Fifty four samples of kidney destined for UK sale were analysed for the presence of this drug. No samples were found to contain lincomycin.

Ammonia caramels: specifications and analysis.

Twenty three UK commercially produced ammonia caramels and eight experimentally produced ammonia caramels have been analysed by a range of physical and chemical tests, which include solids content, nitrogen levels, colour intensity and pH. A statistical treatment of the results is reported.

Drug-induced cicatricial pemphigoid affecting the conjunctiva. Light and electron microscopic features.

Cicatricial pemphigoid (CP) is a chronic inflammatory disease which can affect the conjunctiva. It is a slowly progressive disorder of unknown but presumed autoimmune etiology. Pseudopemphigoid, or CP associated with ocular drug administration, has also been described. These cases, which appear clinically indistinguishable from unilateral idiopathic CP affecting the conjunctiva, have been related to the use of echothiophate iodide, pilocarpine, idoxuridine, and epinephrine. We report the histopathologic and ultrastructural characteristics of 22 biopsies from ten patients with iatrogenic CP following the use of various ocular drugs. All patients presented with clinically obvious, active CP affecting the conjunctiva. Light microscopy and electron microscopy revealed findings identical to those previously reported for idiopathic CP of the conjunctiva: squamous metaplasia, increased numbers of desmosomes, basal lamina modifications suggestive of damage and attempted repair, subepithelial inflammatory cell infiltration, and diminished intravascular space within the stroma. These patients responded to immunosuppressive therapy. The authors wonder if it is possible that these patients were destined to develop CP, but that with topical ocular drug use, a more rapid emergence of the chronic cicatrizing feature of CP developed.