Foot wounds in diabetic patients. A comprehensive approach incorporating use of topical growth factors.

Managing nonhealing foot wounds in diabetic patients requires an understanding of the wounds' multiple contributing causes, including neuropathy, vascular occlusive disease, infection, and impaired wound healing. Proper attention to each cause may require consultations with vascular or orthopedic surgeons, diabetic education nurses, podiatrists, orthotists, and pedorthists. Wounds that fail to heal may respond to topical application of growth factors as part of a comprehensive clinical approach to the diabetic foot wound. An aggressive approach to diagnosis and treatment can result in improved wound healing and limb salvage.     

Management of a diabetic foot ulcer using larval therapy

Diabetic foot ulcers should be treated to maintain health status, improve quality of life, reduce the number of amputations and lower costs. Many centres that treat diabetic foot ulcers use a multidisciplinary team approach, which comprises medical staff, nurses, podiatrists and an orthotist. At the Manchester Diabetes Centre, larval therapy has been used for several years to debride sloughy diabetic foot ulcers. This case history demonstrates the adverse effects of diabetes on feet, and the multidisciplinary team's contribution to successful treatment and healing of a complex foot lesion.     

The relationship between quality of nursing care and the ward as a learning environment: developing a methodology

This paper describes the development of a methodology to study the relationship between quality of care received by patients and the quality of the ward as a learning environment for nurses in training. Firstly, the literature review and background literature to the research question are described. Secondly, the methodology or rationale for the choice of methods is discussed. Key research perspective include (a) the role of the participant observer in generating low level grounded theory or working hypotheses and (b) triangulation of the data using a multi-method approach. The organization of the project is outlined schematically and the research setting and data collection described. The final section of the paper discusses preliminary findings as illustrative of the grounded theory approach, i.e. the analysis of the data as they are collected and the formulation of working hypotheses to be tested and developed as the research progresses.     

Evaluation of the impact of an educational initiative in diabetic foot management

The diabetic foot project was an initiative designed to help develop a training package for community nurses and podiatrists. It also aimed to evaluate the impact of two days' training on the knowledge and reported practice of nurses and podiatrists in the management of the diabetic foot. The study used a two-group pre- and post-test design, which replicated the work of Luker and Kenrick (1993) and Nelson and Jones (1997). The Wilcoxon signed-rank test was used to determine if there was a difference between the experimental and control group scores. The results reported demonstrate the positive effect of the study days on practitioners' knowledge and reported practice, and the study has highlighted the potential to improve practitioners' knowledge and reported practice.     

The diabetic foot

A comprehensive program focused on foot-specific patient education, skin and nail care, and protective footwear lowers the incidence of diabetic foot ulcers and lower extremity amputations. Orthopedic or podiatric consultations are warranted for those “at risk” or with foot ulcers. The author has stated that he does not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article.     

Podiatric care for diabetic patients with foot problems: an observational study

The aims of this study were to describe podiatric care for diabetic patients with foot problems and to explore the changes in knowledge, self-care behaviour and physical functioning after podiatric care. The treatment characteristics of 26 diabetic patients referred to podiatry were assessed. Prior to the first podiatric visit (T1) and 20 weeks later (T2) these patients filled in a structured questionnaire and performed a six-minute walking test. In half the number of patients preventive goals were set and strived for by general education about the diabetic foot and advice on footwear and self-care behaviour. With regard to treatment, reduction of pain was the most frequently selected goal. To achieve this reduction, a variety of interventions was applied. After podiatric care, patients reported having less severe foot pain and some improvements in functional ability and self-care behaviour were found. This study offers clues to start controlled clinical trials on the effectiveness of podiatry for diabetic patients. Trials should not only be directed to (the role of podiatry in) ulcer healing; it may be even more significant to study its effectiveness for the purpose of prevention and treatment of early-stage diabetic foot symptoms.     

Managing faecal retention and incontinence in neurodisability

The large number of patients with faecal retention and/or incontinence in continuing care wards and rehabilitation units presents a considerable challenge. In order to maintain dignity and minimize the unpleasant odour so commonly associated with these wards and units, effective bowel management should be planned for individual patients. For an effective bowel management regime a team approach should be adopted, involving, where possible, the patient and carer as well as all the health professionals administering the care. Two case studies illustrate the use of assessment and management of bowel problems in patients with severe complex neurodisability. Bowel dysfunction in this patient population, in general, is poorly covered in the literature. The present article, by relating theory to practice, offers information and guidance for nurses working with patients who have bowel-related problems.     

The referral process in health visiting

The aim of this paper is to explore the concept of referral as it emerged from an in-depth qualitative study of health visiting practice. The study was conducted using a grounded theory approach to data collection and analysis (Glaser and Strauss, 1967). Forty-five experienced health visitors were interviewed using a semi-structured interview guide. The interviews were tape recorded and later transcribed. A detailed analysis is presented of the processes involved in referring. This includes working up the client for referral, working up the agency, third party referrals, and issues of control in the referral process. The outcome of referral in terms of the effect on the client is also discussed. This paper makes a contribution to our understanding of the microprocesses in everyday health visiting practice.     

Etiopathogenesis of reflex sympathetic dystrophy: a review and biopsychosocial hypothesis.

Reflex sympathetic dystrophy (RSD) is an enigmatic condition. Many clinicians, however, believe that psychological factors could contribute to the onset and persistence of the syndrome. In this article we critically review the evidence from psychometric and psychodynamic/biographical studies that suggests a role for such factors. An etiopathogenetic hypothesis based on the authors' clinical experience and the foregoing literature also encompasses elements of stress-coping theory, cognitive-behavioral views on chronic pain, and the psychobiological approach to sympathetic nervous system dysfunction. Implications of this model for future psychological research and the therapeutic treatment of RSD are discussed.     

Applied hand anatomy: its importance in accident & emergency.

Hand injuries account for 10-20% of an Accident & Emergency department's workload. Early recognition of serious injury is vital to ensure appropriate management. This is only possible with a good working knowledge of hand anatomy. Forty consecutive A&E senior house officers (SHOs) were assessed on their knowledge of basic hand anatomy. The results are discussed as are the implications for undergraduate and post-graduate training.     

Learning pathways in contemporary primary care settings – Student nurses’s views

Workforce planning to address nursing supply along with curriculum change affecting practice placements has acted as key drivers shaping learning resources for student nurses within Aberdeen Community Health Partnership. As part of their learning, students are afforded the opportunity to visit a range of contemporary primary care settings such as public health, specialist nurses and NHS 24 on what are known as ‘pathway experiences’. This research adopted a qualitative approach using focus group interviews to discover students’ learning as a result of this initiative. Two main themes emerged, these being ‘Healthcare contexts’ and ‘Nursing know-how’. Students developed a greater awareness and understanding about the delivery of healthcare in primary care settings and they expanded their nursing knowledge and skills. While students valued the experience, they also thought pathways fragmented their time at the base placement and detracted from gaining the practical nursing skills they considered of prime importance in their transit towards qualifying and working within a clinical setting. Implications for the future development of the pathway initiative are discussed.     

Surgical removal of a large mobile left ventricular thrombus via left atriotomy

Left ventricular(LV) thrombus is a life-threatening complication of severe LV dysfunction. Ventriculotomy has been a commonly performed procedure for LV thrombus; however, it often further decrease LV function after surgery. We present an alternative approach to thrombectomy in order to minimize the postoperative LV dysfunction. A 37-year-old female with a postpartum cardiomyopathy found to have poor LV function and a large left ventricular apical thrombus(3 cm × 3 cm) attached to the apex by a narrow stalk. Given her severe LV dysfunction, the LV thrombus was approached via left atriotomy under cardiopulmonary bypass. The LV thrombus was easily extracted with gentle traction via the mitral valve. Postoperatively, the patient was discharged home without any embolization event or inotropic support. LV thrombectomy via left atriotomy through the mitral valve could be an alternative option for the patients with poor LV function with a mobile LV thrombus.     

Expert practice: the interventions used by a community mental health nurse with carers of dementia sufferers.

The role of the Community Mental Health Nurse working with carers of dementia sufferers is investigated using a case study approach. Ten specific themes (socializing, assessing, coping strategies, advice, family dynamics, liaison, education, counselling, crisis intervention and loving) are identified and discussed. Links are drawn between theory and practice and suggestions for future research are made.     

Student nurses' attitudes towards working with older patients

BACKGROUND: The ageing of the United Kingdom (UK) population means that the care of older people will become an increasingly important part of nurses' remit. However, employment statistics suggest that this is an unpopular nursing specialism. This may be due to a number of factors, one of which may be nurses' negative attitudes towards working with older people. This constitutes a potential problem, especially if such attitudes have an impact on the quality of care provided. AIM: To examine the attitudes held by student nurses towards working with older patients. METHODS: Questionnaires incorporating Likert-type scales, two vignettes and demographic questions were designed using the theory of planned behaviour. These were distributed to 172 student nurses undertaking preregistration nursing courses in the UK during the academic session 2000-2001. RESULTS: Student nurses displayed positive intentions towards working with older patients. These were based on their own attitudes and beliefs about what others would wish them to do. Participants believed that their behaviour towards older patients was to a large extent under volitional control. Analysis of the beliefs underlying student nurses' views showed that they differentiated between those participants who had a relatively positive approach to their work with older patients and those with a less positive approach. In addition, the results offered mixed support for the view that more knowledgeable or experienced nurses hold more positive views towards older people. CONCLUSIONS: The findings offer some support for previous studies that have looked at the more general issue of attitudes towards older people. However, the results also indicate that a more rigorous and more highly focused approach to the study of such attitudes is required if the research is to be relevant to the issue of working with older patients. The theoretical, methodological and practical implications of the findings are discussed.     

Cognitive rehabilitation: a model for occupational therapy

A theoretical model that provides a foundation for understanding function and dysfunction in cognition and perception is needed as a prerequisite for the development of effective assessment and treatment tools to be used with the brain-injured adult. Such a model and clear definitions are absent in the occupational therapy literature on adult brain function and dysfunction. This paper represents a cognitive rehabilitation model adapted for occupational therapy from the fields of neuropsychology and cognitive psychology. Differentiation of terms, an overview of the model's theory, and evaluation principles are discussed. Cognitive rehabilitation is presented from an information processing perspective. Three other treatment approaches identified in the literature are discussed and compared with cognitive rehabilitation.     

fMRI Applications in Schizophrenia Research

fMRI has unique potential in the study of psychiatric patients, particularly in characterizing individual variations and changes over time. We have performed four studies of patients with schizophrenia, using three different fMRI acquisition protocols: (1) 3-D echo-shifted FLASH, a multishot volumetric approach; (2) 3-D PRESTO, a hybid of multishot and echo-planar imaging (EPI) methods that also acquires true volumetric data; and (3) a whole-brain isotropic, multislice EPI technique. Patients were studied during sensorimotor activation and during a novel “Nback” working memory paradigm. In general, patients show normal sensorimotor activation responses, although motor cortical activation tends to be less completely lateralized. Prefrontal activation during working memory tends to be reduced in patients with schizophrenia even when performance is normal. A major potential confound in studying this patient population with fMRI is the effect of motion. We propose several methodological standards to address this problem, including comparisons of motion corrections parameters, voxel variances, and the use of an “internal activation standard.”     

Sepsis-induced immune dysfunction: can immune therapies reduce mortality?

Sepsis is a systemic inflammatory response induced by an infection, leading to organ dysfunction and mortality. Historically, sepsis-induced organ dysfunction and lethality were attributed to the interplay between inflammatory and antiinflammatory responses. With advances in intensive care management and goal-directed interventions, early sepsis mortality has diminished, only to surge later after “recovery” from acute events, prompting a search for sepsis-induced alterations in immune function. Sepsis is well known to alter innate and adaptive immune responses for sustained periods after clinical “recovery,” with immunosuppression being a prominent example of such alterations. Recent studies have centered on immune-modulatory therapy. These efforts are focused on defining and reversing the persistent immune cell dysfunction that is associated with mortality long after the acute events of sepsis have resolved.     

Strategies underlying the control of disordered movement

The purpose of this article is fourfold. First, a theory of motor control--the dual-strategy hypothesis--is outlined. Second, the methodologies and theoretical framework that are used to develop this theory are examined. Third, motor dysfunction is discussed in the context of this theory. In particular, Down syndrome, Parkinson's disease, cardiovascular accidents, and spasticity are discussed. Finally, potential applications of the theory to physical therapy are considered.     

Application of surface-enhanced resonance Raman scattering (SERS) to the study of organic functional materials: electronic structure and charge transfer properties of 9,10-bis((E)-2-(pyridin-4-yl)vinyl)anthracene

The electron donor–acceptor properties of 9,10-bis((E)-2-(pyridin-4-yl)vinyl) anthracene (BP4VA) are studied by means of surface-enhanced Raman scattering (SERS) spectroscopy and vibronic theory of resonance Raman spectroscopy. The SERS spectra recorded in an electrochemical cell with a silver working electrode have been interpreted on the basis of resonance Raman vibronic theory assisted by DFT calculations. It is demonstrated that the adsorbate–metal interaction occurs through the nitrogen atom of the pyridyl moiety. Concerning the electron donor–acceptor properties of the adsorbate, it is shown that the charge transfer excited states of BP4VA are not optically active, in contrast, an internal transition to an excited state of BP4VA, which is localized in the anthracene framework, is strongly allowed. The charge transfer states will be populated by an ultrafast non-radiative process, that is, internal conversion. Thus, irradiation of BP4VA interacting with an appropriate surface creates an effective charge separation.

Surface enhanced Raman spectroscopy in conjunction with quantum chemistry is a valuable tool for characterization of organic functional materials.