Depression-free day to utility-weighted score: is it valid?

BACKGROUND: Cost-utility analyses using formulas to convert depression-free days (DFDs) to utility-weighted scores are increasingly common. These formulas are based on linear extrapolation of data documenting the correlation between depression symptom severity and generic health-related quality of life. OBJECTIVE: We sought to examine the validity of formulas converting DFDs to utility weights. METHODS: We undertook an observational study with data collection at baseline, 1 week and 1, 3, 6, 9, and 12 months on 77 subjects (42 inpatient, 35 outpatient) diagnosed with current major depression. Subjects were divided into treatment response categories based on changes in depression severity. Depression severity measures used were the Hamilton Rating Scale for Depression (HAM-17) and Beck Depression Inventory (BDI) and the health-related quality of life measure was the self-administered Quality of Well-Being scale (QWB-SA). DFD calculations were based on depression severity scores and converted to utility weights using available formulas. Utility-weighted data collected over the course of 1 year were used to estimate quality-adjusted life years (QALYs). RESULTS: QALYs estimated from the QWB-SA were significantly lower than those based on utility-weighted DFD calculations but the incremental QALYs were not significantly different. Using a slightly lower utility-weighted conversion factor for the BDI or a larger BDI severity range to calculate DFDs resulted in a better fit compared with the QWB-SA. CONCLUSIONS: Our results support the validity of the existing HAM-17 utility-weighted formula and suggest modifications for the BDI formula. If generic health-related quality of life measures are not available for conducting cost-utility analyses of depression interventions then the existing HAM-17 and modified BDI formulas appear to be reasonable alternatives.     

Characteristics of schools of nursing operating academic nurse-managed centers

Academic nurse-managed centers (ANMCs) can be important sites for addressing the tripartite mission of the academy. Yet, limited information about numbers of ANMCs and the schools sponsoring them is available. This paper presents an update on schools of nursing (SONs) operating ANMCs. A survey was sent to 683 deans and directors of baccalaureate and higher-degree SONs, with 565 responding (response rate: 83%). Ninety-two SONs indicated they had one or more ANMCs. The largest percentage of the SONs with ANMCs were classified as doctoral/research-intensive or extensive universities, a proportion much higher than the national percent of SONs in this category. Schools of Nursing were financially supporting centers at a lower percentage of actual costs than was reported in earlier studies, although grants continue to be a major source of funding. Academic nurse-managed centers are likely to be supported by SONs with substantial research, practice, faculty, and student resources. Overall, the national number of ANMCs seems stationary over the past two decades.     

Nephron injury induced by diagnostic ultrasound imaging at high mechanical index with gas body contrast agent

The right kidney of anesthetized rats was imaged with intermittent diagnostic ultrasound (1.5 MHz; 1-s trigger interval) under exposure conditions simulating those encountered in human perfusion imaging. The rats were infused intravenously with 10 microL/kg/min Definity (Bristol-Myers Squibb Medical Imaging, Inc., N. Billerica, MA, USA) while being exposed to mechanical index (MI) values of up to 1.5 for 1 min. Suprathreshold MI values ruptured glomerular capillaries, resulting in blood filling Bowman's space and proximal convoluted tubules of many nephrons. The re-establishment of a pressure gradient after hemostasis caused the uninjured portions of the glomerular capillaries to resume the production of urinary filtrate, which washed some or all of the erythrocytes out of Bowman's space and cleared blood cells from some nephrons into urine within six hours. However, many of the injured nephrons remained plugged with tightly packed red cell casts 24 h after imaging and also showed degeneration of tubular epithelium, indicative of acute tubular necrosis. The additional damage caused by the extravasated blood amplified that caused by the original cavitating gas body. Human nephrons are virtually identical to those of the rat and so it is probable that similar glomerular capillary rupture followed by transient blockage and/or epithelial degeneration will occur after clinical exposures using similar high MI intermittent imaging with gas body contrast agents. The detection of blood in postimaging urine samples using standard hematuria tests would confirm whether or not clinical protocols need to be developed to avoid this potential for iatrogenic injury.     

Patients referred to a pain management clinic: beliefs, expectations and priorities

AIM: This paper is a report of a study to explore patients' pain-beliefs and emotions at the point of referral to a pain clinic, their expectations of the clinic and their priorities for improvement in aspects of their lives affected by pain. BACKGROUND: Chronic pain is a common experience and, although the percentage of people with pain referred to pain clinics is increasing, they often experience complex journeys through the healthcare system. Patients' beliefs about pain have been shown to influence their experience of pain and treatment outcomes, with a focus on the organic cause of pain reported. METHODS: Three focus groups were convened with 18 participants. Ten statements about pain were distributed to each participant and ranked according to their priorities. The data were collected in 2002-2003. FINDINGS: The participants' beliefs were dominated by the search for a firm diagnosis and cure. Participants held three main beliefs; that the cause of the pain must be established; that other people do not believe in the pain of a person without a firm diagnosis; and that painkillers are a way of 'fobbing you off'. Participants had little knowledge and few concrete expectations of the pain clinic. Their main priorities for improvement were 'less pain', 'some pain free times', and being able to do more 'everyday things'. CONCLUSION: Staff delivering pain management services must understand patients' beliefs and expectations and explain their own perspectives in order to provide a sound basis for working together.     

Factors impacting the expression of membrane-bound proteins in lymphocytes from HIV-positive subjects

BACKGROUND: The cellular transport proteins ABCB1, ABCC1 and ABCG2 have been implicated in the efflux of some antiretroviral drugs, thus decreasing their intracellular concentrations. Decreased drug accumulation in lymphocytes may allow viral replication and the subsequent emergence of viral resistance leading to treatment failure. Expression of HIV co-receptors on the surface of lymphocytes may influence viral tropism and therefore viral pathogenicity and disease progression. Here, we describe the relationship between expression of transport proteins and chemokine receptors in lymphocytes isolated from HIV-infected individuals and also investigate their relationship with demographic, therapeutic and virological factors. METHODS: Peripheral blood mononuclear cells (PBMC) isolated from HIV-positive individuals were co-stained for expression of CD4 and ABCB1, ABCC1, ABCG2, CXCR4 and CCR5. The influence of gender, ethnicity, treatment status, viral load and CD4 count was assessed on expression of each protein as well as correlations between expression of the proteins by univariate and multivariate analyses. RESULTS: Expression of ABCB1 was independently associated with gender (n = 98) and expression of ABCG2 and CXCR4. Gender also correlated with expression of ABCC1 and CXCR4 in univariate analysis with lower expression being detected in females compared with males. CONCLUSIONS: Here we confirm that the previously reported correlation between ABCB1 and CXCR4 observed in PBMC isolated from healthy volunteers is also found in HIV-positive individuals. The influence of gender on the expression of drug efflux proteins could be a determinant of intracellular drug concentrations in vivo.     

Postbaccalaureate nurse residency 1-year outcomes

The authors document the 1-year outcomes of the postbaccalaureate residency program jointly developed and implemented by the University Health-System Consortium and the American Association of Colleges of Nursing. Data on 2 cohorts of residents (n = 679) in 12 sites across the country are presented. The 1-year termination rate was 12%, after those lost to the program because of National Council Licensure Examination failure, serious illness, or death were eliminated from the analysis. Additional analyses using data collected at entry to the program, 6 months, and 1 year using 3 instruments, the Casey-Fink Graduate Nurse Experience Survey, the Gerber's Control Over Nursing Practice Scale, and the McCloskey Mueller Satisfaction Scale, are presented and discussed.     

Short-term effects on outcomes related to the mechanism of intervention and physiological outcomes but insufficient evidence of clinical benefits for breathing control: a systematic review

QUESTIONS: What is the volume, quality, consistency, and generalisability of the evidence for breathing control? What is the effect on outcomes related to the target and mechanism of breathing control, as well as physiological and clinical outcomes? DESIGN: Systematic review with meta-analysis. PARTICIPANTS: People with chronic respiratory disease, post-surgical, or asymptomatic individuals. INTERVENTION: Breathing control (relaxed basal, diaphragmatic, or abdominal breathing) as the sole intervention. OUTCOME MEASURES: All outcome measures providing continuous data. RESULTS: Twenty studies were included within the meta-analysis. A beneficial effect was found for abdominal movement (SMD 1.36, 95% CI 0.42 to 2.31), diaphragm excursion (SMD 1.39, 95% CI 1.00 to 1.77), respiratory rate (SMD -0.84, 95% CI -1.09 to -0.60), tidal volume (SMD 0.98, 95% CI 0.71 to 1.25), arterial oxygen saturation (SMD 0.63, 95% CI 0.25 to 1.02) and percutaneous oxygen (SMD 1.48, 95% CI 0.85 to 2.11). Breathing control had a detrimental effect on the work of breathing (SMD 1.06, 95% CI 0.52 to 1.60) and dyspnoea (SMD 1.47, 95% CI 0.88 to 2.05). CONCLUSION: When used as a sole intervention, there was a beneficial effect on outcomes related to the mechanism of breathing control as well as on short-term physiological outcomes. In people with severe respiratory disease, breathing control resulted in a detrimental effect on dyspnoea and work of breathing. There was no clear evidence of an effect on ventilation or long-term physiological outcomes related to gas exchange or the energy cost of breathing. Overall, evidence was satisfactory with studies demonstrating poor consistency, good generalisability, and satisfactory volume and quality.     

Financial analysis of acetaminophen suicide in a teen girl

There is no doubt that prevention and primary care treatment is less costly than emergency room efforts and tertiary care to save someone's life. Preventive health care is the cornerstone of any health care system designed to reduce costs and human suffering (American Nurses Association, 1997). Unfortunately, emergency room and intensive care nurses frequently care for critically ill children and adults who suffer from conditions that might have been prevented. This case study presents the financial breakdown of the costs at each level of care for an 18-year-old college student who suffers terrible consequences of an acetaminophen overdose.