Effect of preventive primary care outreach on health related quality of life among older adults at risk of functional decline: Randomised controlled trial

Objective: To evaluate the impact of a provider initiated primary care outreach intervention compared with usual care among older adults at risk of functional decline. Design: Randomised controlled trial. Setting: Patients enrolled with 35 family physicians in five primary care networks in Hamilton, Ontario, Canada. Participants Patients: were eligible if they were 75 years of age or older and were not receiving home care services. Of 3166 potentially eligible patients, 2662 (84%) completed the validated postal questionnaire used to determine risk of functional decline. Of 1724 patients who met the risk criteria, 769 (45%) agreed to participate and 719 were randomised. Intervention: The 12 month intervention, provided by experienced home care nurses in 2004-6, consisted of a comprehensive initial assessment using the resident assessment instrument for home care; collaborative care planning with patients, their families, and family physicians; health promotion; and referral to community health and social support services. Main outcome measures: Quality adjusted life years (QALYs), use and costs of health and social services, functional status, self rated health, and mortality. Results: The mean difference in QALYs between intervention and control patients during the study period was not statistically significant (0.017, 95% confidence interval -0.022 to 0.056; P=0.388). The mean difference in overall cost of prescription drugs and services between the intervention and control groups was not statistically significant, (-$C165 (£107; €118; $162), 95% confidence interval -$C16 545 to $C16 214; P=0.984). Changes over 12 months in functional status and self rated health were not significantly different between the intervention and control groups. Ten patients died in each group. Conclusions: The results of this study do not support adoption of this preventive primary care intervention for this target population of high risk older adults. Trial registration: Clinical trials NCT00134836.

High-affinity NO(3-)-H+ cotransport in the fungus Neurospora:induction and control by pH and membrane voltage

High-affinity nitrate transport was examined in intact hyphae of Neurospora crassa using electrophysiological recordings to characterize the response of the plasma membrane to NO3- challenge and to quantify transport activity. The NO3(-)-associated membrane current was determined using a three electrode voltage clamp to bring membrane voltage under experimental control and to compensate for current dissipation along the longitudinal cell axis. Nitrate transport was evident in hyphae transferred to NO3(-)-free, N-limited medium for 15 hr, and in hyphae grown in the absence of a nitrogen source after a single 2-min exposure to 100 microM NO3-. In the latter, induction showed a latency of 40-80 min and rose in scalar fashion with full transport activity measurable approx. 100 min after first exposure to NO3-; it was marked by the appearance of a pronounced sensitivity of membrane voltage to extracellular NO3- additions which, after induction, resulted in reversible membrane depolarizations of (+)54-85 mV in the presence of 50 microM NO3-; and it was suppressed when NH4+ was present during the first, inductive exposure to NO3-. Voltage clamp measurements carried out immediately before and following NO3- additions showed that the NO3(-)-evoked depolarizations were the consequence of an inward-directed current that appeared in parallel with the depolarizations across the entire range of accessible voltages (-400 to +100 mV). Measurements of NO3- uptake using NO3(-)-selective macroelectrodes indicated a charge stoichiometry for NO3- transport of 1(+):1(NO3-) with common K(m) and Jmax values around 25 microM and 75 pmol NO3- cm-2sec-1, respectively, and combined measurements of pHo and [NO3-]o showed a net uptake of approx. 1 H+ with each NO3- anion. Analysis of the NO3- current demonstrated a pronounced voltage sensitivity within the normal physiological range between -300 and -100 mV as well as interactions between the kinetic parameters of membrane voltage, pHo and [NO3-]o. Increasing the bathing pH from 5.5 to 8.0 reduced the current and the associated membrane depolarizations 2- to 4-fold. At a constant pHo of 6.1, driving the membrane voltage from -350 to -150 mV resulted in an approx. 3-fold reduction in the maximum current and a 5-fold rise in the apparent affinity for NO3-. By contrast, the same depolarization effected an approx. 20% fall in the K(m) for transport as a function in [H+]o. These, and additional results are consistent with a charge-coupling stoichiometry of 2(H+) per NO3- anion transported across the membrane, and implicate a carrier cycle in which NO3- binding is kinetically adjacent to the rate-limiting step of membrane charge transit. The data concur with previous studies demonstrating a pronounced voltage-dependence to high-affinity NO3- transport system in Arabidopsis, and underline the importance of voltage as a kinetic factor controlling NO3- transport; finally, they distinguish metabolite repression of NO3- transport induction from its sensitivity to metabolic blockade and competition with the uptake of other substrates that draw on membrane voltage as a kinetic substrate.

NO3- transport across the plasma membrane of Arabidopsis thaliana root hairs:Kinetic control by pH and membrane voltage

High-affinity nitrate transport was examined in intact root hair cells of Arabidopsis thaliana using electrophysiological recordings to characterise the response of the plasma membrane to NO₃^-challenge and to quantify transport activity. The NO₃^--associated membrane current was determined using a three-electrode voltage clamp to bring membrane voltage under experimental control and to compensate for current dissipation along the longitudinal cell axis. Nitrate transport was evident in the roots of seedlings grown in the absence of a nitrogen source, but only 4-6 days postgermination. In 6-day-old seedlings, additions of 5-100 μm NO₃^-to the bathing medium resulted in membrane depolarizations of 8-43 mV, and membrane voltage (V_m) recovered on washing NO₃^-from the bath. Voltage clamp measurements carried out immediately before and following NO₃^-additions showed that the NO₃^--evoked depolarizations were the consequence of an inward-directed current that appeared across the entire range of accessible voltages (-300 to +50 mV). Both membrane depolarizations and NO₃^--evoked currents recorded at the free-running voltage displayed quasi-Michaelian kinetics, with apparent values for K_m of 23 ± 6 and 44 ± 11 μm, respectively and, for the current, a maximum of 5.1 ± 0.9 μA cm^-2. The NO₃^-current showed a pronounced voltage sensitivity within the normal physiological range between -250 and -100 mV, as could be demonstrated under voltage clamp, and increasing the bathing pH from 6.1 to 7.4-8.0 reduced the current and the associated membrane depolarizations 3- to 8-fold. Analyses showed a well-defined interaction between the kinetic variables of membrane voltage, pH_o and [NO₃^-]_o. At a constant pH_o of 6.1, depolarization from -250 to -150 mV resulted in an approximate 3-fold reduction in the maximum current but a 10% rise in the apparent affinity for NO₃^-. By contrast, the same depolarization effected an approximate 20% fall in the K_m for transport as a function in [H⁺]_o. These, and additional characteristics of the transport current implicate a carrier cycle in which NO₃^-binding is kinetically isolated from the rate-limiting step of membrane charge transit, and they indicate a charge-coupling stoichiometry of 2(H⁺) per NO₃^-anion transported across the membrane. The results concur with previous studies showing a high-affinity NO₃^-transport system in Arabidopsis that is inducible following a period of nitrogen-limiting growth, but they underline the importance of voltage as a kinetic factor controlling NO₃^-transport at the plant plasma membrane. © 1995 Springer-Verlag New York Inc.

Stress, coping and burn-out in nursing students

Aim: To explore the relationship between sources of stress and psychological burn-out and to consider the moderating and mediating role played sources of stress and different coping resources on burn-out.

Background: Most research exploring sources of stress and coping in nursing students construes stress as psychological distress. Little research has considered those sources of stress likely to enhance well-being and, by implication, learning.

Method: A questionnaire was administered to 171 final year nursing students. Questions were asked which measured sources of stress when rated as likely to contribute to distress (a hassle) and rated as likely to help one achieve (an uplift). Support, control, self-efficacy and coping style were also measured, along with their potential moderating and mediating effect on burn-out.

Findings: The sources of stress likely to lead to distress were more often predictors of wellbeing than sources of stress likely to lead to positive, eustress states. However, placement experience was an important source of stress likely to lead to eustress. Self-efficacy, dispositional control and support were other important predictors. Avoidance coping was the strongest predictor of burn-out and, even if used only occasionally, it can have an adverse effect on burn-out. Initiatives to promote support and self-efficacy are likely to have the more immediate benefits in enhancing student well-being.

Conclusion: Nurse educators need to consider how course experiences contribute not just to potential distress but to eustress. How educators interact with their students and how they give feedback offers important opportunities to promote self-efficacy and provide valuable support. Peer support is a critical coping resource and can be bolstered through induction and through learning and teaching initiatives. 

Stress, Positive Psychology and the National Student Survey

The aim was to explore the predictive ability of sources of stress and a range of dispositional and coping behaviours on student satisfaction and motivation. Most research exploring sources of stress and coping in students construes stress as psychological distress, with little attempt to consider positive experiences of stress. A questionnaire was administered to 120 first-year UK psychology students. Questions were asked which measured sources of stress when rated as likely to contribute to distress (a hassle) and likely to help one achieve (an uplift). The sources of stress were amended from the UK National Student Survey (NSS, 2011). Support, control, self-efficacy, personality and coping style were also measured, along with their potential affect on
course satisfaction, motivation and feeling part of a learning community. The sources of stress likely to lead to distress were more often significant than sources of stress likely to lead to positive, eustress states. Ironically,
factors one would consider would help students, such as the university support facilities, only did so when rated as a hassle, not as an uplift. Published university league tables draw heavily on student course satisfaction but this negatively correlated with intellectual motivation and feeling part of a learning
community. This suggests course satisfaction alone reveals an incomplete picture of the student experience. Course educators need to consider how course experiences contribute not just to potential distress but to
potential eustress. Teaching quality, effective support and work-life balance are key to student satisfaction and motivation. How educators interact with their students and the opportunities they create in and outside the class to promote peer support are likely to enhance satisfaction and motivation.

Development and Validation of a Forklift Truck Powertrain Simulation

Fuel economy has become an important consideration in forklift truck design, particularly in Europe. A simulation of the fuel consumption and performance of a forklift truck has been developed, validated and subsequently used to determine the energy consumed by individual powertrain components during drive cycles.
The truck used in this study has a rated lifting capacity of 2500kg, and is powered by a 2.6 litre naturally aspirated diesel engine with a fuel pump containing a mechanical variable-speed governor. The drivetrain consisted of a torque convertor, hydraulic clutch and single speed transmission.
AVL Cruise was used to simulate the vehicle powertrain, with coupled Mathworks Simulink models used to simulate the hydraulic and control systems and governor. The vehicle has been simulated on several performance and fuel consumption drive cycles with the main focus being the VDI 2198 fuel consumption drive cycle.
To validate the model, a truck was instrumented and measurements taken to compare the performance and instantaneous fuel consumption to simulated values. The fuel injector pump was modified and calibrated to enable instantaneous fuel flow to be measured.
The model has been validated to within acceptable limits and has been used to investigate the effect four different torque converters have on the fuel consumption and performance of the forklift truck. The study demonstrates how the model can be used to compare the fuel consumption and performance trade-offs when selecting drivetrain components.

Cortisol levels in relation to maternal interaction and child internalizing behavior in preterm and full-term children at 18 months corrected age

Cortisol levels were compared in children born preterm at extremely low gestational age (ELGA; 24-28 weeks), very low gestational age (VGLA; 29-32 weeks), and full-term in response to cognitive assessment at 18 months corrected age (CA). Further, we investigated the relationship between maternal interactive behaviors and child internalizing behaviors (rated by the mother) in relation to child cortisol levels. EGLA children had higher "pretest" cortisol levels and a different pattern of cortisol response to cognitive assessment compared to VGLA and full-terms. Higher cortisol levels in ELGA, but not full-term, children were associated with less optimal mother interactive behavior. Moreover, the pattern of cortisol change was related to internalizing behaviors among ELGA, and to a lesser degree VLGA children. In conclusion, our findings suggest altered programming of the hypothalamic-pituitary-adrenal (HPA) axis in preterm children, as well as their greater sensitivity to environmental context such as maternal interactive behavior.

Children's judgements about pain at age 8-10 years:do extremely low birthweight (<or = 1000 g) children differ from full birthweight peers?

Children's judgements about pain at age 8-10 years were examined comparing two groups of children who had experienced different exposure to nociceptive procedures in the neonatal period: extremely low birthweight (ELBW) <or = 1000 g (N = 47) and full birthweight (FBW) > or = 2500 g (N = 37). The 24 pictures that comprise the Pediatric Pain Inventory, depicting events in four settings: medical, recreational, daily living, and psychosocial, were used as the pain stimuli. The subjects rated pain intensity using the Color Analog Scale and pain affect using the Facial Affective Scale. Child IQ and maternal education were statistically adjusted in group comparisons. Pain intensity and pain affect related to activities of daily living and recreation were significantly higher than psychosocial and medically related pain on both scales in both groups of children. Although the two groups of children did not differ overall in their perceptions of pain intensity or affect, the ELBW children rated medical pain intensity significantly higher than psychosocial pain, unlike the FBW group. Also, duration of neonatal intensive care unit stay for the ELBW children was related to increased pain affect ratings in recreational and daily living settings. Despite altered response to pain in the early years reported by parents, on the whole at 8-10 years of age ELBW children judged pain in pictures similarly to their term peers. However, differences were evident, which suggests that studies are needed of biobehavioural reactivity to pain beyond infancy, as well as research into beliefs, attitudes, and perceptions about pain during the course of childhood in formerly ELBW children.

Pain sensitivity and temperament in extremely low-birth-weight premature toddlers and preterm and full-term controls

High-technology medical care of extremely low-birth-weight (ELBW) infants (<1001 g) involves repeated medical interventions which are potentially painful and may later affect reaction to pain. At 18 months corrected age (CCA), we examined parent ratings of pain sensitivity and how pain sensitivity ratings related to child temperament and parenting style in 2 groups of ELBW children (49 with a birth weight of 480-800 g and 75 with a birth weight of 801-1000 g) and 2 control groups (42 heavier preterm (1500-2499 g) and 29 full-birth-weight (FBW) children (> 2500 g). Both groups of ELBW toddlers were rated by parents as significantly lower in pain sensitivity compared with both control groups. The relationships between child temperament and pain sensitivity rating varied systematically across the groups. Temperament was strongly related to rated pain sensitivity in the FBW group, moderately related in the heavier preterm and ELBW 801-1000 g groups, and not related in the lowest birth-weight group (<801 g). Parental style did not mediate ratings of pain sensitivity. The results suggest that parents perceive differences in pain behavior of ELBW toddlers compared with heavier preterm and FBW toddlers, especially for those less than 801 g. Longitudinal research into the development of pain behavior for infants who experience lengthy hospitalization is warranted.

Judging pain in newborns:facial and cry determinants

Explored the facial and cry characteristics that adults use when judging an infant's pain. Sixteen women viewed videotaped reactions of 36 newborns subjected to noninvasive thigh rubs and vitamin K injections in the course of routine care and rated discomfort. The group mean interrater reliability was high. Detailed descriptions of the infants' facial reactions and cry sounds permitted specification of the determinants of distress judgments. Several facial variables (a brow bulge, eyes squeezed shut, and deepened nasolabial fold constellation, and taut tongue) accounted for 49% of the variance in ratings of affective discomfort after controlling for ratings of discomfort during a noninvasive event. In a separate analysis not including facial activity, several cry variables (formant frequency, latency to cry) also accounted for variance (38%) in ratings. When the facial and cry variables were considered together, cry variables added little to the prediction of ratings in comparison to facial variables. Cry would seem to command attention, but facial activity, rather than cry, can account for the major variations in adults' judgments of neonatal pain.

Family caregiver views on patient-centred care at the end of life

Aim: The purpose of this study was to evaluate the patient-centredness of community palliative care from the perspective of family members who were responsible for the care of a terminally ill family member. Method: A survey questionnaire was mailed to families of a deceased family member who had been designated as palliative and had received formal home care services in the central west region of the Province of Ontario, Canada. Respondents reported on service use in the last four weeks of life; the Client-Centred Care Questionnaire (CCCQ) was used to evaluate the extent to which care was patient-centred. The accessibility instrument was used to assess respondent perception of access to care. Descriptive and inferential statistics were used for data analyses. Results: Of the 243 potential participants, 111 (46.0%) family caregivers completed the survey questionnaire. On average, respondents reported that they used five different services during the last four weeks of the care recipient's life. When asked about programme accessibility, care was also perceived as largely accessible and responsive to patients' changing needs (M=4.3 (SD=1.04)]. Most respondents also reported that they knew what service provider to contact if they experienced any problems concerning the care of their family member. However, this service provider was not consistent among respondents. Most respondents were relatively positive about the patient-centred care they received. There were however considerable differences between some items on the CCCQ. Respondents tended to provide more negative ratings concerning practical arrangement and the organization of care: who was coming, how often and when. They also rated more negatively the observation that service providers were quick to say something was possible when it was not the case. Bivariate analyses found no significant differences in CCCQ or accessibility domain scores by caregiver age, care recipient age, income, education and caregiver sex. Conclusions: Patient-centred care represents a service attribute that should be recognized as an important outcome to assess the quality of service delivery. This study demonstrates how this attribute can be evaluated in the provision of care. © 2011 The Authors. Scandinavian Journal of Caring Sciences © 2011 Nordic College of Caring Science.

Barriers to providing palliative care in long-term care facilities

OBJECTIVE: To assess challenges in providing palliative care in long-term care (LTC) facilities from the perspective of medical directors. DESIGN: Cross-sectional mailed survey. A questionnaire was developed, reviewed, pilot-tested, and sent to 450 medical directors representing 531 LTC facilities. Responses were rated on 2 different 5-point scales. Descriptive analyses were conducted on all responses. SETTING: All licensed LTC facilities in Ontario with designated medical directors. PARTICIPANTS: Medical directors in the facilities. MAIN OUTCOME MEASURES: Demographic and practice characteristics of physicians and facilities, importance of potential barriers to providing palliative care, strategies that could be helpful in providing palliative care, and the kind of training in palliative care respondents had received. RESULTS: Two hundred seventy-five medical directors (61%) representing 302 LTC facilities (57%) responded to the survey. Potential barriers to providing palliative care were clustered into 3 groups: facility staff's capacity to provide palliative care, education and support, and the need for external resources. Two thirds of respondents (67.1%) reported that inadequate staffing in their facilities was an important barrier to providing palliative care. Other barriers included inadequate financial reimbursement from the Ontario Health Insurance Program (58.5%), the heavy time commitment required (47.3%), and the lack of equipment in facilities (42.5%). No statistically significant relationship was found between geographic location or profit status of facilities and barriers to providing palliative care. Strategies respondents would use to improve provision of palliative care included continuing medical education (80.0%), protocols for assessing and monitoring pain (77.7%), finding ways to increase financial reimbursement for managing palliative care residents (72.1%), providing educational material for facility staff (70.7%), and providing practice guidelines related to assessing and managing palliative care patients (67.8%). CONCLUSION: Medical directors in our study reported that their LTC facilities were inadequately staffed and lacked equipment. The study also highlighted the specialized role of medical directors, who identified continuing medical education as a key strategy for improving provision of palliative care.

A Family Booklet About Comfort Care in Advanced Dementia:Three-Country Evaluation

Objectives: To evaluate a booklet on comfort care in dementia from the perspective of family with relevant experience, and assess nursing home resident and family factors associated with evaluations. Design: Retrospective study. Setting: Long term care facilities in French-speaking Canada, and the Netherlands and Italy.
Participants: Bereaved family (n = 138).
Measurements: An 8-item scale assessed the booklet's acceptability. Usefulness was rated on a 0 to 10 scale, and perceived usefulness referred to usefulness if family had had the booklet during the resident's stay. Families indicated preferred ways of obtaining, and the most appropriate time to get the booklet.
Results: Almost all families (94%) perceived the booklet as useful. Canadian and Dutch families evaluated the booklet's contents and format favorably, whereas Italian families' evaluations were less favorable. Almost all families endorsed roles for physicians or nurses and about half additionally accepted availability through own initiative, in print or through the Internet. Preference of timing was highly variable. Better acceptability, usefulness, and availability through own initiative were independently associated with non-Italian nationality, presence of more physical signs discussed in the booklet, feeling ill-prepared, and higher satisfaction with care. A preference of receiving the booklet early was more likely in Italian families, those without university education, and those involved with older residents.
Conclusion: The booklet is suitable to inform Dutch and Canadian families on comfort care in dementia, but implementation in Italy requires further consideration. The booklet may be integrated in advance care planning in long term care, and made available outside long term care settings to serve families who wish to be informed early. © 2012 American Medical Directors Association, Inc.
Keywords: Decision aid; decision making; advance care planning; palliative care; nursing homes; dementia.

Behavior problems in children requiring inpatient rehabilitation treatment for asthma

Forty-eight asthmatic children (age 6-16 years), inpatients at the Hugh McMillan Medical Centre, were rated by their parents on their behavior using Achenbach's Child Behaviour Checklist. Completed checklists were used to determine normalized T scores for behavior syndromes, and these were compared against norms for clinically referred and nonreferred children. Behavior problems were elevated compared with nonreferred children for both boys and girls, with boys scoring at a clinical level. While many behavior problems were recognized, somatic complaints was a prominent syndrome, particularly for those in the 6-11-year age group.

Nanoscale Control of Phase Variants in Strain-Engineered BiFeO3

Development of magnetoelectric, electromechanical, and photovoltaic devices based on mixed-phase rhombohedral-tetragonal (R-T) BiFeO3 (BFO) systems is possible only if the control of the engineered R phase variants is realized. Accordingly, we explore the mechanism of a bias induced phase transformation in this system. Single point spectroscopy demonstrates that the T -> R transition is activated at lower voltages compared to T -> - T polarization switching. With phase field modeling, the transition is shown to be electrically driven. We further demonstrate that symmetry of formed R-phase rosettes can be broken by a proximal probe motion, allowing controlled creation of R variants with defined orientation. This approach opens a pathway to designing next-generation magnetoelectronic and data storage devices in the nanoscale.