It is not parents' fear of hypoglycaemia in isolation that leads to decisions to raise their child's blood glucose but, rather, parental fear in conjunction with other factors and considerations. Hence, to improve diabetes management in children, these factors may need to be addressed; for instance, by training others in diabetes management and using new technologies. Changes to consultations are also recommended.

These studies indicate that a regulatory subset of Iym0hocytes is missing in patients with juvenile rheumatoid arthritis but these patients have antibodies in their serum that react with normal T cells. This regulatory subset of T cells is, however, present in patients whose serum shows little or no reactivity with normal T cells. In addition, patients who are deficient in this regulatory subset of lymphocytes have siguificantly higher numbers of cells secreting Ig as measured by a hemolrtic plaque assay. The significance of these observations old: first, they represent a positive relationship among the loss of regulation, overproduction of immunoglobulin, and the presence of anti-T cell antibodies; and second, and perhaps of equal importance, is the indication that serum from patients with autoimmune diseases may give us a readil av'table reagent with which to dissect further functionally distinct subsets of normal T cells in man. Recent progress in murine systems has demonstrated that both the type and the intensity of the cellular and humoral immune responses can be regulated by a complex series of cellular interactions involving distinct subsets of lymphocytes (1)(2)(3). It has been shown that antigen triggers subpopulations of T lymphocytes capable of helping, amplifying, or suppressing other T-cell or B-cell responses (4, 5). The human T cell, like its counterpart in the mouse, expresses in vitro various functions including proliferation. in response to soluble and cell surface antigens, elaboration of mediators, activation by polyclonal mitogens, and cytotoxic activities (6). In man, it is now clear that regulatory T cells exist and can be defined by their functional properties in both normal (7-9) and pathologic states (10, 11). More recent data support the notion that T-cell help and suppression are mediated by different subpopulations of T cells bearing distinct Fc receptors (12) and cell surface antigens as defined by allo-and heteroantisera (13,14).We have previously shown that sera from four patients with juvenile rheumatoid arthritis (JRA) Patients. Records of all children who have attended the arthritis clinic at the Children's Hospital (Boston, MA) were reviewed. Only those children for whom a positive diagnosis of JRA was confirmed were included in the study (15). There were 30 children with this diagnosis. They were between 3 and 19 years of age and included 5 boys and 25 girls. The time interval between the onset of the disease and the time the blood sample was taken varied between a few weeks (4-6 weeks) and 16 years. The mode of onset was systemic in 3, monoarticular in 9, and pauci or polyarticular in 18. The criteria for classification as active disease or remission were based on objective findings by physical examination alone. Thus, children with at least one swollen joint were considered to have active disease, whether or not they had other physical abnormalities such as limitation of motion, signs of synovitis, or joint deformities. Patients in remission had normal results o...

A lack of awareness exists within healthcare services on the differences between the roles of advanced nurse practitioner (ANP) and clinical nurse specialist (CNS). This may lead to ambiguity in relation to the development, scope of practice and impact of these roles. The aim of this review was to compare the similarities and differences between the ANP and CNS within the research literature. Databases (CINAHL, Medline and Embase) were searched using selected search terms. This resulted in 120 articles of potential interest being identified. Following a rigorous review process for content and relevance, this was reduced to 12. Both roles are valuable and effective, predominately being clinically based with education, leadership and research components. CNS roles are specialist, ANP are more likely to be generalist. Where there is regulation and governance the role of the ANP is clearly defined and structured; however, a lack of governance and regulation is evident in many countries.

AimThis paper is a report of a study conducted to explore the perceptions of adults with type 2 diabetes towards the service redesign.

This study addressed the question 'What are the needs of community nurses in delivering palliative care to people with long-term conditions?' A qualitative exploratory descriptive design was employed. Ten community nurses (Band 5-7) were recruited from a purposive sample following a process of randomised stratified sampling, according to geographical area and Band for matched numbers. Semi-structured interviews were undertaken and audio recorded with written informed consent. The interviews were transcribed verbatim and analysed using an adapted Burnard's framework. The study found that establishing therapeutic relationships, having access to resources, co-ordination and provision of clinical care and collaborative working were all highlighted by the community nurses as needs in delivering palliative care. If these four needs were met, the community nurses believed they could deliver palliative care to their patients. Issues around a lack of resources, community nurses' educational needs and the late referral of patients with non-malignant long-term conditions to community nursing were also identified.

The purpose of this report is to examine health-related quality of life (HRQoL) as measured by the Medical Outcomes Study Short Form-36, across patient populations with chronic disorders and to compare quality of life (QoL) in these subjects with normative data on healthy persons. Six studies, within the Center for Research in Chronic Disorders at the University of Pittsburgh School of Nursing, in patients with urinary incontinence, prostate cancer, chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), fibromyalgia and hyperlipidaemia provided the data for analysis. The results demonstrated that not only did the prostate cancer and hyperlipidaemia patients have the highest QoL across the chronic disorders, but their QoL was comparable to normative data on healthy persons. Homebound, elderly, incontinent patients had the lowest QoL for physical functioning, whereas patients hospitalized with AIDS had the lowest QoL in general health and social functioning. Patients with COPD had the lowest QoL in role-physical, role-emotional and mental health. Patients with fibromyalgia had the lowest QoL in bodily pain and vitality. Compared to normative data, patients with urinary incontinence, COPD, AIDS and fibromyalgia generally had lower QoL. Prostate cancer and hyperlipidaemia patients had QoL comparable to normative data. Compared to normative data, patients with urinary incontinence, COPD, AIDS and fibromyalgia had more variability for role-emotional. AIDS patients had more variability on physical functioning, bodily pain and social functioning compared to the normative data. These data suggest that patients with various chronic disorders may have QoL that is lower in most domains compared to a healthy population. However, there may be differences in the domains affected as well as the extent of variation across specific chronic disorders.

With diabetes an ever-increasing problem across the developed world, a great deal of research has been carried out into the effects of the disease on the patient. Yet despite the fact that type 1 diabetes accounts for only a relatively small proportion of worldwide cases, it has been the focus of research attention. This study aimed to investigate the distress associated with type 2 diabetes, whether gender differences existed in the impact of type 2 diabetes and how men and women viewed dietary management. A multi-method, two-stage research approach was taken. Quantitative data were obtained using the Problem Areas in Diabetes (PAID) questionnaire, and no statistically significant gender difference was identified. Worrying about the future, the possibility of complications and feelings of guilt or anxiety when 'off-track' with diabetes management were sources of significant distress. Treatment mode, length of time diagnosed with diabetes and age were significant factors which impacted on the emotional distress experienced by the individual. A subsample of respondents took part in the survey. Behavioural impact, emotional impact and fear of complications were major themes identified in the interviews. Views of the dietary management of diabetes were also explored within the focus groups and three broad categories identified: dietary restrictions, value judgements and the influence of others. Awareness by health-care professionals of factors influencing adaptation to diabetes is recommended.

Objectives. To evaluate changes in health related quality of life (HRQL) for individuals with Type 2 diabetes following the introduction of a new community-based model of care. Methods. A survey method was used in which HRQL, Problems Areas In Diabetes (PAID) and demographics were assessed before and 18 months after introducing the new service. Results. Overall HRQL and PAID scores were lower than published levels in individuals with diabetes but remained stable during the transition to the new model of care except for the bodily pain domain and deteriorating PAID scores for older patients. Four domains of SF36 health showed deterioration in the highest socio-economic groups. Deterioration was also observed in males, most notably mental health, in patients aged 54 years or less, 75 years or more and patients from socio-economic groups 1 and 2. HRQL was lowest at baseline and follow-up in socio-economic groups 6 & 7. Low levels of distress in patients across all deprivation categories was observed but remained stable over the transition. Conclusions. HRQL and distress associated with diabetes remained stable following the introduction of the new community-based model of care except for deterioration in the bodily pain domain and deteriorating PAID scores for older patients. Relevance for Practice. (i) Health related quality of life assessment is practical and acceptable to patients. (ii) In clinical governance terms it is good practice to monitor the impact of change in service delivery on the health of the patients in your care. (iii) Screening with health related quality of life tools such as generic and disease specific tools could help identify health problems otherwise undetected within current clinical care. Systematic identification of the most vulnerable groups with Type 2 diabetes should allow care to be better targeted.