Preparing for hemodialysis: patient stressors and responses

This qualitative study explored stressors experienced by individuals with chronic kidney disease (CKD). Individuals on hemodialysis were asked to share their recollections regarding stressors they experienced as they approached dialysis. Content analysis was used and the following themes emerged: (a) stressors; (b) emotional responses; (c) learning, preparation, and acceptance; and (d) regret and dissatisfaction. The results of this study have important implications for patient education and support in the care of patients with CKD.

Accidental head injuries in children under 5 years of age

AIM

To evaluate the type and nature of head injuries sustained by children under the age of 5 years who present to a busy accident and emergency (A&E) department following an accidental fall.

MATERIALS AND METHODS

This study included all children under the age of 5 years, who over an 8-month period were referred to our A&E Department with head injury following an accidental fall. Data were collected regarding the height of the fall, whether or not stairs were involved, the type of surface that the child landed on and the height of the child. This was correlated with any soft-tissue injury or skull fracture.

RESULTS

A total of 72 children (aged 4 months to 4.75 years) fulfilled all the criteria for an accidental fall. The heights of the falls ranged from less than 50 cm to over 3 m, with the majority below 1 m. Of the falls, 49 were onto a hard surface and 23 were onto a soft surface. Of the 72 children, 52 had visible evidence of head injury, 35 (71%) of 49 being the result of falls onto hard surfaces and 17 (74%) of 23 onto soft (carpeted) surfaces. There was no significant difference in the type of surface that resulted in a visible head injury. A visible head injury was seen in all children who fell from a height of over 1.5 m and in 95% of children who fell over 1 m. Of the 72 children, 32 (44%) had skull radiographs performed in accordance with established guidelines and 4 (12.5%) were identified as having a fracture. Of the 3 linear parietal fractures 2 were inflicted by falls of just over 1 m (from a work surface) and 1 by a fall of 80 to 90 cm onto the hard-edged surface of a stone fire surround. The 4th was a fracture of the base of skull following a fall from more than 3 m (from a first-storey window).

CONCLUSIONS

In the vast majority of domestic accidents children do not suffer significant harm. Skull fractures are rare and probably occur in less than 5% of cases. To cause a skull fracture the fall needs to be from over 1 m or, if from a lesser height, then a small-area impact point should be considered an integral component of the injury.

Hyperpigmented scar due to minocycline therapy

A 20-year-old woman presented with a heavily pigmented scar on the left lower abdomen following excision of a benign compound nevus. Reexcision showed an organizing scar with pronounced hemosiderinlike pigment deposition and no residual melanocytic lesion. Results of further histopathologic workup showed positive staining with both Perls stain for iron and Fontana-Masson stain. These findings led to further questioning of the patient, which revealed a history of minocycline therapy--information that had not been provided during her initial evaluation. Hyperpigmented scars may result from minocycline ingestion. We present a review of the literature, with particular regard to the possible mechanisms of minocycline hyperpigmentation and the differential diagnosis of hyperpigmented scars.

Nanometer size diesel exhaust particles are selectively toxic to dopaminergic neurons: the role of microglia, phagocytosis, and NADPH oxidase

The contributing role of environmental factors to the development of Parkinson's disease has become increasingly evident. We report that mesencephalic neuron-glia cultures treated with diesel exhaust particles (DEP; 0.22 microM) (5-50 microg/ml) resulted in a dose-dependent decrease in dopaminergic (DA) neurons, as determined by DA-uptake assay and tyrosine-hydroxylase immunocytochemistry (ICC). The selective toxicity of DEP for DA neurons was demonstrated by the lack of DEP effect on both GABA uptake and Neu-N immunoreactive cell number. The critical role of microglia was demonstrated by the failure of neuron-enriched cultures to exhibit DEP-induced DA neurotoxicity, where DEP-induced DA neuron death was reinstated with the addition of microglia to neuron-enriched cultures. OX-42 ICC staining of DEP treated neuron-glia cultures revealed changes in microglia morphology indicative of activation. Intracellular reactive oxygen species and superoxide were produced from enriched-microglia cultures in response to DEP. Neuron-glia cultures from NADPH oxidase deficient (PHOX-/-) mice were insensitive to DEP neurotoxicity when compared with control mice (PHOX+/+). Cytochalasin D inhibited DEP-induced superoxide production in enriched-microglia cultures, implying that DEP must be phagocytized by microglia to produce superoxide. Together, these in vitro data indicate that DEP selectively damages DA neurons through the phagocytic activation of microglial NADPH oxidase and consequent oxidative insult.

T cell epitope-specific defects in the immune response to cat allergen in patients with atopic dermatitis

Atopic dermatitis (AD) is often associated with high titer IgE antibodies (ab) to allergens, and IL-10-mediated regulation of IFN-gamma has been proposed to contribute to this IgE ab production. However, the relevance of IL-10 and IFN-gamma to IgE associated with AD has not been examined in the context of an allergen-specific system. Analysis of PBMC responses in vitro showed deficient T cell proliferation to overlapping IL-10- (peptide (P) 2:1) and IFN-gamma- (P2:2) inducing chain 2 major epitopes of cat allergen (Fel d 1) in cultures from sensitized AD patients (mean IgE to cat=20.9 IU/ml). Diminished IFN-gamma induction by Fel d 1 and P2:2, along with elevated peptide-induced IL-10 (except for P2:1) was observed in PBMC cultures from AD subjects compared with non-AD (sensitized and non-sensitized) subjects. Neither T cell proliferation nor IFN-gamma production to chain 2 epitopes could be restored by anti-IL-10 mAb in cultures from sensitized AD subjects. Moreover, allergen avoidance was associated with a paradoxical decrease in both IL-10 and IFN-gamma in peptide-stimulated PBMC from these subjects. Control of IFN-gamma production to chain 2 epitopes by IL-10 may be relevant to sensitization status. Development of high titer IgE ab in AD could reflect a failure of this mechanism.

Children's Perceptions of Dangerous Substances

The aim of this research was to examine age differences in children's perceptions of dangerous substances. Children's responses to photographs of child models encountering alcohol, a syringe, medicine, glue, and household bleach were coded for recognition of substance, awareness of potential danger, and understanding of danger or harm. Responses from 59 children (28 girls and 31 boys, who were all children of the required age in an urban primary school) were compared across three age groups (6–7 years, 8–9 years, and 10–11 years). 15 to 18 of 20 children in each of three age groups recognised all the dangerous substances. Significant differences across age groups were found for awareness of the potential harm from alcohol, glue, and medicine, but not for the syringe or bleach. Children reported less serious consequences from ingesting alcohol than other substances, the consequences of sniffing glue tended to be confused with the sticking properties of glue, children's understanding of transmission of germs, disease, and AIDS through syringes was varied, and there was a tendency among the older children to underestimate the potential harm of self-administration of medicines. Findings were discussed in relation to children's concepts of danger and safety education.

Determination of the charge state distribution of a highly ionized coronal Au plasma

We present the first definitive measurement of the charge state distribution of a highly ionized gold plasma in coronal equilibrium. The experiment utilized the Livermore electron beam ion trap EBIT-II in a novel configuration to create a plasma with a Maxwellian temperature of 2.5 keV. The charge balance in the plasma was inferred from spectral line emission measurements which accounted for charge exchange effects. The measured average ionization state was 46.8+/-0.75. This differs from the predictions of two modeling codes by up to four charge states.

Impaired functioning of thermolabile methylenetetrahydrofolate reductase is dependent on riboflavin status: implications for riboflavin requirements

BACKGROUND

Methylenetetrahydrofolate reductase (MTHFR; EC 1.7.99.5) supplies the folate needed for the metabolism of homocysteine. A reduction in MTHFR activity, as occurs in the homozygous state for the 677C-->T (so-called thermolabile) enzyme variant (TT genotype), is associated with an increase in plasma total homocysteine (tHcy).

OBJECTIVE

In vitro studies suggest that the reduced activity of thermolabile MTHFR is due to the inappropriate loss of its riboflavin cofactor. We investigated the hypothesis that MTHFR activity in the TT genotype group is particularly sensitive to riboflavin status.

DESIGN

We studied tHcy and relevant B-vitamin status by MTHFR genotype in a cross-sectional study of 286 healthy subjects aged 19-63 y (median: 27 y). The effect of riboflavin status was examined by dividing the sample into tertiles of erythrocyte glutathionine reductase activation coefficient, a functional index of riboflavin status.

RESULTS

Lower red blood cell folate (P = 0.0001) and higher tHcy (P = 0.0082) concentrations were found in the TT group than in the heterozygous (CT) or wild-type (CC) groups. However, these expected relations in the total sample were driven by the TT group with the lowest riboflavin status, whose mean tHcy concentration (18.09 micromol/L) was almost twice that of the CC or CT group. By contrast, adequate riboflavin status rendered the TT group neutral with respect to tHcy metabolism.

CONCLUSIONS

The high tHcy concentration typically associated with homozygosity for the 677C-->T variant of MTHFR occurs only with poor riboflavin status. This may have important implications for governments considering new fortification policies aimed at the prevention of diseases for which this genotype is associated with increased risk.

The Leeds University Maternity Audit Project

OBJECTIVES

To measure levels of and changes in compliance with evidence-based recommendations in obstetrics in the UK. To identify barriers to and factors associated with compliance.

DESIGN

A quantitative case-note audit for 1988 and 1996, and a qualitative interview study of key staff.

SETTING

Twenty maternity units, selected at random from all UK units

SUBJECTS

Fifty consecutive cases of pre-term delivery (PTD), Caesarean section (CS), instrumental delivery (ID), and perineal repair (PR) operations in each period in each unit. The lead clinician, midwifery manager, a senior midwife, neonatologist, and middle-grade obstetrician in each unit.

MAIN OUTCOME MEASURES

Maternal steroid use in PTD, antibiotic use in CS, use of the ventouse (vacuum extractor) rather than forceps as instrument of first choice for ID, and use of polyglycolic acid (PGA) sutures for PR in each time period. Facilities for implementing, staff attitudes to, and the degree of planning to follow each recommendation.

MAIN RESULTS

The median proportion of ventouse as instrument of first choice in each unit was 8% (range 0-32%) in 1988, rising to 64% (range 0-98%) in 1996. PGA use for PR was 0% (range 0-30%) in 1988, and 72% (range 0-100%) in 1996. Steroid use for eligible PTD was median 0% (range 0-23%) in 1988, rising to 82% (range 63-95%) in 1996. Antibiotic use for CS was 7% (range 0-25%) rising to 84% (range 10-100%) in 1996. There was no relationship between unit size, type of unit, facilities, staff attitudes or degree of planning, and compliance with the recommendations, nor was the level of adherence to one standard typically correlated with adherence to the others. However, there was a positive correlation (R = 0.6, P < 0.005) between local availability of the Cochrane database of perinatal trials and unit compliance with the audit standards in the latter time period.

CONCLUSIONS

We have documented a massive shift in practice in line with the evidence, although many units still have substantial room for improvement. About 2000 wound infections, 200 deaths due to prematurity, nearly 8000 women in pain from catgut sutures, and 1500 cases of severe perineal trauma from forceps remain preventable. The reasons why units vary remain obscure, although the qualitative interviews often revealed local factors such as key enthusiastic staff. There was no sign of evidence being positively driven into practice by any systematic managerial process. The relationship between Cochrane availability and high-standard care may be simply a marker of commitment to the evidence, but it remains plausible that if senior staff make Cochrane available for their juniors, audit compliance improves.

A qualitative evaluation of questions and responses from five occupational questionnaires developed to assess exposures

Questionnaires are increasingly being used in the workplace to assess exposures to chemicals and other agents. Although the literature contains much information on questionnaire design in general, little information is available on the challenges related to questionnaires applied to the occupational setting. Questionnaires on dry cleaning workers, nurses, farmers, car mechanics, and truck drivers were administered to a total of 25 people currently performing one of these jobs. After asking each question, the interviewer probed to identify the difficulties the respondents had in answering the questions. Overall, the respondents were able to answer the questions. Problems were found, however, with particular questions that reduced the effectiveness of the questionnaire. These included the use of unclear terms, questions open to multiple interpretations, difficult computational requirements (e.g., asking for averages for highly variable tasks), ineffective transitions between topics, and overlapping response categories. This type of testing is a crucial part of questionnaire development and can be used to effectively identify potential problems with questions and, therefore, improve them to enhance collection of higher-quality data for assessments of occupational exposures.

Enhancing an appointment diary on a pocket computer for use by people after brain injury

People with memory loss resulting from brain injury benefit from purpose-designed memory aids such as appointment diaries on pocket computers. The present study explores the effects of extending the range of memory aids and including games. For 2 months, 12 people who had sustained brain injury were loaned a pocket computer containing three purpose-designed memory aids: diary, notebook and to-do list. A month later they were given another computer with the same memory aids but a different method of text entry (physical keyboard or touch-screen keyboard). Machine order was counterbalanced across participants. Assessment was by interviews during the loan periods, rating scales, performance tests and computer log files. All participants could use the memory aids and ten people (83%) found them very useful. Correlations among the three memory aids were not significant, suggesting individual variation in how they were used. Games did not increase use of the memory aids, nor did loan of the preferred pocket computer (with physical keyboard). Significantly more diary entries were made by people who had previously used other memory aids, suggesting that a better understanding of how to use a range of memory aids could benefit some people with brain injury.

Comparison of pocket-computer memory aids for people with brain injury

Two styles of pocket computer memory aid were compared as support for people who had sustained non-progressive, closed-head brain injury. A purpose-designed interface provided a diary with auditory alarms, a notebook and links between diary entries and specific notepages. One computer had a physical keyboard, the other did not. Twelve adult volunteers were loaned each computer for 2 months, with a 1 month gap between, in counterbalanced order. It was found that all participants could use the memory aids, and most (83%) found them useful. Little customizing was needed, but amount of use varied widely. Predictors of usage included use of other reminding systems before joining the project, and speed in calculator addition which may reflect working memory. High users preferred the computer with a physical keyboard; low users made more entries with the palm-size computer. These data highlight the need to distinguish ability to use from willingness to use.

Northern Initiative for Social Action: An Occupation-Based Mental Health Program

Northern Initiative for Social Action (NISA) is a consumer-run, occupation-based, nonprofit organization located in northeastern Ontario, Canada. The NISA organization has grown in response to research revealing few opportunities for participation in personally meaningful and socially valued occupation for persons with mental illness living in the community of study. This article describes a mixed-design research study conducted by the ParNorth Research Unit of NISA and an occupational therapist. The study purposes were to (a) better understand the emerging characteristics of the NISA program and identify which the participants found helpful; (b) evaluate whether participation in NISA improved members' quality of life; and (c) ascertain whether participation reduced members' need for more traditional and costly methods of care (e.g., hospitalization, crisis services). Focus groups, daily participant observation, a quality of life interview, a consumer member survey and objective review of hospitalization data were used for data collection. Qualitative results indicated that NISA helped to meet participants' being, belonging, and becoming needs. Quantitative data indicated that overall, NISA members perceive an improvement in their subjective quality of life and sense of well-being. Their perceptions are supported by minimal use of crisis services and hospitalization, improved socioeconomic status, and several members' success in obtaining paid employment either within or outside NISA. Future challenges include the need to clearly describe the evolving NISA model and to ensure that the growth of this new organization does not exceed secured human or fiscal resources.