Adolescents' attitudes to general practice in north London

A questionnaire-based survey, undertaken in North London state secondary schools, illustrated some stumbling blocks and a lack of knowledge that is likely to inhibit an effective use of general practice among 12-18 year olds. A review of the current arrangements and some adjustment of current services might increase the likelihood of achieving Health of the Nation targets for teenage pregnancies, and may also improve health care for this important and vulnerable section of the population.

Laparoscopic versus open appendectomy: a prospective randomized trial of 81 patients

OBJECTIVE

To compare the efficacy of laparoscopic appendectomy (LA) and open appendectomy (OA) in the treatment of acute appendicitis.

DESIGN

A prospective randomized trial.

SETTING

A university teaching hospital.

PATIENTS

Eighty-one patients with a diagnosis of acute appendicitis were prospectively randomized to undergo either LA or OA. The two groups were matched for age and sex.

INTERVENTIONS

LA or OA.

MAIN OUTCOME MEASURES

Number of days in hospital and time to full recovery.

RESULTS

The mean hospital stay for LA was 3.23 days compared with 3.03 days for OA (p < 0.001). The mean number of narcotic injections required for patients in the LA group was 4.05 compared with 5.58 for patients in the OA group (p < 0.001). The mean time to complete recovery for patients in the LA group was 9.0 days compared with 16.2 days for patients in the OA group (p < 0.001). The mean operative time for LA was 73.8 minutes compared with 45.0 minutes for OA (p < 0.001). Three patients in the LA group had intra-abdominal abscesses (p > 0.25). No significant difference in wound infection rates was demonstrated (p > 0.05). Similarly, pain scores at 7 and 28 days showed no significant difference (p > 0.05).

CONCLUSIONS

With LA significantly fewer narcotic injections are required and there is a more rapid return to normal activities. LA takes longer to perform and was associated with three intra-abdominal abscesses. In cases of simple acute appendicitis the hospital stay for LA is significantly shorter.

Induction of programmed cell death and immunosuppression by exogenous sphingolipids are separate processes

Gangliosides are highly immunosuppressive molecules but the mechanism(s) by which they act upon cells remains to be fully defined. Several metabolic products of exogenous gangliosides, including ceramide, have recently been suggested as second messengers in programmed cell death (PCD). Therefore, we have probed the role of gangliosides and ceramides in the induction of PCD and in the inhibition of in vitro lymphoproliferation. PCD was caused only by exogenous ceramides with short fatty acyl groups-d18:1-C2:0 (C2-ceramide, where d18:1 is sphingosine and C2:O is an acetyl group) and d18:1-C6:0 (C6-ceramide, where C6:O is a hexanoyl group). None of the gangliosides studied induced PCD, including naturally occurring GM3, synthetic d18:1-C18:0 GM3 (C18-Cer GM3, where C18:0 is a stearoyl group), or even d18:1-C2:0 GM3 (C2-Cer GM3), which itself contains a PCD-causing ceramide. However, these gangliosides were highly immunosuppressive, inhibiting antigen-induced lymphoproliferation at micromolar concentrations. We conclude that exogenous sphingolipids cause inhibition of lymphoproliferation and PCD by two separate and distinct mechanisms of action.

Quantitative morphology of physiologically identified and intracellularly labeled neurons from the guinea-pig laterodorsal tegmental nucleus in vitro

Mesopontine cholinergic neurons have been implicated in the initiation and maintenance of rapid eye movement sleep via their efferent connections to the thalamus and the medial pontine reticular formation. As a first step toward understanding how these modulatory neurons integrate synaptic input, we have investigated the dendritic architecture of laterodorsal tegmental nucleus neurons. The principal cells of the guinea-pig laterodorsal tegmental nucleus were identified electrophysiologically in a brain slice preparation, then were intracellularly injected with biocytin and reconstructed using a computer-aided tracing system. The somata were large (27 +/- 3 microns; n = 11) and gave rise to an average of 4.8 primary dendrites which, in most cases, emerged from the soma in a pattern that was radially symmetric in the plane of the slice. Primary dendrites had an average of 3.7 endings. A single axon arose from either the soma or a proximal dendrite and exited the nucleus with a medial and/or lateral trajectory. Some axons also gave rise to a local terminal plexus composed of fine fibers bearing numerous punctate swellings that ramified profusely within the neuron's dendritic field. Total dendritic area averaged about 10(5) microns2, and therefore the average contribution of the soma to the total surface area (20%) was significantly larger than the values reported for many other cell types. Dendritic diameters were non-uniform in three respects. Some processes were sparsely spiny. Most processes were varicose, with the degree of varicosity increasing substantially in secondary and tertiary dendritic segments. There was also a large degree of taper in dendritic processes; those processes with a non-negative taper had an average diameter decrease of 40 +/- 25%. Dendritic processes deviated from the criteria necessary for a Rall equivalent cylinder approximation due to non-uniformity in morphotonic path length, failure to conform to the Rall 3/2 branching rule and non-uniformity of dendritic diameter. An analysis was done to assess the impact of dendritic varicosities on the extraction of cable parameters for these cells. Voltage traces were simulated by solving the cable equation for a varicose dendrite and then membrane parameters were recovered using an equivalent cylinder model. Errors in the extracted values of specific membrane conductance and specific membrane capacitance were quite small (< or = 5%), while larger errors were seen for electrotonic length (< or = 21%) and intracellular resistivity (< or = 5%). These data indicate that the principal cells of the laterodorsal tegmental nucleus, while possessing a relatively simple dendritic structure in terms of number and branchiness of dendrites, display a heterogeneity of dendritic process types. Processes range from smooth to markedly varicose, and can be aspiny or sparsely spiny. The possibility that the dendritic varicosities function as sites of either electrical or chemical compartmentalization is discussed. The degree of error resulting from a Rall equivalent cylinder approximation in light of these varicosities indicated that a generalized cable model approach may prove more effective in estimating their cable parameters.

1995 Roussel Lecture. Management of adenocarcinoma of the head of the pancreas: 10 questions for the 1990s

Carcinoma of the head of the pancreas is a lethal condition because it presents clinically late in the disease and because of its unfavourable biologic course. Surgical approaches have become progressively more aggressive in recent years, without a significant increase in long-term survival. Controversy persists as to the appropriate surgical procedure for this disease, nonoperative or operative palliation, and and future prospects for management. This review considers questions often posed by clinicians and offers answers based on a literature reivew and the experience of the hepatobiliary service at the Toronto Hospital, Toronto General Division.

Adjusting to criminal victimization: the correlates of postcrime distress

This article explores the correlates of immediate and short-term psychological distress among victims of burglary, robbery, and nonsexual assault. A panel design was employed. Crime victims were interviewed within 1 month following the incident and again 3 months later. Four sets of predictors were examined: demographics, previctimization adjustment and stress, features of the crime incident, and victims' perceptions. Measures of distress included a range of standard indices of adjustment and symptomatology. Demographic characteristics and victim perceptions accounted for the greatest proportions of variance in the outcome measures at Time 1 and Time 2. The strongest predictors of psychological adjustment at the end of 3 months included adjustment after 1 month, education, victim injury, victims' beliefs that their lives had been endangered during the crime episode, and victims' appraisals of the world as meaningful. Implications for treatment and directions for future studies are discussed.

Gender and nursing in colonial Victoria, 1840-1870

The role of the nurse in health care has been the subject of a debate over time which engages with the ambiguity about the role of the nurse, the boundaries of nursing work, and the question of the status of women and men within the profession. In this paper we report on a historical analysis of the nature of nursing work in colonial Victoria, Australia, which was undertaken in order to understand how the nursing role evolved and was socially constructed in early Australia. A significant absence of accounts of nurses between 1840 and 1870, and a lack of comparative analysis of male and female roles in nursing care in this period, suggested a need to reveal some of the social, political and economic influences on the delineation of nursing work and the relevance of these factors to the relationships between hospital staff. The study adopted three strategies or methods. First, the scattered and diffuse references to the origin and development of the role and function of the nurse in this were collated, particularly identifying nursing duties and the existing division of labour. Following this, hospital administrative structures were analysed. Finally, an interpretive methodology of textual analysis was employed and the portrayal of nursing in a number of texts, including hospital histories, annual reports and contemporary literature were examined. This provided us with a socio-cultural and historical perspective on the nature of nursing work in early Victoria.

Social work with transport disabled persons: a wayfinding perspective in health care

Transport disabled persons confront extensive architectural and psychosocial barriers during their travel to community based health care services by mass transit. The current health care reform movement affords social work an opportunity to consolidate its expertise with this population. The Certificate of Need program is a method with which social work can provide service to people with transportation disabilities. Social work can also continue its use of the Americans with Disabilities Act and the Urban Mass Transportation Act to assist people with transport disabilities to access community based health care services.

Enhancement of proxy appointment for older persons: physician counselling in the ambulatory setting

OBJECTIVE

To determine the effectiveness of physician-initiated counselling on the rate of health care proxy appointment.

DESIGN

Observational study of an intervention in a convenience sample.

SETTING

A geriatric outpatient clinic in a tertiary care teaching hospital, New York, New York.

PARTICIPANTS

A total of 687 patients enrolled in the geriatric clinic during the study period March 1991 through June 1993.

INTERVENTION

Physician counselling about the New York State Health Care Proxy Law, distribution of educational materials and healthcare proxy forms, and reminders in 331 of 466 eligible patients.

MEASUREMENTS

Rate of healthcare proxy appointment in eligible and counselled groups; predictors of appointment and non-appointment; time elapsed from counselling to appointment; reasons for non-appointment; characteristics of the proxy appointment process.

RESULTS

A healthcare proxy was appointed for 31.5% of patients eligible for counselling and for 44% of patients who actually received the intervention, compared with a 2.3% proxy appointment rate at baseline. Eighty-one percent of the patients completing the proxy appointment process did so at or before their third clinic return visit after the counselling intervention. Of the counselled patients who did not appoint a proxy, 25% explicitly declined, and 75% had not come to a decision by the end of the study period. Proxy completion was associated with ethnicity, education, and more frequent clinic visits. Of those who appointed a proxy, 97% had good or fair comprehension of the procedure, 92% discussed the appointment with their designees, 63% appointed a daughter or son, and 80% discussed their wishes for care at the end of life with their proxy.

CONCLUSIONS

Physician counselling of older outpatients is an effective means of increasing healthcare proxy appointments.

Expression of basic fibroblast growth factor in colorectal carcinoma

Basic fibroblast growth factor (bFGF) has been shown to be a potent mitogen for a variety of cell types including colonic epithelial cells. Basic FGF has also been reported to have angiogenic activity. Thus, it has been proposed that bFGF expression might correlate with invasiveness and prognosis in human carcinomas. In the present study, bFGF expression has been evaluated in samples from 44 patients with large bowel carcinoma. Samples from the tumours and corresponding normal mucosae were collected at the time of surgery and frozen sections evaluated using a chick polyclonal antibody to bFGF and standard immunoperoxidase techniques. The expression of bFGF was significantly less within the tumours than in the corresponding normal mucosa (p<0.001). Five of the tumours were Dukes' stage A, 21 Dukes' stage B and 18 Dukes' stage C. Basic FGF expression tended to decrease with progression from Dukes' stage A to Dukes' stage C (p<0.05). This finding also paralleled loss of differentiation. Of the 44 patients, 8 have since died of their disease and only 3 of these had tumours which expressed bFGF. An attempt to correlate the expression of bFGF with that of another putative marker of colorectal disease progression, the cell-cell adhesion molecule E-cadherin, revealed no significant correlation.

Can we measure the effectiveness of our organizations?

Based on an action learning programme involving clinical directors and their business managers, explores the options open to analysing the effectiveness of a directorate including its place in an organizational structure.

Interpreting phenomenology for nursing research

Originally there were few things about which I was clear in relation to my research. I was interested in the nurse-patient relationship in a clinical setting and I wanted to examine especially 'ordinariness in nursing' ( 1 ), a phenomenon I had noticed in my own practice. It was the nature of this ordinariness that I most wanted to define, so phenomenology, which appeared to deal with the assumptions of getting to know more about a particular phenomenon, seemed to be an appropriate approach. Eventually I was able to develop and defend the use of my own research method, which combined the contextual features of the research setting, some assumptions of the underlying methodology, and my sense of myself as a 'Being-in-the-world'.

Interdigitation of nitric oxide synthase-, tyrosine hydroxylase-, and serotonin-containing neurons in and around the laterodorsal and pedunculopontine tegmental nuclei of the guinea pig

The topography of neurons containing nitric oxide synthase (NOS) and monoamines was investigated in the guinea pig mesopontine tegmentum. NOS-containing neurons were identified with NADPH-diaphorase (NADPH-d) histochemistry, and monoamine-containing neurons were identified with tyrosine hydroxylase (TH) and serotonin (5-HT) immunocytochemistry. The distribution of NADPH-d positive cells was centered on the laterodorsal tegmental (LDT) and pedunculopontine tegmental (PPT) nuclei. Diaphorase-containing cells had a mean soma diameter of 23.0 +/- 4.1 microns (n = 160) and were distributed inhomogeneously, with numerous cells found within densely packed clusters. A nearest-neighbor analysis revealed that these cells were closely spaced, with up to 20% within one cell diameter and more than 50% within two cell diameters of a neighboring NADPH-d cell. Within the LDT and PPT, NADPH-d positive cells were mixed with smaller, diaphorase-negative cells (diam: 12.8 +/- 3.3 microns; n = 182; P << 0.01). TH-containing cells were not organized into a compact LC as in rat and their distribution more closely resembled that observed in cat. On average, TH-containing cells (diam: 21.2 +/- 4.8 microns; n = 160) were smaller than NADPH-d cells (P < 0.01). 5-HT-containing cells were mainly located in the raphe nuclei, as in other species. 5-HT-containing cells (diam: 18.2 +/- 4.4 microns; n = 161) were smaller on average than both the NADPH-d (P < 0.01) and TH-containing cells (P < 0.01). An analysis of the overlap in soma distributions revealed that TH-containing cells were largely interdigitated with NADPH-d containing cells. As much as 78% of the area occupied by the NADPH-d cells of LDT was contained within the area occupied by TH cells. Substantial numbers of TH and 5-HT immunoreactive processes were seen in both LDT and PPT. Varicose 5-HT and TH-containing fibers, as well as thicker, possibly dendritic processes containing TH were often seen in close apposition to NADPH-d containing somata and proximal dendrites. These results support the hypothesis that NADPH-d cells of both the PPT and LDT receive input from TH and 5-HT cells. Moreover, the clustered substructure of LDT and PPT and the extensive overlap of NADPH-d and TH-containing somata raise the possibility that the membrane permeable messenger nitric oxide plays a role in modulating TH-containing somata and their processes as well as 5-HT-containing processes in the LDT and PPT.

Reflective midwifery practice: facilitating midwives' practice insights using a distance education reflective practitioner model

A study was undertaken to evaluate a reflective practitioner model with midwives, who self-selected into the project when they were studying the Bachelor of Health Science (Nursing) unit NR278, Advanced Nursing Practice, Midwifery. The theoretical assumptions that influenced the research were those forwarded by Schon (1983) and Boud, Keogh and Walker (1985), who argued that practitioners are often unaware of the sophisticated knowledge they have regarding the intricacies of their practice, but that this personal knowledge can be make explicit through reflective processes. The aim of the study was to research the use of a distance education reflective practitioner process that encouraged midwives to examine their practice with a view to making changes where necessary. All the research objectives were met to some extent, although each experience of the research process was particular to the individual participant. Analysis consisted of: interpretation of the participant's insights into their individual experiences; the researcher's interpretations of participant's experiences; and collective themes arising out of the research. This paper concentrates mainly on the participant's insights into their individual experiences of practising midwifery, using a reflective practitioner model.

Nursing as healing work

This paper describes the therapeutic potential of nursing practice as healing work, by addressing the growing trend in nursing to consider how the work of nursing and the nurse-client relationship are potentially of a healing nature. The work of nursing, presencing, concern and authenticity are discussed, before a redefinition of healing is offered. To exemplify nursing as healing work, some stories are shared from nurses working in different work settings. These stories are of human interest, especially in terms of their healing outcomes.

An event recorder for infant feeding research

An Event Recorder program was developed for the HP 48 calculator to record the durational events associated with breastfeeding behavior. The Event Recorder menu structure is flexible and allows for the recording of response variables such as menstrual history and fertility symptoms. A Windows program was written in Visual C++ to give a graphical representation of the time-series data and to extract useful measures of breastfeeding activity from the raw data for each 24-h day postpartum. These time varying covariates include the mean and median bout length, median interbout interval, breastfeeding frequency and total 24-h suckling duration. The HP 48 calculator has proven to be a robust instrument for the self-recording of breastfeeding data collected as part of a prospective study on the factors that maintain postpartum amenorrhea. We have found also that the behavioral data collected are easily transferred electronically each month when our field workers make home visits.

The surgical anatomy of the deep femoral artery

Lower extremity ischemia is a common disorder that in the majority of cases is associated with occlusion of the superficial femoral artery. The deep femoral artery is recognized as an important collateral pathway to the genicular arterial system, thus accounting for the appearance of symptoms only after its involvement in the disease process. Surgical exposure of the deep femoral artery is often necessary in vascular reconstructive procedures. Furthermore, because it supplies the bulk of the thigh musculature, plastic surgeons have shown great interest in the muscular branches of the deep femoral artery when designing procedures that incorporate myocutaneous flaps. This article gives a detailed account of the embryology, anatomical relations, important variations, and branches of the deep femoral artery. Recommendations for the surgical exposure of this artery at different levels are also presented.

A standardized patient program in a mandatory geriatrics clerkship for medical students

This article describes the development and implementation of a new standardized patient program in a required geriatrics clinical clerkship for fourth-year medical students. A student survey was also conducted to provide evaluations of the program and to determine the frequency with which students' clinical skills are directly evaluated by faculty. Thirty-six percent reported never having been observed while obtaining a history and 24% having been observed only once; 26% had never been observed while completing a physical examination and 39% had been observed only once. The implementation of a standardized patient program provided students with direct feedback on their clinical skills and was rated positively, (good, very good, or outstanding) by 76% of the students.

Clinical evaluation of the Franklin Applied Physics Cosmetic Cover for lower limb prostheses: a preliminary report

The Franklin Applied Physics (FAP) Cosmetic Cover is the result of research and development directed by Dr. Robert Erb at the Franklin Research Center, Norristown, PA. The FAP Cover is a silicone rubber cosmesis designed to improve the appearance of lower limb prostheses and provide wider social integration for the wearer. The Technology Transfer Section, Rehabilitation Research and Development Service, Department of Veterans Affairs, coordinated a pilot study of four pre-commercial covers at selected sites. Participating prosthetists and subjects evaluated fit, relevant physical criteria, and overall potential value of the cover. The following statements summarize responses of the participants: 1) well accepted with regard to overall fit, appearance, and ease of donning/doffing; 2) lightweight, highly elastic, and easy to maintain; and 3) split toe and closed toe versions are needed for above-knee and below-knee models. Data gleaned from the pilot study were used to define dimensions for standardized off-the-shelf sizing and to make recommended modifications, resulting in pre-market models that are ready for a national field evaluation.