Reliability of the Salford Needs Assessment Schedule for Adolescents

BACKGROUND

For adolescents, there is no specific needs assessment instrument that assesses significant problems that can benefit from specified interventions. A new instrument (S.NASA) was developed by incorporating and adapting three well established adult needs assessment instruments. The S.NASA covers 21 areas of functioning including social, psychiatric, educational and life skills.

METHOD

Client and carer interviews were conducted by different researchers. A week later the interviews were repeated using a crossover design. Significant (cardinal) problems were generated from the clinical interviews using a pre-defined algorithm. Final need status (three categories) was made by clinicians assessing the cardinal problems against defined interventions. The interventions were generated from discussions with clinicians and a survey of appropriate professionals working with adolescents. RESULTS. Pre-piloting led to the final version being administered to 40 adolescents from secure units, forensic psychiatric and adolescent psychiatric services. There were 25 males and 15 females, mean age 15.5 years. Overall there were moderate to good inter-rater and test-retest reliability coefficients, the test-retest reliability coefficients for the total scores on the needs assessment interviews ranged from 0.73 to 0.85. Consensual and face validity was good, the adolescents and staff finding the instrument useful and helpful.

CONCLUSIONS

This new needs assessment instrument shows acceptable psychometric properties. It should be of use in research projects assessing the needs and the provision of services for adolescents with complex and chronic problems.

What do service planners and policy-makers need from research?

Nine policy preoccupations have been identified in a recent study of dementia care policies in all European countries. These are used to structure a set of issues which researchers might usefully address to assist service planners and policy-makers. Areas where there is already a research literature are identified. Some description and commentary on the application of current policies in the UK is provided to illustrate the need for research. It is suggested that service planners and policy-makers march to some distant drum which is only remotely related to research, if at all. However, the importance of a research base is stressed with the suggestion that research in related fields could usefully be transferred.

Lipoproteins inhibit macrophage activation by lipoteichoic acid

Regulation of lipid metabolism during infection is thought to be part of host defense, as lipoproteins neutralize endotoxin (LPS) and viruses. Gram-positive infections also induce disturbances in lipid metabolism. Therefore, we investigated whether lipoproteins could inhibit the toxic effects of lipoteichoic acid (LTA), a fragment of gram-positive bacteria. LTA activated RAW264.7 macrophage cells, stimulating production of tumor necrosis factor (TNF) in a dose-dependent matter, but produced less TNF than that seen after LPS activation. High density (HDL) or low density lipoprotein (LDL) alone inhibited the ability of LPS to stimulate TNF production, but had little effect on the activation by LTA. When a maximally effective dose of LTA was mixed with lipoproteins and 10% lipoprotein-depleted plasma (LPDP), the ability of LTA to stimulate macrophage production of TNF was inhibited. HDL, LDL, and the synthetic particle, Soyacal, when mixed with LPDP, were able to inhibit the ability of LTA to activate macrophages. Lipopolysaccharide-binding protein (LBP) substituted for LPDP in catalyzing lipoprotein neutralization of LTA by HDL. Antibody to LBP inhibited the ability of LPDP to induce LTA neutralization by HDL.Thus, lipoproteins can prevent macrophage activation by fragments from both gram-positive and gram-negative microorganisms.-Grunfeld, C., M. Marshall, J. K. Shigenaga, A. H. Moser, P. Tobias, and K. R. Feingold. Lipoproteins inhibit macrophage activation by lipoteichoic acid.

Oncogenes, growth factors and phorbol esters regulate Raf-1 through common mechanisms

We have uniformly examined the regulatory steps required by oncogenic Ras, Src, EGF and phorbol 12-myristate 13-acetate (PMA) to activate Raf-1. Specifically, we determined the role of Ras binding and the phosphorylation of serines 338/339, tyrosines 340/341 and the activation loop (491-508) in response to these stimuli in COS-7 cells. An intact Ras binding domain was found to be essential for Raf-1 kinase activation by each stimulus, including PMA. Brief treatment of COS-7 cells with PMA was found to rapidly promote accumulation of the active, GTP-bound form of Ras. Furthermore, loss of the serine 338/339 and tyrosine 340/341 phosphorylation sites also blocked Raf-1 activation by all stimuli tested. Loss of the serine 497 and serine 499 PKCalpha phosphorylation sites failed to significantly reduce Raf-1 activation by any stimulus including PMA. Alanine substitution of all other potential phosphorylation sites within the Raf-1 activation loop had little or no effect on kinase regulation by Ras[V12] or vSrc although some mutants were less responsive to PMA. These results suggest that in mammalian cells, Raf-1 can be regulated by a variety of different stimuli through a common mechanism involving association with Ras-GTP and multiple phosphorylations of the amino-terminal region of the catalytic domain. Phosphorylation of the activation loop does not appear to be a significant mechanism of Raf-1 kinase regulation in COS-7 cells.

Assessing relatives' needs for psychosocial interventions in schizophrenia: a relatives' version of the Cardinal Needs Schedule (RCNS)

BACKGROUND

The methodology for measuring the needs of patients with severe mental illness is now well established through the MRC Needs for Care Assessment Schedule and its modification in the form of the Cardinal Needs Assessment. This paper reports the rationale and construction of a relatives' version of the Cardinal Needs Schedule and looks at preliminary data reporting on reliability and validity.

METHODS

Potential problem areas for relatives were identified from the literature. The criteria determining Cardinal Needs for each problem included objective threshold, carer concern, and carer cooperation. The reliability of the Schedule was assessed in a study whereby 27 relatives of patients with established schizophrenic illness completed two Schedules administered by two independent raters within a short time period.

RESULTS

The Schedule was acceptably reliable for most areas of need although there were some difficulties associated with the cooperation criteria. Concurrent measures of relatives and patients including EE, relative distress and patient psychopathology indicated that the Relatives' Cardinal Needs Schedule shows acceptable validity when used with a sample of 45 relatives.

CONCLUSIONS

The paper suggests that the Schedule may prove to be a useful tool for both clinicians and researchers interested in establishing and evaluating family interventions.

Design, testing, and results of an outcomes-managed approach to patients requiring prolonged mechanical ventilation

BACKGROUND: Outcomes management that uses critical pathways may decrease costs while improving outcomes for patients who require prolonged mechanical ventilation. OBJECTIVE: To study the efficacy of an outcomes-managed approach to weaning patients from prolonged (more than 3 days) mechanical ventilation. METHODS: A method of multidisciplinary care delivery was designed that included an outcomes manager, a care pathway for patients receiving mechanical ventilation, and weaning protocols. Data collection consisted of three parts: a retrospective review of 124 patients who required prolonged ventilation during a 1-year period before implementation of the care model, a 6-month prospective study in which 91 patients were alternately assigned by month to an outcomes-managed approach or a non-outcomes-managed approach, and a 6-month prospective study of 90 patients in which an outcomes-managed approach without alternate-month assignment was used. RESULTS: Outcomes management had no significant effect on total duration of mechanical ventilation or length of stay in the hospital, days of mechanical ventilation without tracheostomy, days of mechanical ventilation with tracheostomy, or outcome (weaned, withdrawal from mechanical ventilation, death, or transfer without weaning). However, duration of mechanical ventilation was 1.3 days shorter, length of stay in the hospital was 2.1 days shorter, and the cost per case was $ 3341 less for patients in the outcomes-managed group than for patients in the non-outcomes-managed group. CONCLUSION: Outcomes-managed care did not have a significant effect on duration of ventilation, length of stay in the hospital, or outcome in patients receiving long-term mechanical ventilation.

A community needs assessment: the care needs assessment pack for dementia (CarenapD)--its development, reliability and validity

OBJECTIVE

To develop and evaluate a multidisciplinary needs assessment tool for people with dementia living in the community and their carers.

DESIGN

The measure was developed through applying a theory of need, generating content, consultation with potential users and refinement and evaluation. Validity was established incrementally through the development process.

SETTING

The development and evaluation was conducted in a variety of settings, including multidisciplinary dementia community care teams, social work departments, day hospitals, and inpatient and residential care.

PATIENTS

The evaluation included community patients with a formal diagnosis of dementia (N = 34) and consultation with a multidisciplinary group of potential users (N = 23). The development process included inpatients with a formal diagnosis of dementia (N = 157) and consultation with potential users (N = 170) from a range of professions including both health and social care.

MEASURES

Interrater reliability was assessed using the kappa statistic. Social validity was estimated using a measure developed for this purpose as part of the development process.

RESULTS

The evaluation of interrater reliability demonstrated that three-quarters of assessors agreed on at least 85% of items in the CarenapD. The kappa statistic demonstrated that agreement for 76.2% of items in the CarenapD was 'good' or better (ie kappa >0.75), for 12.4% of items it was 'fair' or 'moderate' (ie kappa 0.35-0.60) and for the remaining 12 (11.4%) items for which kappa could not be calculated there was low intra-item variance and high agreement (>90%). There was good evidence for social validity.

CONCLUSIONS

The CarenapD is a reliable and valid multidisciplinary assessment of need for people with dementia living in the community and their carers.

Design, testing, and results of an outcomes-managed approach to patients requiring prolonged mechanical ventilation

BACKGROUND

Outcomes management that uses critical pathways may decrease costs while improving outcomes for patients who require prolonged mechanical ventilation.

OBJECTIVE

To study the efficacy of an outcomes-managed approach to weaning patients from prolonged (more than 3 days) mechanical ventilation.

METHODS

A method of multidisciplinary care delivery was designed that included an outcomes manager, a care pathway for patients receiving mechanical ventilation, and weaning protocols. Data collection consisted of three parts: a retrospective review of 124 patients who required prolonged ventilation during a 1-year period before implementation of the care model, a 6-month prospective study in which 91 patients were alternately assigned by month to an outcomes-managed approach or a non-outcomes-managed approach, and a 6-month prospective study of 90 patients in which an outcomes-managed approach without alternate-month assignment was used.

RESULTS

Outcomes management had no significant effect on total duration of mechanical ventilation or length of stay in the hospital, days of mechanical ventilation without tracheostomy, days of mechanical ventilation with tracheostomy, or outcome (weaned, withdrawal from mechanical ventilation, death, or transfer without weaning). However, duration of mechanical ventilation was 1.3 days shorter, length of stay in the hospital was 2.1 days shorter, and the cost per case was $ 3341 less for patients in the outcomes-managed group than for patients in the non-outcomes-managed group.

CONCLUSION

Outcomes-managed care did not have a significant effect on duration of ventilation, length of stay in the hospital, or outcome in patients receiving long-term mechanical ventilation.

Are frequent inner cannula changes necessary?: A pilot study

OBJECTIVE

To determine the incidence of obstruction and colonization in adult patients in the surgical and medical intensive care units who received inner cannula changes daily versus those who did not.

DESIGN

Quasi-experimental prospective study using a convenience sample of patients randomly assigned to one of two methods.

SETTING

Mid-Atlantic university-affiliated tertiary care center.

PATIENTS

Sixty patients within 24 hours of receiving a surgical tracheostomy.

OUTCOME MEASURES

Obstruction and bacterial colonization of inner cannula.

INTERVENTIONS

All inner cannulas were checked daily for obstruction and cultured on postoperative days 1 and 3.

RESULTS

No statistically significant difference was noted in colonization (p = 0.13) between protocols, and no obstructions were noted in either.

CONCLUSION

The study suggests that the routine practice in critical care units of changing tracheostomy inner cannulas may be unnecessary. Although the results of this study are limited, and may not be generalized to other populations, it demonstrates that practice standards related to the care of tracheostomy inner cannula need to be challenged.

Phosphorylation of Raf-1 serine 338-serine 339 is an essential regulatory event for Ras-dependent activation and biological signaling

Activation of the Raf serine/threonine protein kinases is tightly regulated by multiple phosphorylation events. Phosphorylation of either tyrosine 340 or 341 in the catalytic domain of Raf-1 has been previously shown to induce the ability of the protein kinase to phosphorylate MEK. By using a combination of mitogenic and enzymatic assays, we found that phosphorylation of the adjacent residue, serine 338, and, to a lesser extent, serine 339 is essential for the biological and enzymatic activities of Raf-1. Replacement of S338 with alanine blocked the ability of prenylated Raf-CX to transform Rat-1 fibroblasts. Similarly, the loss of S338-S339 in Raf-1 prevented protein kinase activation in COS-7 cells by either oncogenic Ras[V12] or v-Src. Consistent with phosphorylation of S338-S339, acidic amino acid substitutions of these residues partially restored transforming activity to Raf-CX, as well as kinase activation of Raf-1 by Ras[V12] or v-Src. Two-dimensional phosphopeptide mapping of wild-type Raf-CX and Raf-CX[A338A339] confirmed the presence of a phosphoserine-containing peptide with the predicted mobility in the wild-type protein which was absent from the mutant. This peptide could be quantitatively precipitated by an antipeptide antibody specific for the 18-residue tryptic peptide containing S338-S339 and was demonstrated to contain only phosphoserine. Phosphorylation of this peptide in Raf-1 was significantly increased by coexpression with Ras[V12]. These data demonstrate that Raf-1 residues 338 to 341 constitute a unique phosphoregulatory site in which the phosphorylation of serine and tyrosine residues contributes to the regulation of Raf by Ras, Src, and Ras-independent membrane localization.

Heme compounds in dinosaur trabecular bone

Six independent lines of evidence point to the existence of heme-containing compounds and/or hemoglobin breakdown products in extracts of trabecular tissues of the large theropod dinosaur Tyrannosaurus rex. These include signatures from nuclear magnetic resonance and electron spin resonance that indicate the presence of a paramagnetic compound consistent with heme. In addition, UV/visible spectroscopy and high performance liquid chromatography data are consistent with the Soret absorbance characteristic of this molecule. Resonance Raman profiles are also consistent with a modified heme structure. Finally, when dinosaurian tissues were extracted for protein fragments and were used to immunize rats, the resulting antisera reacted positively with purified avian and mammalian hemoglobins. The most parsimonious explanation of this evidence is the presence of blood-derived hemoglobin compounds preserved in the dinosaurian tissues.

Implementing reproductive health awareness: progress to date

This paper describes the experience of various institutions in integrating a reproductive health awareness (RHA) approach into different health, school and community-based programs. RHA, an educational approach that evolved from the Institute's client empowerment approach to natural family planning and fertility awareness, is based on helping women and men to participate actively in their own family planning and reproductive health care by developing skills in self-observation, communication and self-advocacy. In addition to providing the Institute with an avenue for responding to the Cairo and Beijing mandates, RHA has also provided a means to introduce family planning, particularly natural methods of family planning, into programs and institutions. RHA has continued to evolve and strengthen during the process of field testing its contributions to existing reproductive health programs.

Reproductive health awareness: an integrated approach to obtaining a high quality of health

The Georgetown University Institute for Reproductive Health has evolved a multi-dimensional approach to reproductive health education which has grown from their work in natural family planning and fertility awareness. This cohesive approach offers help to community, educational, and health organizations in providing knowledge and skills development in body/self-care, gender awareness, sexuality, and interpersonal communications.