'Ordinariness' in nursing: a study (Part 1)

This is the first of two articles describing aspects of ordinariness in nursing as they were explored in a phenomenological study on clinical nursing. By way of introduction, it provides an overview of the first phase of the study in terms of its background and method, and describes aspects of ordinariness, showing their relevance to nursing practice. In exploring this phenomenon, this study affirmed a shared sense of humanity as a general group and the enhancing effect this affinity can have on interpersonal relationships.

Hepatitis C RNA in liver of chronic hepatitis C patients before and after interferon alfa treatment

BACKGROUND

Successful treatment of chronic hepatitis C with interferon alfa is frequently followed by relapse. Because loss of hepatitis C viral RNA (HCV-RNA) in serum is not predictive of sustained response, the loss of HCV-RNA in liver as a predictor of sustained response was investigated.

METHODS

Twenty-one patients with chronic hepatitis C treated with recombinant interferon alpha had HCV-RNA sequences determined in frozen liver tissue before and after treatment and in serum at the end of treatment. Reverse double polymerase chain reaction was used to detect sequences to the 5' nontranslated region of the HCV genome using double nested primers.

RESULTS

HCV-RNA disappeared in the liver in 10 of 11 (91%) complete responders whereas it remained detectable in the liver or serum of 7 of 8 (87%) nonresponders. Five complete responders relapsed biochemically during 6 month's follow-up; 4 of these had no detectable HCV-RNA in liver at end of treatment.

CONCLUSIONS

Disappearance of HCV-RNA in liver correlates with initial clinical outcome, but as previously reported with serum HCV-RNA, this loss does not necessarily allow prediction of a sustained response.

Fate of infected and eroded hemodialysis grafts and autogenous fistulas

Between 1970 and 1991, we placed 1,090 grafts (bovine and polytetrafluoroethylene) in 1,041 patients and created 1,034 autogenous fistulas in 856 patients for hemodialysis. Subsequent revisions for complications resulted in a total of 3,944 operations performed in patients with grafts and 1,633 operations in patients with autogenous fistulas. A total of 255 infections developed in 158 of the patients with grafts, whereas 8 infections developed in 7 patients with autogenous fistulas. The puncture infection rate was 5%/yr (12%/yr for a second puncture infection). The clean wound infection rate was 3% for grafts and 0.4% for autogenous fistulas. We made an attempt to salvage the graft, usually with a segmental bypass, in 75% of patients with a graft infection. Grafts were salvaged in 80% of patients in whom salvage was attempted (60% of all patients with an infection). The results in the few patients with infected autogenous fistulas were relatively poor.

Phenomenology: one way to understand nursing practice

This article reviews some of the debates about the relative merits of qualitative research and gives some examples of phenomenological enquiry in nursing. Given that nursing occurs in "the real world of practice", the view is forwarded that a research method chosen to understand nursing practice must be able to generate meaning from the people who are involved in nursing, that is, the nurses and patients in everyday practice settings. Phenomenology is suggested as a method for understanding nursing practice and some phenomenological research is reviewed.

Survival of elderly patients with transfusion-related acquired immunodeficiency syndrome

OBJECTIVE

To determine the influences of age and risk group on the survival of AIDS patients. We concentrated on transfusion because it is the commonest risk factor for AIDS in patients over 70 years of age.

DESIGN

Survival curve regression analysis.

PARTICIPANTS

Patients aged 13 years and over with AIDS acquired through transfusion, and patients 65 years or older with AIDS as a result of intravenous drug use (IVDU). Data were obtained from the New York City Department of Health.

MAIN OUTCOME

The patients were divided into four groups, ages 13-40 years, 41-64 years, and 65 years and over with AIDS as a result of transfusion, and 65 years and older with AIDS as a result of IVDU. The survivals of the three transfusion-related AIDS groups were compared, as were the 65 years-and-over groups with AIDS as a result of transfusion or IVDU. AIDS-defining diagnoses between those over and under 65 years with AIDS as a result of transfusion were also compared.

RESULTS

The median survival for the three transfusion-related AIDS groups were 273 days, 58 days, and 60 days, respectively. There was a significant association between shorter survival and increasing age. This was largely due to the longer survival of the patients aged 13-40 years. There was no difference in AIDS-defining diagnosis between those over and under 65 years with transfusion-related AIDS. The survival curves of the elderly with AIDS as a result of transfusion or IVDU were not different.

CONCLUSION

Age over 40 years is an independent risk factor for poor survival among transfusion-related AIDS patients. Among the elderly, patients with transfusion-related AIDS have similar survivals to patients with IVDU-related AIDS.

Identification of progastrin derived peptides in colorectal carcinoma extracts

The possible production of gastrin by colorectal carcinomas has been studied. Extracts of 44 tumours and adjacent macroscopically normal tissue were examined in radioimmunoassay using the following antibodies: (i) L289 raised to a C-terminal fragment of progastrin which shows specificity for intact progastrin, but not the extreme C-terminal tryptic peptide; (ii) LW60 raised to a C-terminal fragment of progastrin which reacts with progastrin and its C-terminal tryptic peptide; (iii) 109-21 which was raised to, and reacts with, Gly-extended forms of heptadecapeptide gastrin--that is, biosynthetic intermediates on the pathway producing active gastrin; and (iv) L2 which reacts with amidated, biologically active gastrins. All samples contained detectable material in assays using LW60; in general, concentrations measured with this antibody were higher than with the other antibodies, and in particular there were higher concentrations in tumour compared with normal tissue extracts. Tumour extracts also contained higher concentrations of immunoreactivity compared with normal tissue, in assays using antibodies L289 and 109-21. In contrast, amidated gastrins were found in similar concentrations in tumour and normal tissue, and concentrations were the lowest of those recorded in the four assays. Separation on Sephadex G50 revealed peaks compatible with progastrin and its C-terminal flanking peptide, and two other peaks that are so far unidentified. In conclusion most colorectal carcinomas contain peptides derived from the gastrin precursor, progastrin, but for the most part these tumours do not convert progastrin into biologically active products.

Children of HIV positive haemophilic men

All 14 children who were conceived at the time their 12 haemophilic fathers were anti-HIV positive were shown to be HIV negative and to be healthy physically and mentally. Eleven of the 12 female partners have remained anti-HIV negative and one has seroconverted. Despite counselling it is likely that children will continue to be conceived by anti-HIV positive haemophiliacs.

Client feedback--development of an instrument for psychiatric inpatients

A client feedback instrument and method has been developed to improve service delivery to psychiatric inpatients. Results indicate that the strongest cause of patients believing they can cope with life out of hospital is the quality of communication between staff, followed by communication with staff and satisfaction with the centre overall. A secondary finding was that good response rates can be achieved and reliable data can be gathered from psychiatric patients. Further development options and potential application to other psychiatric hospitals are discussed.

Childhood immunisation and family size

This paper reports an investigation into the associations between the number of children in the family and the vaccination uptake performance of those children. Using data from child health computer system the pertussis vaccination status was studied in 3,694 children aged 12 to 14 months. The findings show a strong association between vaccination uptake and the number of children in the family. The uptake rates reduced steadily from 86% for families with only one child to 58% for families with five children or more. Children from larger families were not only less likely to complete their full course of pertussis vaccination, but were also vaccinated later. Logistic regression analysis, which allowed for other associated factors, estimated that one 'child unit' increase in family size decreases the odds of being vaccinated by a factor of 1.7 in rural and suburban families and 1.3 in inner-city families respectively. Health professionals involved with the immunisation service should use child health computer data to target their problematic populations more effectively to achieve high vaccination uptake rates.

Coadministration of haloperidol and SCH-23390 prevents the increase in "perforated" synapses due to either drug alone

Perforated synapses, which have a discontinuous density along the postsynaptic membrane, undergo changes in numbers under various experimental conditions. We have previously shown that 14-day administration of haloperidol, a typical neuroleptic which induces extrapyramidal side effects (EPS) and tardive dyskinesia (TD) in patients, causes an increase in the percentage of perforated synapses within the caudate nucleus. This increase was reversed if the animals were taken off the drug for an equal period of time (14 days). There was no effect within the nucleus accumbens. The atypical antipsychotic drug, clozapine, which when administered precipitates a very much lower incidence of EPS and TD, had no effect on the percentage of perforated synapses within either the caudate or nucleus accumbens. Because clozapine binds to both dopamine (DA) D1 and D2 receptors, it was of interest to determine if any changes in perforated synapses occurred following administration of the specific D1 antagonist, SCH-23390. Furthermore, because the action of D2 agonist may be dependent on the activation of the D1 receptor, we asked whether concomitant blockade of the D1 receptor could prevent the increase in perforated synapses due to the action of haloperidol, a drug which upregulates D2 receptors. We found that 14-day treatment with SCH-23390 (1.0 mg/kg per day) or haloperidol (0.5 mg/kg per day) caused an increase in the percentage of perforated synapses within the caudate but not the nucleus accumbens. There was a corresponding increase in DA D1 and D2 receptors in the caudate following administration of SCH-23390 or haloperidol, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomised controlled trial of laparoscopic versus mini cholecystectomy. The McGill Gallstone Treatment Group

Laparoscopic cholecystectomy (LC) has gained wide acceptance for treatment of cholelithiasis in preference to open cholecystectomy, though it has not been formally compared with mini cholecystectomy (MC). We have compared these two techniques in a randomised trial. 70 patients with ultrasound-proven cholelithiasis were randomly allocated LC (38) or MC (32); 37 and 25, respectively, underwent the assigned procedure. The mean hospital stay (including 1 preoperative day) was significantly shorter in the LC than the MC group (median 3 [interquartile range 2-3] vs 4 [3-5], p = 0.001) as was duration of convalescence (mean 11.9 [SD 9.1] vs 20.2 [16.5] days, p = 0.04). The rate of return to normal activities was 1.77 times greater in the LC group than in the MC group (95% confidence interval 1.01-3.11, p = 0.03). In regression analysis, the type of cholecystectomy done was the only variable significantly associated with the duration of convalescence. Although there was significant postoperative improvement in all of three quality of life scores in both groups, LC patients improved more quickly than did MC patients. This randomised trial shows the superior effectiveness of LC over MC in treating cholelithiasis.

Mortality prediction in infants with congenital diaphragmatic hernia: potential criteria for ECMO

Over the last ten years the survival of infants born with congenital diaphragmatic hernia who reach the Intensive Care Unit of the Royal Children's Hospital, Melbourne has been constant at 56 +/- 6%. Experimental therapies such as extracorporeal membrane oxygenation, high-frequency oscillation and lung transplantation are now being considered as therapeutic options, and as such the ability to predict survival or death of these infants is increasingly important. The records of all infants with congenital diaphragmatic hernia admitted to the Intensive Care Unit between 1 January 1980 and 30 April 1989 were reviewed; blood gas, ventilatory details, and outcome information was obtained. Receiver operating curve analysis was used to determine the best predictor of death. An oxygenation index (MAP x FiO2/PaO2) > 0.3 or ventilation index (PIP x RR x CO2/1000) > 70 predicted a 94% mortality with a specificity of 96% and a sensitivity of 82%.

Neurobehavioral effects from acute exposures to methyl isobutyl ketone and methyl ethyl ketone

Subjects were tested for neurobehavioral performance in an environmental chamber to detect the presence of subclinical central nervous system effects from 4-hr exposures to methyl isobutyl ketone (MIBK) at 100 ppm, methyl ethyl ketone (MEK) at 200 ppm, MIBK at 50 ppm with MEK at 100 ppm, or a placebo (i.e., a 5-min presentation of 25 ppm MEK-MIBK at each exposure period outset). Subjects were 68 males and 75 females recruited from local universities; ages ranged from 18 to 32 years. Ethanol by ingestion (95%-0.84 ml/kg) was used as a positive control. Five psychomotor tests (choice reaction time [CRT], simple reaction time [SRT], visual vigilance, dual task [auditory tone discrimination and tracking], memory scanning), one sensorimotor test (postural sway), and a test of mood (profile of mood states) were used to measure neurobehavioral effects. Additionally, chemical measurements (blood and breath) and reports of sensory and irritant effects were measured. The chemical exposures produced statistically significant performance effects on only 4 of 32 measures (% correct responses-visual vigilance, movement time-CRT, SRT, % incorrect responses-dual task). These effects, however, were not substantial and could not be attributed directly to the chemical exposures. Alcohol ingestion, however, produced significant decrements on every performance test except memory scanning and mood. An interaction occurred between gender and alcohol ingestion, such that more statistically significant performance decrements were found for females than for males. Significant odor sensations and irritant effects were reported by the subjects during the chemical exposures. The MEK results agree with earlier MEK experiments at comparable exposure conditions, and the MIBK results are consistent with a recent Swedish study that used MIBK exposures and showed no significant behavioral performance decrements from single MIBK exposures at 50 ppm with 50 W exercise. Additionally, the MIBK-MEK combination exposure showed no evidence of any interaction effects on either the behavioral or chemical measurements. The principal effects resulting from exposures to MEK and MIBK at the durations and concentrations used in the study are limited to sensory and irritant effects.

Intact Parathyroid Hormone: Performance and Clinical Utility of an Automated Assay Based on High-Performance Immunoaffinity Chromatography and Chemiluminescence Detection

The performance and clinical utility of an automated assay of intact parathyroid hormone (parathyrin, PTH) are evaluated. The method is based on the extraction of PTH from plasma by an HPLC column containing immobilized anti-(44-68 PTH) antibodies. The PTH retained is detected with a postcolumn reactor and use of anti-(1-34 PTH) chemiluminescent-labeled antibodies. The total cycle time of the assay is 6.5 min per injection after a 1-h incubation. The lower limit of detection for PTH in a 66-microL plasma sample was 0.5 pmol/L based on peak heights and 0.2 pmol/L based on peak areas. Mean analytical recovery for PTH added to plasma was 97%. The within-day precisions (CVs) for 4.2 and 30 pmol/L PTH plasma samples were 9.2% and 5.6% and the day-to-day precisions were 10.3% and 5.7%, respectively. No significant interferences from 1-34, 44-68, or 53-84 PTH fragments were noted, even at highly increased concentrations of fragments. The correlation of results with those of a manual assay of intact PTH was 0.97, and the results showed good agreement with disease state for patients with hypo- or hyperparathyroidism. The specificity of the assay for primary hyperparathyroidism was greater than 95%. We discuss the advantages (speed and quality control) of this approach over current immunoassays and the potential use of this method for detecting other analytes.

Intact parathyroid hormone: performance and clinical utility of an automated assay based on high-performance immunoaffinity chromatography and chemiluminescence detection

The performance and clinical utility of an automated assay of intact parathyroid hormone (parathyrin, PTH) are evaluated. The method is based on the extraction of PTH from plasma by an HPLC column containing immobilized anti-(44-68 PTH) antibodies. The PTH retained is detected with a postcolumn reactor and use of anti-(1-34 PTH) chemiluminescent-labeled antibodies. The total cycle time of the assay is 6.5 min per injection after a 1-h incubation. The lower limit of detection for PTH in a 66-microL plasma sample was 0.5 pmol/L based on peak heights and 0.2 pmol/L based on peak areas. Mean analytical recovery for PTH added to plasma was 97%. The within-day precisions (CVs) for 4.2 and 30 pmol/L PTH plasma samples were 9.2% and 5.6% and the day-to-day precisions were 10.3% and 5.7%, respectively. No significant interferences from 1-34, 44-68, or 53-84 PTH fragments were noted, even at highly increased concentrations of fragments. The correlation of results with those of a manual assay of intact PTH was 0.97, and the results showed good agreement with disease state for patients with hypo- or hyperparathyroidism. The specificity of the assay for primary hyperparathyroidism was greater than 95%. We discuss the advantages (speed and quality control) of this approach over current immunoassays and the potential use of this method for detecting other analytes.

JC virus associated meningoencephalitis in an immunocompetent girl

JC virus is most commonly acquired during childhood, and no clinical illness has been associated with primary infection, which is assumed to be asymptomatic. The only disease associated with JC virus to date is progressive multifocal leucoencephalopathy (PML), which is usually caused by viral reactivation in immunocompromised adults. A chronic meningoencephalitis associated with an active JC virus infection in an immunocompetent 13 year old girl is described.

Extrastriatal dopamine D2 receptors: distribution, pharmacological characterization and region-specific regulation by clozapine

The distribution of dopamine D2 receptors in the rat brain was determined by quantitative autoradiography of the binding of [125I]epidepride and the effects of chronic drug administration on regulation of receptors in striatal and extrastriatal brain regions were characterized. [125I]Epidepride (2200 Ci/mmol) bound with high affinity to coronal tissue sections from the rat brain (Kd = 78 pM), and specific binding was detected in a number of discrete layers, nuclei or regions of the hippocampus, thalamus, cerebellum and other extrastriatal sites. Pharmacological analysis of radioligand binding to hippocampal and cerebellar membranes indicated binding to dopamine D2 receptors, and approximately 10% of the binding appeared to represent low affinity idazoxan-displaceable binding to alpha-2 adrenoceptors. The binding to extrastriatal regions resembled previously reported radioligand binding to dopamine D2 receptors in striatal and cortical membranes. Chronic (14 day) administration of two dopamine D2 receptor antagonists, either the typical neuroleptic haloperidol (1.5 mg/kg i.p.) or the atypical neuroleptic clozapine (30 mg/kg i.p.), caused a significant increase in the density of [125I]epidepride binding sites in the medial prefrontal cortex and parietal cortex. Only haloperidol caused a significant increase in the density of [3H]spiperone and [125I]epidepride binding sites in the striatum and a slight increase in [125I]epidepride binding sites in the hippocampus. Similar administration of amphetamine (5 mg/kg i.p.) had no significant effect on the density of dopamine D2 receptors in any brain region examined. In addition, no drug-induced changes in the characteristics of dopamine D2 receptors in discrete areas of the cerebellum were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of single pin versus multiple pin fixation in treatment of slipped capital femoral epiphysis

From January 1982 to December 1987, 114 hips of 80 patients underwent pinning for treatment of slipped capital femoral epiphysis (SCFE). Three groups were differentiated based on the number of pins used. The average length of follow-up was 2 years 5 months. The mean time to physeal closure was 5.43 months in the single pin group, 5.54 months in the two pin group, and 6.44 months in the three or more pin group. These differences were not statistically significant. There was a statistically significant decrease in the rate of pin-related complications and reoperations in the single pin group as compared with the two pin and multiple pin groups. We conclude that central single pin fixation for treatment of SCFE dependably results in physeal closure while minimizing pin-related complications.

Delayed posttraumatic diaphragmatic hernia: case report and literature review

The case of a 36-year-old man with an unsuspected delayed posttraumatic diaphragmatic hernia is described. This entity often presents with vague clinical symptoms and non-specific radiographic findings long after the initiating trauma has been forgotten. Therefore, the preoperative diagnosis of this entity is notoriously difficult, but failure to make this diagnosis carries a high mortality rate. A high index of suspicion must be maintained.