Relatives' lived experiences of complementary therapies in a critical care department--a phenomenological study

This phenomenological study examined relatives' lived experiences of complementary therapies in the Department of Critical Care Medicine at Royal Hobart Hospital. Participants in the study, 20 relatives of critically ill patients, were involved in a non-structured, audiotaped interview. Subsequently, transcripts were analysed using a phenomenological transformative process to identify common themes in the text. Study findings suggested four emerging conceptual categories, which with further analysis uncovered the essence of the phenomenon as extending and enriching a caring atmosphere.

Change in ventricular size and effect of ventricular catheter placement in pediatric patients with shunted hydrocephalus

OBJECTIVE

The multicenter, randomized pediatric cerebrospinal fluid shunt valve design trial found no difference in the rate of shunt failure between a standard valve, a siphon-reducing valve (Delta; Medtronic PS Medical, Goleta, CA), and a flow-limiting valve (Orbis Sigma; Cordis, Miami, FL); however, the valves were expected to have different effects on ultimate ventricular size. Also, the catheter position or local environment of the ventricular catheter tip might have affected shunt failure. Therefore, we performed a post hoc analysis to understand what factors, other than valve design, affected shunt failure and to identify strategies that might be developed to reduce shunt failure.

METHODS

Ventricular size was measured at as many as six different intervals, using a modified Evans' ratio (with incorporation of the frontal and occipital dimensions), in 344 patients. Ventricular catheter location was defined as being in the frontal horn, occipital horn, body of the lateral ventricle, third ventricle, embedded in brain, or unknown. The ventricular catheter tip was described as surrounded by cerebrospinal fluid, touching brain, or surrounded by brain parenchyma within the ventricle (slit ventricle). Repeated measures analysis of variance for unbalanced data was used to analyze ventricular size. A Cox model (with incorporation of time-dependent covariates) was used to evaluate the contribution of age, etiology, shunt design, ventricular size, ventricular catheter location, and environment among the cases.

RESULTS

Ventricular volume decreased in an exponential fashion, forming a plateau at 14 months, and was similar for the three valves (P = 0.4). Frontal and occipital ventricular catheter tip locations were associated with a reduced risk of shunt failure (hazard ratios, 0.60 [P = 0.02] and 0.45 [P = 0.001], respectively). Ventricular catheter tips surrounded by cerebrospinal fluid or touching the brain were associated with a reduced risk of failure (hazard ratios, 0.21 and 0.33, respectively; P = 0.0001). Patients with myelomeningocele or large ventricles had increased risk of malfunction (hazard ratios, 1.78 [P = 0.006] and 2.33 [P = 0.03], respectively).

CONCLUSION

Decline of ventricular size over time is not affected by these different shunt valve designs. This suggests that the mechanical models of hydrocephalus on which the designs were based are inadequate. Ventricular catheter tip location and ventricular catheter environment are important. Techniques to accurately place ventricular catheters and new valve designs that effectively control ventricular size might reduce shunt malfunction.

Rapid identification of Candida dubliniensis with commercial yeast identification systems

Candida dubliniensis is a newly described species that is closely related phylogenetically to Candida albicans and that is commonly associated with oral candidiasis in human immunodeficiency virus-positive patients. Several recent studies have attempted to elucidate phenotypic and genotypic characteristics of use in separating the two species. However, results obtained with simple phenotypic tests were too variable and tests that provided more definitive data were too complex for routine use in the clinical laboratory setting. The objective of this study was to determine if reproducible identification of C. dubliniensis could be obtained with commercial identification kits. The substrate reactivity profiles of 80 C. dubliniensis isolates were obtained by using the API 20C AUX, ID 32 C, RapID Yeast Plus, VITEK YBC, and VITEK 2 ID-YST systems. The percentages of C. dubliniensis isolates capable of assimilating or hydrolyzing each substrate were compared with the percentages from the C. albicans profiles in each kit's database, and the results were expressed as percent C. dubliniensis and percent C. albicans. Any substrate that showed >50% difference in reactivity was considered useful in differentiating the species. In addition, assimilation of methyl-alpha-D-glucoside (MDG), D-trehalose (TRE), and D-xylose (XYL) by the same isolates was investigated by the traditional procedure of Wickerham and Burton (L. J. Wickerham and K. A. Burton, J. Bacteriol. 56:363-371, 1948). At 48 h (the time recommended by the manufacturer for its new database), we found that the assimilation of four carbohydrates in the API 20C AUX system could be used to distinguish the species, i.e., glycerol (GLY; 88 and 14%), XYL (0 and 88%), MDG (0 and 85%), and TRE (15 and 97%). Similarly, results with the ID 32 C system at 48 h showed that XYL (0 and 98%), MDG (0 and 98%), lactate (LAT; 0 and 96%), and TRE (30 and 96%) could be used to separate the two species. Phosphatase (PHS; 9 and 76%) and alpha-D-glucosidase (23 and 94%) proved to be the most useful for separation of the species in the RapID Yeast Plus system. While at 24 h the profiles obtained with the VITEK YBC system showed that MDG (10 and 95%), XYL (0 and 95%), and GLY (26 and 80%) could be used to separate the two species, at 48 h only XYL (6 and 95%) could be used to separate the two species. The most useful substrates in the VITEK 2 ID-YST system were TRE (1 and 89%), MDG (1 and 99%), LAT (4 and 98%), and PHS (83 and 1%). While the latter kit was not yet commercially available at the time of the study, it would appear to be the most valuable for the identification of C. dubliniensis. Although assimilation of MDG, TRE, and XYL proved to be the most useful for species differentiation by the majority of commercial systems, the results with these carbohydrates by the Wickerham and Burton procedure were essentially the same for both species, albeit following protracted incubation. Thus, it is the rapidity of the assimilation achieved with the commercial systems that allows the differentiation of C. dubliniensis from C. albicans.

GRASP55, a second mammalian GRASP protein involved in the stacking of Golgi cisternae in a cell-free system

We have identified a 55 kDa protein, named GRASP55 (Golgi reassembly stacking protein of 55 kDa), as a component of the Golgi stacking machinery. GRASP55 is homologous to GRASP65, an N-ethylmaleimide-sensitive membrane protein required for the stacking of Golgi cisternae in a cell-free system. GRASP65 exists in a complex with the vesicle docking protein receptor GM130 to which it binds directly, and the membrane tethering protein p115, which also functions in the stacking of Golgi cisternae. GRASP55 binding to GM130, could not be detected using biochemical methods, although a weak interaction was detected with the yeast two-hybrid system. Cryo-electron microscopy revealed that GRASP65, like GM130, is present on the cis-Golgi, while GRASP55 is on the medial-Golgi. Recombinant GRASP55 and antibodies to the protein block the stacking of Golgi cisternae, which is similar to the observations made for GRASP65. These results demonstrate that GRASP55 and GRASP65 function in the stacking of Golgi cisternae.

Seasonal influences on admissions for affective disorder and schizophrenia in Ireland: a comparison of first and readmissions

Although genetic and environmental factors operating before or around the time of birth have been demonstrated to be relevant to the aetiology of the major psychoses, a seasonal variation in the rates of admission of such patients has long been recognised. Few studies have compared first and readmissions. This study examined for seasonal variation of admission in the major psychoses, and compared diagnostic categories by admission status. Patients admitted to Irish psychiatric inpatient facilities between 1989 and 1994 with an ICD-9/10 diagnosis of schizophrenia or affective disorder were identified from the National Psychiatric Inpatient Reporting System (NPIRS). The data were analysed using a hierarchical log linear model, the chi-square test, a Kolmogorov-Smirnov (KS) type statistic, and the method of Walter and Elwood. The hierarchical log linear model demonstrated significant interactions between the month of admission and admission order (change in scaled deviance 28.77, df = 11, P < 0.003). Both first admissions with mania, and readmissions with bipolar affective disorder exhibited significant seasonality. In contrast, only first admissions with schizophrenia showed significant seasonal effects. Although first admissions with mania and readmissions with bipolar disorder both show seasonality, seasonal influences appear to be more relevant to onset of schizophrenia than subsequent relapse.

Geographic variations in dental services provided to older adults in Ontario, Canada

In an initial study, Leake et al. (J Public Health Dent 1996; 52: 182-90) found that older Ontarians living in metropolitan communities received almost twice the amount of dental care than older Ontarians living in non-metropolitan communities. Since data were collected for the 2 years prior to the enrollment of subjects in a longitudinal study, factors responsible for this variation could not be explored. This paper extends these findings by examining the volume of dental services received by these subjects in the 3 years between the baseline and follow-up phases of the longitudinal study. During this 3-year period, geographic variations in the volume of services provided were also observed. In a regression analysis, geographic location remained a significant predictor of the number of services received after controlling for six other explanatory variables: insurance coverage, number of teeth, restorative treatment need, self-rated oral health, regular dental visits and use of specialist services. Together, these explained only 24% of the variance in service provision. Since patient-reported outcomes were better in the communities with higher volumes of provision, further research concerning the patient and dentist factors influencing treatment provision is warranted.

Using an annual over-75 health check to screen for depression: validation of the short Geriatric Depression Scale (GDS15) within general practice

OBJECTIVE

To validate the short Geriatric Depression Scale (GDS15) as a screening instrument and determine the optimal cutpoint for detecting depression among older people living in the community.

DESIGN

Two stage study with the first stage consisting of a health check of people aged 75 years and over by a practice nurse which included the GDS15. A second-stage diagnostic interview including the criterion standard was carried out blind to GDS15 score.

SETTING

A large general practice in Melton Mowbray, Leicestershire, UK.

PATIENTS

A random sample (stratified according to first-stage GDS15 score) of 257 older people living in the community, without significant cognitive impairment, were selected for the second-stage diagnostic interview.

MEASURES

The first-stage GDS15 score was compared with diagnostic status for depression and anxiety disorders (according to ICD-10 criteria) and presence of depressive symptoms at the second-stage clinical interview.

RESULTS

Ninety-three per cent of those eligible for the study were successfully screened with the GDS15. A cutpoint of <3/3+ had a sensitivity of 100% and specificity of 72% in detecting cases of depression but fewer than one in five of those testing positive reached a diagnostic threshold. Only 25% of those with a diagnosis of depression had any mention of mental health problems in their medical notes in the year prior to the clinical interview. For detecting depressive symptoms the same cutpoint was 79% sensitive and 78% specific with a positive predictive value of 46%.

CONCLUSIONS

Used as part of an annual over-75 health check in primary care, the GDS15 would detect a significant amount of hidden morbidity which would serve the original purpose of the annual elderly health checks in the UK.

Subjective and external assessments of quality of life in schizophrenia: relationship to insight

OBJECTIVE

This study assessed the manner in which insight influenced schizophrenic patients' evaluation of their objective life conditions and the concurrent validity between patients' and clinicians' assessments of patients' global quality of life.

METHOD

Forty out-patients who fulfilled DSM-III-R criteria for schizophrenia were independently interviewed using the Lancashire Quality of Life Profile and the Standard of Living Interview. Insight was assessed using a self-report questionnaire, the Insight Scale.

RESULTS

For insightful patients there was a significant but modest correlation between objective and subjective indicators of quality of life. Likewise, a significant correlation between subjective and external evaluations of global quality of life was limited to those individuals who had good insight.

CONCLUSION

Diminished insight may limit the usefulness of the self-report methodology for assessing quality of life for some individuals with schizophrenia.

Assessment of separate contributions to perinatal mortality of infertility history and treatment: a case-control analysis

BACKGROUND

Few studies have described the perinatal risks associated with infertility, other than for infertility treated by in-vitro fertilisation or gamete intrafallopian transfer. The aim of this analysis was to estimate the risks of perinatal death associated with treated and untreated infertility.

METHODS

A population-based case-control study of perinatal deaths was carried out in Leicestershire Health District over the period 1990-94, during which 60,922 babies were delivered. Of these, 567 perinatal deaths were associated with 542 women. 972 mothers were randomly selected as controls. Medical, obstetric, and social data were collected for cases and controls from the medical notes and interviews with the women. The relative risks of perinatal death associated with treated and untreated infertility before the index pregnancy were estimated as odds ratios by means of unconditional logistic regression analysis.

FINDINGS

65 (10%) of cases and 34 (3.5%) of the controls had infertility before the index pregnancy. History of infertility in the index pregnancy, irrespective of treatment, increased the risk of perinatal death (odds ratio 2.9 [95% CI 1.8-4.5]). The population attributable risk fraction for perinatal death related to infertility was 6.2% (3.4-9.0). 45 (54%) of the deaths, even in the untreated group, were associated with immaturity. Compared with women without infertility, women with untreated infertility were at increased risk of perinatal death (3.3 [1.6-6.8]). The risk of perinatal death associated with multiple births did not explain this finding. Similarly, treated infertility also increased the risk of perinatal death (2.7 [1.5-4.7]); the risks associated with multiple births explained some, but not all, of this excess. In Leicestershire, the overall underlying risk of a mother experiencing at least one perinatal death over the study was 9.0 per 1000 women. For women who experience infertility, this risk increases by about 18 per 1000 (6-30).

INTERPRETATION

Counselling for women before any form of infertility treatment should include discussion of the risks of perinatal death. Our results would benefit from confirmation. However, we advocate that at antenatal booking a history of infertility, irrespective of treatment, should be sought, because these women have a significantly increased risk of perinatal death, particularly associated with prematurity.

Missense mutations in the most ancient residues of the PAX6 paired domain underlie a spectrum of human congenital eye malformations

Mutations of the human PAX6 gene underlie aniridia (congenital absence of the iris), a rare dominant malformation of the eye. The spectrum of PAX6 mutations in aniridia patients is highly biased, with 92% of all reported mutations leading to premature truncation of the protein (nonsense, splicing, insertions and deletions) and just 2% leading to substitution of one amino acid by another (missense). The extraordinary conservation of the PAX6 protein at the amino acid level amongst vertebrates predicts that pathological missense mutations should in fact be common even though they are hardly ever seen in aniridia patients. This indicates that there is a heavy ascertainment bias in the selection of patients for PAX6 mutation analysis and that the 'missing' PAX6 missense mutations frequently may underlie phenotypes distinct from textbook aniridia. Here we present four novel PAX6 missense mutations, two in association with atypical phenotypes: ectopia pupillae (displaced pupils) and congenital nystagmus (searching gaze), and two in association with more recognizable aniridia phenotypes. Strikingly, all four mutations are located within the PAX6 paired domain and affect amino acids which are highly conserved in all known paired domain proteins. Our results support the hypothesis that the under-representation of missense mutations is caused by ascertainment bias and suggest that a substantial burden of PAX6 -related disease remains to be uncovered.

Calcaneal ultrasound attenuation in an elderly population: measurement position and relationships with body size and past fractures

This study demonstrates, the relationship between past fracture, body size and broadband ultrasound attenuation (BUA) and investigates two sites of BUA measurement in a representative elderly population of men and women (n = 2106). We measured BUA at a fixed position and at a consistent anatomic position within the calcaneus. We found fixed BUA was less closely correlated with stature and age than anatomic BUA. Both correlations were substantially weaker in men than in women. Mean BUA was significantly lower in women with a past fracture compared with nonfracturers (fixed BUA 63.3 vs 69.4 dB/MHz, p = 0.0004; anatomic BUA 77.6 vs 81.7 dB/MHz, p = 0.013). However, in women, the fixed BUA was better than the anatomic BUA at discriminating between fracturers and nonfracturers (OR 1.38/SD (95% CI 1.12-1.68) and OR 1.22/SD (0.99-1.52), respectively) when adjusted for body size and age. There was no significant difference in either BUA in men with or without a past fracture. In conclusion, currently the fixed position for BUA measurement is preferable and, whilst we have demonstrated that it is possible to locate an anatomically consistent point in the calcaneus, the position chosen by this study did not provide a measurement with more discriminatory capability than the fixed position. In women, BUA behaves similarly to bone mineral density in relation to stature and in its strength of association with past fracture, while the lack of association in men may reflect differing contributions by bone strength to fracture risk in the sexes.

Seasonal influences on admissions in schizophrenia and affective disorder in Ireland

Although the seasonal patterns of admissions of affective disorder have been extensively studied, less attention has been given to the seasonal admission patterns of schizophrenia. The traditional method of aggregating the data over a study period, rather than analysing by year of admission may obscure potentially relevant fluctuations in the seasonal pattern. We examined the year-to-year variation in the admission patterns of schizophrenia and affective disorder in Ireland. Using the National Psychiatric Inpatient Reporting System (NPIRS), individuals admitted with an ICD-9/10 diagnosis of a first episode of schizophrenia or affective disorder during the 6-year period 1989-1994 were identified. Seasonal variations in their admission patterns were examined statistically and graphically. There was a significant seasonal variation in the monthly admission patterns of both schizophrenia and affective disorder. This pattern was more marked for individuals with affective disorder. However, the seasonal pattern was not constant from year to year, particularly for schizophrenia.

Frontal and occipital horn ratio: A linear estimate of ventricular size for multiple imaging modalities in pediatric hydrocephalus

OBJECTIVE

Measurement of ventricular size is important in pediatric patients with hydrocephalus, especially those who are being followed with cerebrospinal fluid (CSF) shunts. While volumetric techniques are a more accurate estimate of true ventricular volume, they are often impracticable when multiple modalities including ultrasound are used. Volumetric area and linear measurements were compared to find the most reasonable measurement method.

METHODS

Sixty-four computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) scans from 25 children aged 0-17 years with hydrocephalus, before and after treatment, were measured. Measurements included ventricular volume, a ventricular/brain ratio, and four standard linear measures (Evans' ratio, Huckman's measurement, minimal lateral ventricular width, and lateral ventricular span at the body). We also included a new ratio, which accounts for often disproportionate occipital horn expansion in pediatric patients, called the frontal and occipital horn ratio. Volume and linear measurements were compared using the Spearman's correlation coefficients and correlations were further differentiated using a Z test statistic. The frontal and occipital horn ratio was also measured on CT, MRI, and US scans from 44 normal children aged 0-17 years to identify normal values. The effect of age was determined by linear regression.

RESULTS

The best linear correlation with ventricular size was the frontal + occipital horn ratio (r = 0.852) and was equivalent to the ventricular/brain ratio (r = 0.891), previously shown to have the highest correlation with ventricular volume. Evans' ratio correlates less well (r = 0.423). The normal frontal and occipital horn ratio is 0.37 and is independent of age.

CONCLUSIONS

The frontal and occipital horn ratio is a simple method of evaluating ventricular size in pediatric hydrocephalus patients with CSF shunts.

A comparison of temperature measurements using three ear thermometers

Following anecdotal and research-based reports of inaccuracies encountered with the use of ear thermometers in patient care settings, this two-phase study was designed to compare the accuracy of three ear thermometers when used in a multioperator environment. The within-subject variation (limits of agreement) in ear temperature measurements obtained with the three ear thermometers in a multioperator condition by using an oral temperature reference standard ranged from +/- 1.25 degrees F to 1.85 degrees F. In multioperator, multisubject patient care environments using a pulmonary artery catheter core temperature as the reference standard, the limits of agreement for ear temperature measurements obtained with the three different ear thermometers ranged from +/- 2.19 degrees F to 2.85 degrees F. These results suggest that there is substantial variation in ear measurements and raise questions about the use of ear thermometers when there are multiple personnel taking temperatures, as occurs in hospital-based clinical practice environments. Handedness of the operator, position of the patient, and the ear used for measurement did not produce clinically significant variability in ear temperature measurements.

Rapid identification of Candida dubliniensis by indirect immunofluorescence based on differential localization of antigens on C. dubliniensis blastospores and Candida albicans germ tubes

There is a clear need for the development of a rapid and reliable test for the identification of Candida dubliniensis and for the discrimination of this species from Candida albicans. In the present study we have investigated the potential use of C. dubliniensis-specific antigens as a basis for its identification. We produced an anti-C. dubliniensis serum which, after adsorption with C. albicans blastospores, was found to differentially label C. dubliniensis isolates in an indirect immunofluorescence test. In this test, the antiserum reacted with blastospores and germ tubes of C. dubliniensis and with blastospores of Candida krusei and Rhodotorula rubra but did not react with blastospores of several other Candida species including C. albicans. The antiserum also reacted with C. albicans germ tubes. The anti-C. dubliniensis adsorbed serum reacted with specific components of 25, 28, 37, 40, 52, and 62 kDa in the C. dubliniensis extract and with a variety of antigens from other yeast species. The antigens from non-C. dubliniensis yeasts showing reactivity with the anti-C. dubliniensis adsorbed serum are mostly expressed within the cell walls of these yeast species, and this reactivity does not interfere with the use of the anti-C. dubliniensis adsorbed serum in an indirect immunofluorescence test for the rapid identification of C. dubliniensis.

Spontaneous abnormal involuntary movements in first-episode schizophrenia and schizophreniform disorder: baseline rate in a group of patients from an Irish catchment area

OBJECTIVE

This study investigated the rate of spontaneous abnormal involuntary movements in a group of patients presenting with a first episode of schizophrenia or schizophreniform psychosis.

METHOD

Seventy-nine patients with a first episode of schizophrenia or schizophreniform psychosis who presented to a catchment area psychiatric service over a 3-year period, and who were neuroleptic-naive or had been medicated for less than 1 month, were examined for the presence of involuntary movements with use of the Abnormal Involuntary Movement Scale.

RESULTS

Six patients (7.6%) had spontaneous dyskinesia as defined by the criteria of Schooler and Kane, and nine other patients had mild orofacial involuntary movements. The patients with spontaneous dyskinesia had completed significantly fewer years of education than the patients without dyskinesia. Spontaneous involuntary movements were unrelated to age at presentation for treatment.

CONCLUSIONS

Spontaneous abnormal involuntary movements were evident among a proportion of patients with first-episode schizophrenia or schizophreniform psychosis at baseline presentation and were associated with reduced educational attainment. This finding supports previous suggestions that abnormal involuntary movements in schizophrenia may be related to the pathophysiology of the illness and therefore cannot be attributed entirely to the adverse effects of neuroleptic medication.

Epileptic aphasia: a consequence of regional hypometabolic encephalopathy?

A series of 25 children, 13 females and 12 males, who had an acquired communication disorder together with epilepsy, but did not fulfil the strict criteria of the Landau-Kleffner syndrome, was studied. All children had a clinical neurological evaluation, speech and language assessment, an awake and sleep EEG, cranial MRI, SPET scan, and audiometry. Clinical seizures were most often polymorphic in type (17 of 25). Atypical absences were the commonest individual seizure type occurring in 15 cases. All patients had an unequivocal epileptiform EEG. Normal sleep phenomena were only observed in 10 cases, enhancement of epileptiform activity in sleep was seen in 16. Cranial MRI was abnormal in six and normal in 19 cases. The SPET scans were abnormal in 22 of 25 children. The language deficits were classified neurologically as receptive aphasia, 24 of 25; expressive aphasia, 20 of 25; nominal aphasia, eight of 25; articulatory dyspraxia, 10 of 25; and auditory agnosia, nine of 25. It is hypothesized that the loss of communication skills is due to an encephalopathy secondary to the persistent epileptic discharge and manifests as a hypometabolic area on the SPET scan.

Automatic adjustment of pacemaker stimulation output correlated with continuously monitored capture thresholds: a multicenter study. European Microny Study Group

Pacing threshold is affected by many factors. A pacing system able to confirm capture at each beat and automatically adjust its output close to the actual pacing threshold is highly desirable. This study evaluates the safety and efficacy of the Autocapture function of the Pacesetter Microny SR+. One hundred thirteen patients were recruited from 16 centers in 7 European countries and followed up for 1 year. All pacemakers were implanted with Pacesetter's low polarization, bipolar leads. The key feature of Autocapture is the immediate delivery of a 4.5 V safety backup pulse 62.5 ms after any ineffective ongoing low output pulse. Holter recordings confirmed total reliability of this feature without any exit block. The measured evoked response (ER) signal was stable over time. Acute and chronic pacing thresholds measured by VARIO and Autocapture tests correlated (r > 0.79) over the period of the study. The incidence of backup pulses was 1.1% during pacing. With Autocapture programmed ON, the overall total current consumption was 4.1 microA for VVI and 5.0 microA for VVIR pacing. This study proved that the Autocapture safely and reliably regulates the pacemaker's output according to the prevailing threshold thus providing maximum patient safety and prolonging service life.