Understanding the social context of violent and aggressive incidents on an inpatient unit

The English National Service Framework for Mental Health stipulates that the highest quality of health care should be provided for mental health service users. Incidents of aggression and violence militate against achieving that goal, yet such incidents are frequently reported in inpatient settings. Much research in this area reflects a dualistic, perpetrator/victim conceptualization of incidents. This study aimed to take a more systemic approach by treating violent and aggressive incidents as social interactions and by seeking to understand the social contexts in which they took place. In this paper we describe and discuss the main themes to emerge from 15 staff accounts of 11 incidents on one ward. A striking theme reflected throughout the interview data was the lack of staff engagement with clients, and particularly an inability to look at the world through clients' eyes in interpreting their behaviour. We conclude that the 'zero tolerance' campaigns currently being conducted in the UK in relation to aggression towards NHS staff are unlikely to succeed without attention to understanding why aggressive behaviour arises and identifying features of the caring environment that may contribute to it. Rather than adopting a position of 'zero tolerance', we argue that three steps are required following an aggressive incident: emotional support; critical reflection and learning; and the pursuit of accountability.

Metabolic effects of Troglitazone in patients with diet-controlled type 2 diabetes

BACKGROUND

In order to study the mechanisms of action of Troglitazone (TGZ) in vivo in Type 2 diabetes, its effects were studied on glucose metabolism, lipolysis and very low-density lipoprotein (VLDL) apolipoprotein B100 (apoB) kinetics.

MATERIALS AND METHODS

A placebo-controlled, double-blind study was performed in 24 diet-treated patients randomized to receive TGZ 600 mg day(-1), TGZ 200 mg day(-1) or placebo for 8 weeks. Glucose and glycerol turnover were assessed after an overnight fast, and during sequential low-dose insulin infusions (0.01 U kg(-1) h(-1) followed by 0.015 U kg(-1) h(-1)) using 6,6-2H Glucose and 1,2,3-2H Glycerol. Very low-density lipoprotein apoB secretion was measured using l-13C-leucine, monitoring isotopic enrichment by gas chromatography-mass spectrometry. Treatment effects were analyzed by analysis of covariance, adjusting for baseline.

RESULTS

Therapy resulted in a significant group differences in fasting plasma glucose adjusting for baseline (P=0.039). This was most evident at TGZ 600 mg daily [glucose decrease from (mean +/- SD) 9.2 +/- 2.7 to 6.6 +/- 0.9 mmol L(-1)]. HbA1c and insulin levels did not change significantly. Plasma nonesterified fatty acid (NEFA) levels decreased (P=0.045), most evidently at TGZ 200 mg daily, but glycerol was not significantly affected. Although no significant effects were observed on VLDL apoB or triglyceride concentrations, there were treatment differences in the absolute secretion rate of VLDL apoB of borderline (P=0.056) statistical significance, with a decrease observed at TGZ 600 mg daily [geometric mean, SD range, 0.94 (0.41-2.15) to 0.40 (0.14-1.13 mg kg(-1) h(-1))]. Very low-density lipoprotein apoB fractional secretion rate and pool size were unaffected. The VLDL triglyceride: apoB molar ratio differed between treatment groups (P=0.013), being higher in the TGZ 600 mg group [5714 (4128-7741) to 8092 (5669-11552)]. Neither glucose nor glycerol rates of appearance were significantly altered by TGZ and nor did TGZ affect their suppression by insulin.

DISCUSSION

The PPARgamma agonist, troglitazone, decreases fasting glucose and NEFA levels in diet-treated Type 2 diabetes. It may also decrease VLDL particle secretion. These effects would be considered beneficial. The biological importance of the increase in VLDL-triglyceride enrichment warrants further study.

Continuing education opportunities for recently qualified mental health diplomates

While successive reports concerned with mental health services have emphasized the importance of continuing professional development for mental health nurses, there have been long-standing concerns about the provision of appropriate courses and opportunities for attendance. Drawing from a longitudinal study of the careers of a cohort of mental health diplomates, this paper focuses on fulfilment of their continuing education plans in the early post-qualification period. During the first 6 months, just under half the cohort had wanted to start a course but been unable to do so. For some, even at this early career stage, dissatisfaction with continuing education opportunities was cited as reason for leaving, or considering leaving, a first job. Reasons for starting courses included career progress and meeting the care-giving needs of the immediate work situation. Diplomates may need guidance on their continuing education needs; there was much uncertainty about plans to take courses and moreover, demand for courses which they had wanted to start but been unable to do so, was not always sustained.

Clinical use of rituximab in haematological malignancies

Rituximab is a chimeric human/mouse monoclonal antibody that is approved for the treatment of relapsed and refractory non-Hodgkin's lymphoma (NHL) and in combination with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy as first-line therapy for diffuse large B-cell NHL, where it has shown the first survival advantage over CHOP alone in more than 20 years. Strategies to help define the optimal therapeutic usage of rituximab are being assessed, including first-line and maintenance or extended therapy, and the combination of rituximab with chemotherapy in indolent NHL. Emerging data suggest that earlier use may yield higher response rates, extended therapy can prolong remission, and the addition of rituximab to chemotherapy can increase clinical and molecular remission rates when compared with those achieved using chemotherapy alone. Studies in the peritransplant setting suggest a role for rituximab in vivo purging prior to transplant and/or maintenance rituximab as a means of clearing minimal residual disease. Rituximab has also shown activity in other B-cell disorders such as chronic lymphocytic leukaemia. The full potential of this immunotherapeutic agent remains to be defined in ongoing and future clinical trials.

First magnetomyographic recordings of uterine activity with spatial-temporal information using 151 channel sensor array (SARA)

The lack of an effective method for the diagnosis and management of labor points to the need for a new device. SARA-SQUID Array for Reproductive Assessment, is capable of recording spatial-temporal biomagnetic activity. The SARA system is first of its kind in the world dedicated to maternal-fetal research. We non-invasively recorded the magnetomyographic (MMG) signals corresponding to the uterine electrical activity from 7 pregnant mothers. The detailed physiological information obtained simultaneously from 151 sensors spread over the entire abdomen, will help in understanding the origin and propagation of the uterine activity. This information could give us better insight into the mechanism of uterine contraction and may help in better diagnosis and management of labor.

Relation between insulin kinetics and insulin sensitivity in pregnancy

BACKGROUND

Different time-concentration profiles of plasma insulin following insulin modification of a frequently sampled intravenous glucose-tolerance-test (FSIVGTT) were observed in a study investigating maternal metabolism and fetal macrosomia. We aimed to investigate whether these differences were related to the volume of distribution of insulin, insulin clearance, or both.

DESIGN

Forty-four women were studied between 33 and 35 weeks' gestation using an insulin-modified FSIVGTT. Specific insulin was assayed with an enzyme-linked immunosorbent assay. Insulin sensitivity was calculated using the minimal model and the homeostasis model assessment (HOMA). The volume of distribution and clearance of insulin were calculated from measurements between 2 and 155 min after insulin modification using a one-compartment model.

RESULTS

In accordance with the method for deriving the volume of distribution, there was a significant negative correlation between the increment in insulin concentration and the volume of distribution (rho=-0.92, P<0.0001). The insulin increment was also related negatively to the clearance of insulin (rho=-0.88, P<0.0001). There was a significant correlation between the volume of distribution and both the insulin sensitivity index (rho=0.56, P<0.0001) and HOMA-%S (rho=0.30, P=0.048), and between the clearance of insulin and both the insulin sensitivity index (rho=0.83, P<0.0001)) and HOMA-%S (rho=0.34, P=0.025).

CONCLUSION

The different time-concentration profiles of plasma insulin resulted from differences in the volume of distribution and clearance of insulin. There was a correlation between insulin kinetics and the insulin sensitivity index. Further research is required to investigate possible mechanisms by which insulin kinetics may be related to insulin sensitivity.

Ultrasound-guided radiofrequency submucosal tongue-base excision for sleep apnoea: a preliminary report

Surgery for sleep apnoea is challenging, particularly in patients with macroglossia. This has led us to develop a new procedure for reduction of the tongue base with low morbidity. Two types of bipolar radiofrequency probe were used via a percutaneous approach under an aseptic technique and general anaesthesia on 15 consecutive patients with retropalatal and retrolingual collapse. The lingual neurovascular bundles and probe were simultaneously identified with intraoperative real-time ultrasound to prevent neurovascular damage, and five patients had additional tongue mucosal suture advancement. All patients had previous or concurrent palatal surgery. The increase in cephalometric (retrolingual) posterior airspace (PAS) was 4 mm with a Spinevac wand and mucosal suture advancement, which is comparable to current-staged monopolar radiofrequency protocols requiring treatment for up to 6 months. Overall, 40% polysomnographic success was achieved, but it was 80% when additional phase 1 procedures were used. Morbidity was minimal with careful adherence to the perioperative care protocol.

[Computer-assisted radiologic quantification of hand and foot changes in rheumatoid arthritis]

Driven by the increasing implementation of electronical picture archiving and communications system (PACS) into every days practice a fully operative Java application software was developed to support the efficacy of the scoring process in rheumatoid arthritis. This software, namely the "Rheuma-Coach" offers the possibility to use the Larsen- or the Ratingen-Score. We measured time savings of approximately 20% per case if this computer assistance was used. The lack of a standard for the positioning of limbs was confirmed.

In vivo CAMPATH-1H prevents GvHD following nonmyeloablative stem-cell transplantation

BACKGROUND

We have investigated a novel nonmyeloablative conditioning regimen in 44 patients with hematological malignancies. The median patient age was 41 years. Many of the patients had high-risk features, including 19 patients with a previous failed transplant.

METHODS

Recipient conditioning consisted of CAMPATH-1H 20 mg/day on Days -8 to -4, fludarabine 30 mg/m(2) on Days -7 to -3 and melphalan 140 mg/m(2) on Day -2. Thirty-six recipients received unmanipulated G-CSF mobilized PBSC from HLA identical siblings and eight received unmanipulated BM from MUD. GvHD prophylaxis was with CYA alone for 38 patients and CYA plus MTX for six sibling recipients.

RESULTS

Forty-two of the 43 evaluable patients had sustained engraftment. Results of chimerism analysis using microsatellite PCR indicate that 18 of 31 patients studied were full donor chimeras, while the other patients were mixed chimeras in one or more lineages. At a median follow-up of 9 months (range, 3-29 months) 33 patients remain alive in CR, or with no evidence of disease progression. Seven patients relapsed or progressed post-transplant and four of them subsequently died. Four patients died from regimen-related complications. There were no cases of Grades III-IV acute GvHD. Only two patients developed Grade II acute GvHD and only one had chronic GvHD. The estimated probability of non-relapse mortality at 1 year was 11%.Results: Although longer follow-up is needed to establish the long-term remission rates, this study demonstrates that this nonmyeloablative preparative regimen is associated with durable engraftment, minimal toxicity and low incidence of GvHD.

Haemotoxicity of thiamphenicol in the BALB/c mouse and Wistar Hanover rat

Chloramphenicol (CAP) is haemotoxic in man, inducing two forms of toxicity. First, a commonly-occurring, dose-related, reversible bone marrow depression, which develops during treatment. Second, a rarer aplastic anaemia (AA), developing after treatment, is irreversible, and often fatal. Thiamphenicol (TAP) was developed as a replacement for CAP; however, there are no toxicological investigations in the mouse or rat on the dose-related haemotoxicity of TAP, in repeat dose gavage studies. Therefore, we have conducted a comprehensive investigation in these species, administering TAP for 7-17 days, to define haematological changes. Female BALB/c mice were gavaged with TAP, daily for 7-17 days at 400-1500 mg/kg; female Wistar Hanover rats were dosed with TAP daily at 50-375 mg/kg for 9 or 10 days. Haematological changes were studied at 1, 7 and 14 days post-dosing. In mice at day 1, TAP caused decreases in RBC, HCT and Hb; reticulocytes and platelets were reduced; changes were dose-related and reversible. Marrow cell counts were reduced; marrow was hypocellular, with erythroid depletion and progenitor cell vacuolation; the myeloid/erythroid (M:E) ratio was increased. In the rat, changes were not as clear-cut; there was anaemia with indications of reduced reticulocyte and platelet counts, and evidence of decreased neutrophils and lymphocytes. Marrow erythroid cells were decreased, precursor cells vacuolated, and the M:E ratio increased. We conclude that TAP induced haematological changes in the mouse and rat, parallelling the dose-dependent, reversible marrow depression reported in man; TAP is more haemotoxic in the rat than in the mouse.

Increasing antioxidant levels in tomatoes through modification of the flavonoid biosynthetic pathway

Flavonoids are a diverse group of phenolic secondary metabolites that occur naturally in plants and therefore form an integral component of the human diet. Many of the compounds belonging to this group are potent antioxidants in vitro and epidemiological studies suggest a direct correlation between high flavonoid intake and decreased risk of cardiovascular disease, cancer and other age-related diseases. Enhancing flavonoid biosynthesis in chosen crops may provide new raw materials that have the potential to be used in foods designed for specific benefits to human health. Using genetic modification, it was possible to generate several tomato lines with significantly altered flavonoid content and to probe the role and importance of several key enzymatic steps in the tomato flavonoid biosynthetic pathway. Most notably an up to 78-fold increase in total fruit flavonols was achieved through ectopic expression of a single biosynthetic enzyme, chalcone isomerase. In addition, chalcone synthase and flavonol synthase transgenes were found to act synergistically to up-regulate flavonol biosynthesis significantly in tomato flesh tissues.

Energy intake deficit and physical performance at altitude

BACKGROUND

Physical performance of sea-level (SL) residents acutely exposed to altitude (ALT) is diminished and may improve somewhat with ALT acclimatization.

HYPOTHESIS

A large reduction in lean body mass (LBM), due to severe energy intake deficit during the first 21 d of ALT (4300 m) acclimatization, will adversely affect performance.

METHODS

At ALT, 10 men received a deficit (DEF) of 1500 kcal x d(-1) below body weight (BW) maintenance requirements and 7 men received adequate (ADQ) kcal x d(-1) to maintain BW. Performance was assessed by: 1) maximal oxygen uptake (VO2max); 2) time to complete 50 cycles of a lift and carry task (L+C); 3) number of one-arm elbow flexions (10% BW at 22 flexions x min(-1); and 4) adductor pollicis (AP) muscle strength and endurance time (repeated 5-s static contractions at 50% of maximal force followed by 5-s rest, to exhaustion). Performance and body composition (using BW and circumference measures) were determined at SL and at ALT on days 2 through 21.

RESULTS

At SL, there were no between-group differences (p > 0.05) for any of the performance measures. From SL to day 21 at ALT, BW and LBM declined by 6.6 +/- 3 kg and 4.6 kg, respectively, for the DEF group (both p < 0.01), but did not change (both p > 0.05) for the ADQ group. Performance changes from day 2 or 3 to day 20 or 21 at ALT were as follows (values are means +/- SD): VO2max (ml x min(-1)): DEF = +97 +/- 237, ADQ = +159 +/- 156; L + C (s): DEF = -62 +/- 35*, ADQ = -35 +/- 20* (*p < 0.05; improved from day 3); arm flex (reps): DEF = -2 +/- 7, ADQ = +2 +/- 8; AP endurance (min): DEF = +1.4 +/- 2, ADQ = + 1.9 +/- 2; AP strength (kg): DEF = -0.7 +/- 4, ADQ = -1.2 +/- 2. There were no differences in performance between groups.

CONCLUSIONS

A significant BW and LBM loss due to underfeeding during the first 21 d of ALT acclimatization does not impair physical performance at ALT.

The transforming growth factors beta in development and functional differentiation of the mouse mammary gland

The transforming growth factors beta (TGF-beta) are multifunctional regulators with diverse effects on a variety of developmental processes and differentiated functions. In the mammary gland, a considerable amount of evidence has accumulated indicating that TGF-beta plays a critical role during several phases of the mammary cycle. TGF-beta regulates growth and patterning of the mammary ductal tree in the virgin mouse. During pregnancy, TGF-beta is required for alveolar development and functional differentiation, while at the same time inhibiting secretion of milk proteins. At parturition this inhibition is lifted, permitting initiation of lactation.

User satisfaction with home telecare based on broadband communication

Home telecare services based on broadband communication were established in five locations in Europe. Two different types of telecare unit were developed: one based on a PC or set-top box containing a videoconferencing codec and another on off-the-shelf videoconferencing units. The participants in the project were 13 medical staff, 135 patients and 88 people informally caring for the patients. Questionnaires were used to evaluate user satisfaction with eight telecare services. Almost all participants rated the usability of the system as good or excellent. A total of 105 telecare sessions were scored by the medical staff. Overall, the quality of audio and video communication was judged satisfactory. For the patients and carers, the perceived quality of communication was also satisfactory and did not vary significantly between sites. The medical staff were reasonably satisfied with how the service supported them in their work. Except for the item about being able to support patients in a critical situation, medical staff agreed that an improved quality of health services was offered through telecare. All participants agreed that personal information was treated confidentially and that there was little risk in using the telecare services. The medical staff trusted the assessments they could make remotely while using the telecare system. Although the findings cannot be generalized due to the small number of telecare sessions and the relatively short duration of the experiment, the results encourage further research.

Preoperative and early postoperative magnetic resonance imaging in two cases of childhood choroid plexus carcinoma

We present and illustrate the MRI appearances of two children with choroid plexus carcinoma. The MRI characteristics of these rare tumours are reviewed. Since total surgical resection is a significant prognostic factor, early postoperative MRI was performed in both cases to ensure surgical clearance. In one case a complete resection was documented and this patient remains well at short-term follow-up. Residual tumour was noted in the second case, but despite "second look" surgery there was subsequent local relapse.

Chemokine GRO1 and the spatial and temporal regulation of oligodendrocyte precursor proliferation

Oligodendrocyte precursor proliferation is precisely regulated spatially and temporally during development to allow optimal myelination of the central nervous system (CNS). We propose that a paracrine regulatory pathway involving the chemokine GRO1 and platelet-derived growth factor (PDGF) permit local control of precursor proliferation in the brain. GRO1, PDGF, and their receptors act synergistically to precisely regulate oligodendrocyte precursor proliferation in vitro and in vivo in the rat CNS. The nature of the paracrine regulatory loop with astrocyte and neuronal GRO1 expression in a pattern that is closely correlated with PDGF alpha R(+) oligodendrocyte precursors suggests that the GRO1/PDGF regulatory mechanism provides local control of oligodendrocyte precursor proliferation during development.

[Temporomandibular joint pain: radiological diagnosis]

Pain in the temporomandibular joint is often the result of internal derangement, other causes are traumatic, functional or inflammatory processes. Conventional radiography is indicated in case of suspected trauma or for specialised preoperative measurements to plan the treatment of various facial dysplasias. MRI and CT should be used in the context with the results of clinical investigation and of axiography to differentiate the various functional and morphological abnormalities of this joint.