Mediating the cultural boundaries between medicine, nursing and management--the central challenge in hospital reform

This paper documents the resilience of medical and nursing profession-based subcultures and the extent of the differences between them. Against this background, we assess the capacity and willingness of medical and nursing managers to promote changes that will extend the accountability of clinicians and engender more evidence-based, financially driven and output-oriented approaches to service delivery.

Epidemiological studies of human and animal Salmonella typhimurium DT104 and DT104b isolates in Ireland

A total of 122 human and animal Salmonella Typhimurium DT104 isolates and 6 epidemiologically related DT104b isolates from human and animal products were analysed by pulsed-field gel electrophoresis (PFGE). Genomic DNA was subjected to macrorestriction with three enzymes, SpeI, SfiI and XbaI. A total of 14 restriction fragment length polymorphism (RFLP) profiles were identified when the PFGE patterns from the three enzymes were combined. The majority of isolates (81.2%) exhibited the same RFLP profile. Six animal DT104 isolates, susceptible to enrofloxacin and resistant to naladixic acid, were identified from the antibiotic susceptibility test. Four of these isolates had a different PFGE profile from the common RFLP. In addition, 4 of the 6 isolates were geographically clustered in one region. It was concluded that there was one predominant strain of S. Typhimurium DT104 in Ireland and that the potential and selection pressures for emergence of fluoroquinolone-resistant isolates were present.

Exploratory Biochemical Data Analysis: a Comparison of Two Sample Means and Diagnostic Displays

The occurrence of acne in women with hyperandrogenemia is well known; a question remains, however, as to whether a further positive relationship can be detected between the intensity of acne and the levels of testosterone, androgen precursors and sex hormone binding globulin (SHBG). A procedure of interactive data analysis extracting relevant information from original data was applied. Exploratory data analysis (EDA) identifies basic statistical features and patterns of data using a variety of diagnostic displays. The need for this step is particularly acute in biochemical and clinical data, the distribution of which is mostly non-Gaussian and often corrupted by the outliers. The omission of EDA can lead to incorrect results and false conclusions. In the EDA (i) several graphical tools for summarizing data are applied, (ii) the peculiarities of a sample distribution are investigated, (iii) a construction of distribution is carried out, (iv) a graphical comparison of the sample distribution with selected theoretical distributions is employed. The proposed procedure is illustrated by typical case study in the evaluation of differences between mean values of serum levels of testosterone, androgen precursors and SHBG in a group of patients with mild and severe forms of acne. A knowledge of the interval estimate of the mean value in both groups enables their comparison at the chosen probability level. As will be apparent from the evaluation of inter-group SHBG differences, an incorrect approach to the determination of group mean values could result in a complete misinterpretation of the data. The results indicate that androgens are not significantly related to the intensity of acne, and that SHBG is higher in patients with more severe forms of acne.

Allopregnanolone, pregnenolone sulfate, and epitestosterone in breast cyst fluid

The risk of breast cancer is 2 to 5 times higher in patients suffering from gross cystic disease. Breast cysts are categorized into two groups (type I and type II) according to the concentration of electrolytes in the cyst fluid. The two types also differ with respect to accumulation of steroids and steroidogenic enzyme activity. In type I cysts a higher risk of breast carcinoma could be expected. Here, we studied a possible relationship between the type of cyst and levels of epitestosterone (an endogenous antiandrogen), allopregnanolone (a product of 5alpha-reductase activity), and pregnenolone-sulfate (an activator of N-methyl-D-asparate receptors). We have found five times higher levels of epitestosterone in BCF in comparison with the circulation. Allopregnanolone levels were similar to those in plasma of women in the luteal phase of the menstrual cycle. Pregnenolone-sulfate levels in BCF were about two orders of magnitude higher when compared with the circulation. No differences were found in concentrations of the steroids studied between the types of cysts.

Analysis of large and small samples of biochemical and clinical data

Statistical software often offers a list of various descriptive statistics of location and scale, but rarely selects an efficient estimate that is statistically adequate for an actual univariate sample. The sample interval estimate for a specified degree of uncertainty seems to be more meaningful if it covers an unknown value of the population parameter. The concept of an interval estimate in medicine is then used for medical decision-making. The proposed methodology, which uses the S-Plus algorithm for biochemical, biological and clinical data analysis contains the following steps: (i) Exploratory data analysis identifies basic statistical features and patterns of the data, the distributions of which are mostly non-normal, non-homogeneous and often corrupted by outliers. (ii) Sample assumptions about data, independence of sample elements, normality and homogeneity are examined. (iii) Power transformation and the Box-Cox transformation to improve sample symmetry and stabilize the spread. (iv) Classical and robust statistics for both large (n>30) and medium-sized samples (15<n<30), point and interval estimates for the parameters of location, scale and shape. For an analysis of small samples (4<n<20) the Horn procedure of pivot measures is recommended. The proposed methodology is demonstrated in two case studies, a large sample analysis of mean pregnenolone concentrations in the umbilical blood of newborns, and a small sample analysis of mean haptoglobin concentrations in human serum.

Immunomodulatory 7-hydroxylated metabolites of dehydroepiandrosterone are present in human semen

Seminal fluid represents a milieu enabling spermatozoa to break the ovum membrane and suppress its immune response and, at the same time, to protect male germ cells against infection. Among constituents of the seminal fluid, various steroids, including dehydroepiandrosterone (DHEA) and its sulphate, were detected. With respect to immunomodulatory and antioxidative properties of the latter steroid and its 7-hydroxylated metabolites, believed to be at least in some instances the locally active species, their presence in seminal fluid is of particular interest. Here for the first time unconjugated 3beta,7alpha-dihydroxy-5-androsten-17-one (7alpha-OH-DHEA) and its 7beta-hydroxyisomer have been detected and quantified in semen. Eight semen samples were extracted with diethyl ether and following evaporation and solvent partition both isomers were detected by gas chromatography-mass fragmentometry using the ions m/z 358 and 343 for quantification. Another portion was separated by HPLC and in the fractions corresponding to 7-OH-DHEA isomers the steroids were measured by recently developed specific radioimmunoassays (RIA). Mean concentrations of 7-OH-DHEA as measured by RIA amounted 5.75+/-1.29 and 5.39+/-0.75 nmol/l (mean+/-SEM) for 7alpha- and 7beta-OH-DHEA, respectively.

Neuroactive steroids, their precursors, and polar conjugates during parturition and postpartum in maternal and umbilical blood: 1. Identification and simultaneous determination of pregnanolone isomers

A rapid method for the identification and measurement of four pregnanolone isomers and their polar conjugates in human plasma was developed using a simple quadrupole GC/MS system with electron impact ionization. Steroid levels were measured in the plasma of 13 and three women at delivery with subarachnoidal and epidural analgesia, respectively, and in corresponding samples of umbilical plasma. A good correlation (r=0.94, P<0.001, n=8) was found between the allopregnanolone in maternal plasma determined by GC/MS and that measured by RIA. Epipregnanolone (3beta-hydroxy-5beta-pregnan-20-one) was identified and measured for the first time in human plasma; its concentration in both maternal and umbilical plasma was much lower than that of other pregnanolone isomers. The levels of 3beta-hydroxy-pregnanolone isomers were significantly higher in the umbilical plasma than in the maternal plasma, while the differences in 3alpha-hydroxy-isomers were insignificant. The differences in conjugates were insignificant except in the case of allopregnanolone, the levels of which were lower in umbilical plasma. In all of the pregnanolone isomers, a significantly lower conjugated/unconjugated steroid ratio was found in the umbilical plasma than in the maternal plasma. The possible role of the sulfatation of pregnanolone isomers around parturition is discussed.

Serum concentrations of some neuroactive steroids in women suffering from mixed anxiety-depressive disorder

Concentrations of neurosteroids may be influenced by some physiological or pathological factors. We investigated neuroactive steroids in the serum of women suffering from anxiety-depressive disorder treated with fluoxetine and in a control group, in both the follicular and the luteal phases of the menstrual cycle. Two groups of neuroactive steroids were measured by radioimmunoassays: 1) the positive allosteric modulator of GABA(A) receptors, allopregnanolone with its precursor progesterone and 2) pregnenolone sulfate and dehydroepiandrosterone sulfate (DHEAS) acting on GABA(A) receptors by an opposite mechanism. Significantly higher levels of pregnenolone sulfate (p < 0.0001) were found in patients in both phases of the menstrual cycle. Significantly higher values were recorded in pregnenolone (p < 0.001) and 17alpha-hydroxypregnenolone (p < 0.01) levels in the patients group in the follicular phase. Our results indicate that imbalance in neuroactive steroids may play a negative role in origin and course of psychiatric and neurological disorders.

The importance of language and culture in pediatric care: case studies from the Latino community

BACKGROUND

Few studies have examined culture's effect on pediatric care.

OBJECTIVES

To analyze 3 cases illustrating the importance of culture in pediatrics.

METHODS

Case analysis with a cultural competency model.

RESULTS

No interpreter was available for the parents of a 3-year-old brought to the emergency department because of abdominal pain; she was discharged twice, returned with an acute abdomen, and was hospitalized for treatment of appendiceal rupture and peritonitis. A 2-year-old fractured her clavicle in a fall but was placed in social services' custody because of a pediatrician's misinterpretation. Parents of a ventilation-dependent 2-week-old with encephalopathy, seizures, and renal failure were unaware of the infant's poor prognosis, despite use of an interpreter.

CONCLUSIONS

Culture can have a significant impact on pediatric care; use of a simple model can ensure that pediatricians provide culturally competent care.

The pathophysiological implications of circulating androgens on bone mineral density in a normal female population

In this cross-sectional study performed on 147 healthy or osteoporotic, but otherwise normal premenopausal (n = 26 and n = 13, respectively) or postmenopausal (n = 40 and n = 68, respectively) women aged 40.1+/-9.9 and 61.9+/-8.9 years, respectively (range 20-82 years), serum ovarian and adrenal sex steroids and their relationship to bone mineral density (BMD) were evaluated. The levels of dehydroepiandrosterone sulfate (DHEAS), dehydroepiandrosterone (DHEA), androstenedione (AD), and estradiol correlated positively with BMD at the hip and spine as did serum testosterone with BMD at the spine. An inverse relationship was found between sex hormone binding globulin (SHBG) levels and BMD at the spine and hip. After adjustment for age, body mass, and sex steroid confounders, the bioavailable testosterone value (but not the DHEAS, DHEA, AD, or SHBG) values was demonstrated to be an independent determinant of BMD at the spine (beta 0.18, P<0.02) and hip (beta 0.24, P<0.02). Similarly, estradiol was found to be an independent determinant of BMD at the spine (beta 0.25, P<0.007). However, only SHBG levels (but not other steroid parameters) correlated positively with indices of bone remodeling, namely, serum osteocalcin and cross-linked telopeptide of type I collagen (ICTP). The present study suggests that a major decline in index of free testosterone (testosterone/SHBG) may influence the development of female osteoporosis. The clinical significance of circulating SHBG levels in the assessement of bone metabolic turnover remains to be established.

A clinical nomogram for predicting long-term survival in advanced colorectal cancer

From our prospectively accrued database of patients with gastrointestinal cancer, 1057 patients with advanced colorectal cancer were identified with the aim of determining predictive factors for survival of greater than 2 years and to use this information to develop a predictive nomogram. Patient's baseline characteristics, type and number of chemotherapy regimens received, and response to chemotherapy were assessed by univariate and multivariate logistic regression comparing those who survived greater than or less than 2 years. A total of 161 (15.2%) patients survived more than 2 years, so-called long survivors (LS). In multivariate analysis, positive predictive factors for LS were: good performance status (PS), normal serum carcinoembryonic antigen (CEA), rectal primary, Dukes' stage A-B, well or moderate differentiation, two or less disease sites, response to chemotherapy and treatment used protracted venous infusion (PVI) 5-fluorouracil (5-FU) in first-line chemotherapy, and the increasing number of chemotherapy treatments received. From these PS, CEA, number of sites and response to first-line chemotherapy were used to develop a nomogram capable of predicting the probability of survival beyond 2 years for an individual patient. This large study confirmed the relevance of known prognostic factors in metastatic colorectal cancer and demonstrated the importance of response to chemotherapy as an independent factor to predict LS. By combining these, we developed a nomogram which provides information which is likely to prove useful in the management of patients with advanced colorectal cancer.

Cambio en las escuelas: Mexican-American parent attitudes toward school health education

The purpose of this study was to determine the attitudes of Mexican-American (MA) parents of children toward school health education programs in South Texas. The Parent Attitude Scale (PAS) was developed and validated by American Cancer Society (ACS) staff and volunteer health educators. The validated survey was used to question randomly selected parents in the McAllen, Texas, school district regarding their attitudes toward school health education. Of 253 parents contacted, 235 (92.9%) parents were interviewed. Mann-Whitney U-Tests indicated that Mexican-American (MA) parents consider school health education to be more important than non-Mexican-American parents do. MA parents, overall, felt that it was more important that their child has good health habits and more important that their child's teacher provide support to them by teaching good health habits than non-MA parents. MA parents also felt that health was more important relative to other subjects at school than non-MA parents. The data indicate strong support for school health education efforts among MA parents in southern Texas. Such support may grow stronger with appropriate parent-recruitment efforts, including those by the ACS. Mexican-American parents may also represent an untapped resource for social and political support for school health programming.

UFT/leucovorin plus irinotecan in advanced or metastatic colorectal cancer

UFT (with leucovorin) and irinotecan both have single-agent activity in colorectal cancer, with non-cross-resistant mechanisms of action. Combining these drugs would be anticipated to increase response rates while maintaining the advantages of a regimen based on an orally administered fluoropyrimidine. This trial aims to determine the maximum tolerated dose, side-effect profile, dose-limiting toxicity, and response rate for the combination of UFT plus leucovorin, and irinotecan. The design is for an initial phase I study investigating escalating doses of UFT (250 to 350 mg/m2/d) and irinotecan (200 to 300 mg/m2) with fixed doses of leucovorin at 90 mg/d, in up to five cohorts of six patients each. UFT and leucovorin are given orally on days 1 to 14 of a 21-day cycle and irinotecan is given intravenously on day 1. The maximum tolerated dose is defined as the dose at which three of six patients in a cohort have a dose-limiting toxicity in the first cycle of treatment. In the second part of the study, the cohort below that experiencing maximum tolerated dose will be expanded up to a total of 20 patients in order to assess further the toxicity and response rate (phase II). To date, 17 assessable patients have been recruited, with a median age of 64 years (range: 35-80 years). At the first dose level (UFT 250 mg/m2/d and irinotecan 200 mg/m2), no dose-limiting toxicities were seen, and in cohort 2 (UFT 250 mg/m2/d and irinotecan 250 mg/m2), there was one grade 3 diarrhea. In cohort 3 (UFT 250 mg/m2/d and irinotecan 300 mg/m2), currently there have been two grade 3/4 toxicities (both neutropenic fever). Thus, the maximum tolerated dose has not yet been reached. Response has been assessed in the first six patients, with three having partial response, two having stable disease, and one having progressive disease (response rate 50%). We conclude that this regimen appears feasible with acceptable toxicity at these dose levels. There is also evidence of significant antitumor activity similar to that seen with other fluoropyrimidine-based combination regimens but without the requirement for indwelling catheters or inpatient admission.

Prevalence of Müllerian duct anomalies detected at ultrasound

The true prevalence of müllerian duct abnormalities is not well established. We used standard ultrasound examinations to establish the prevalence of müllerian duct abnormalities in girls and women who were evaluated for reasons unrelated to the presence of uterine anomalies. Prospective ultrasound examinations for nonobstetric indications in 2,065 consecutive girls and women (aged 8-93) showed that 8 had anomalies, including bicornuate uterus, septate uterus, and double uterus. In this first attempt to determine the prevalence of uterine anomalies in the general population, using noninvasive methodology, the rate of anomalies was 3.87 per 1,000 women (exact 95% confidence interval: 1.67-7.62), or approximately 1 in 250 women. This prevalence estimate may be greater than the true rate if selection biases are strong, or less than the true prevalence if ultrasound detection rates are low. As a first attempt to establish the prevalence by pelvic ultrasound in a consecutive series, these data may serve as a baseline estimate.

Forensic studies of a stabbed infant bottlenose dolphin

A 4-6-week-old male bottlenose dolphin (Tursiops truncatus) was found freshly dead on a beach. He belonged to a nearby dolphin group that was known to have considerable curiosity about human activity and to frequently approach pleasure craft. An autopsy revealed an otherwise healthy animal with death due to a stab wound that had passed completely through the body, incising the aorta. Careful assessment of the wounds indicated that the blade of the weapon had been at least 190 mm in length and 22 mm in width, with a single edge. This report demonstrates that standard forensic techniques may be extremely useful in determining the cause of death in animals, in documenting injuries to assist in the investigation of such cases, and in providing facts to aid in the successful prosecution of those guilty of killing or injuring animals.

An investigation into the efficacy of intravenous diclofenac in post-operative dental pain

OBJECTIVE

To evaluate the efficacy of single doses of intravenous diclofenac sodium (25, 50 and 75 mg) in patients with post-operative pain after third-molar surgery in a randomised, placebo-controlled study.

METHODS

Two hundred and sixty-nine patients (168 females) who required the removal of their impacted third molars participated in the study, which had received prior ethical approval. Surgery was completed under general anaesthesia and, during the early post-operative period, patients received either a single intravenous dose of diclofenac (25, 50 or 75 mg) or matched placebo in random, double-blind order. Pain intensity was assessed on 10-cm visual analogue scales at fixed time points throughout a 4-h investigation period. Other efficacy variables obtained included time until rescue medication and overall assessment at 4, 6, 12 and 24 h after dosing.

RESULTS

Throughout the 4-h investigation period, patients treated with diclofenac reported significantly less pain than those treated with placebo (P < 0.001). No differences were observed among the three doses of diclofenac (P = 0.22). Similar results were observed at 6, 12 and 24 h after dosing. Significant differences were also noted between the placebo group and all the diclofenac treatment groups with respect to time until rescue medication (P < 0.001) and the proportion of patients taking such medication.

CONCLUSION

Single doses of i.v. diclofenac (25, 50 and 75 mg) provide significant pain relief after third-molar surgery. The efficacy of this preparation does not appear to be dose related.

The best correlation of the new index of hyperandrogenism with the grade of increased body hair

OBJECTIVE

Hyperandrogenemia is the most frequent endocrine disorder in fertile women causing a variety of negative metabolic disturbances. Establishing the diagnosis of androgen overproduction has important implications for the follow-up and treatment of patients. The aim of our study was to identify the optimal laboratory marker of androgen production by correlating the markers to the presence or grade of increased body hair as a clinical sign of hyperandrogenism.

DESIGN

Prospective observational study.

METHODS

A total of 62 women with acne were included into the study. The serum concentrations of testosterone, androstenedione, dehydroepiandrosterone (DHEA), DHEA sulfate (DHEAS) and sex hormone-binding globulin (SHBG) were evaluated. The index of free testosterone (IFT) and a new index of hyperandrogenism (IHA) were calculated. The monitored laboratory markers were correlated to the presence or grade of increased body hair using several statistical methods.

RESULTS

The statistical significance of differences between the average levels of laboratory markers between hirsute and non-hirsute women decreased in the following order: IHA, androstenedione and DHEA. Of all the above laboratory markers, only increased IHA was present significantly more often in hirsute women. The significance of correlation between the grade of increased body hair and the tested variables decreased in the following order: IHA, IFT, DHEA, androstenedione, DHEAS and testosterone.

CONCLUSIONS

The clinical marker of hyperandrogenism correlates most closely to IHA, reflecting the levels of all commonly determined androgens or androgen precursors and SHBG. Its simple calculation makes IHA a suitable tool for determining total production of androgens in clinical practice, especially in cases with borderline elevations of values.

The role of androgens in determining acne severity in adult women

BACKGROUND

Although many arguments have been put forth supporting the role of androgens in the aetiology of acne, their part in determining the severity of the disease is not well established.

OBJECTIVES

The aim of our study was to evaluate the relationship between acne severity and the clinical and laboratory markers of androgenicity in a large group of patients.

METHODS

Ninety women over 17 years of age with acne were enrolled into the study. The levels of testosterone, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulphate and sex hormone binding globulin (SHBG) were measured. Menstrual cycle regularity, hirsutism score, acne severity and ultrasound evaluation of polycystic ovaries were recorded. One-way analysis of variance, chi(2)-test and correlation analysis were used for data processing.

RESULTS

Hirsutism was documented in 19 (21%) subjects, elevated levels of at least one androgen in 73 (81%) subjects, an irregular cycle was reported by 43 (48%) women, and polycystic ovaries were found in 45 (50%) women. The patients were divided into three groups according to acne severity. Acne was graded using the Leeds technique as minor in 43 (48%) cases, mild in 27 (30%) and moderate in 20 (22%). We did not demonstrate a positive correlation between the grade of acne severity and any of the clinical or laboratory markers of androgenicity assessed. On the contrary, women with a higher grade of acne severity showed lower values of the index of free testosterone, a lower hirsutism score and higher SHBG levels.

CONCLUSIONS

Our study suggests that the severity of acne manifestation in adult women is not determined by androgen production.

A cross-national study of differences in the identities of nursing in England and Australia and how this has affected nurses' capacity to respond to hospital reform

This paper examines similarities and differences in the identity of nursing in England and Australia. In doing this we examine how in each country nursing has developed different ideologies and strategies. Our analysis draws on data derived from a cross-national study of hospital staff in England and Australia. We demonstrate how differences in the occupational identity of nursing in each country are registered in their values, attitudes and beliefs. We suggest that these differences reflect the interplay of factors such as the strategic stances of nursing professional and industrial organisations and how nurses in each country have positioned themselves in responding to recent changes in health policy.

A multicenter study evaluation of the digene hybrid capture II signal amplification technique for detection of hepatitis B virus DNA in serum samples and testing of EUROHEP standards

We have evaluated the new Digene Hybrid Capture II HBV DNA Test (HCII HBV), which is a 96-well microtiter plate-based signal amplification assay. This test uses hybrid capture technology that specifically detects RNA-DNA hybrids. HCII HBV is able to quantify hepatitis B virus (HBV) DNA at between 1.4 x 10(5) and 1.7 x 10(9) HBV copies per ml in a standard format. By using a modified sample preparation method, which allows the input of 30-fold more serum for an ultrasensitive format, the sensitivity of the assay can be increased reproducibly to approximately 8,000 copies of HBV per ml. By using a combination of these two formats, the assay can quantify over a total range of 6 logs. In our multicenter evaluation study, the mean laboratory-to-laboratory coefficients of variation were 22, 7, and 12% at the three sites, respectively, with a combined specificity of 98.4%. The linearities of both the standard test and the ultrasensitive test were excellent, with Spearman correlation coefficients of 0.997 and 0.999, respectively. Furthermore, the intra-assay reproducibility for the standard assay gave coefficients of variation of from 13 to 33, 9 to 21, and 3 to 8% at the three sites, respectively. HCII HBV was shown to be genotype independent when the EUROHEP standards for genotypes A and D were used. This assay allows the accurate measurement of HBV DNA levels in serum and can be clinically used for the monitoring of responses to antiviral agents for patients chronically infected with HBV.