Congenital brachial palsy: incidence, causes, and outcome in the United Kingdom and Republic of Ireland

OBJECTIVES

To determine the incidence and study the causes and outcome of congenital brachial palsy (CBP).

DESIGN

Active surveillance of newborn infants using the British Paediatric Surveillance Unit notification system and follow up study of outcome at 6 months of age.

SETTING

The United Kingdom and Republic of Ireland.

PARTICIPANTS

Newborn infants presenting with a flaccid paresis of the arm (usually one, rarely both) born between April 1998 and March 1999.

MAIN OUTCOME MEASURES

Extent of the lesion at birth and degree of recovery at 6 months of age.

FINDINGS

There were 323 confirmed cases giving an incidence of 0.42 per 1000 live births (1 in 2300). Significant associated risk factors in comparison with the normal population were shoulder dystocia (60% v 0.3%), high birth weight with 53% infants weighing more than the 90th centile, and assisted delivery (relative risk (RR) 3.4, 95% confidence interval (CI) 2.9 to 3.9, p = 0.0001). There was a considerably lower risk of CBP in infants delivered by caesarean section (RR 7, 95% CI 2 to 56, p = 0.002). At about 6 months of age, about half of the infants had recovered fully, but the remainder showed incomplete recovery including 2% with no recovery. The relative risk of partial or no recovery in infants with extensive lesions soon after birth compared with those with less extensive lesions was 11.28 (95% CI 2.38 to 63.66, p = 0.000005).

CONCLUSIONS

The incidence of CBP in the United Kingdom and Republic of Ireland is strikingly similar to that previously reported nearly 40 years ago. Most cases are due to trauma at delivery, which is not necessarily excessive or inappropriate. Given the uncertainty about the appropriate management of these infants, serious consideration should be given to a formal clinical trial of microsurgical nerve repair.

"God, why did this happen to me?": three perspectives on theodicy

This article closely examines the way three people dealt with the theodicy question. The three study subjects participated in extended interviews about their religious beliefs and activities, past and present. The interviews were summarized and analyzed to identify the person's religious resources, statements about theodicy, and mental well-being. The subjects' comments highlight the unique and diverse ways in which people wrestle with theodicy. They also indicate that dealing with the question can extend over many years. Implications for ministry are discussed.

Competence and British nursing: a view from history

In the light of current political and professional debate in the United Kingdom concerning preparing nurses for competence, this paper takes an historical perspective, and considers how nursing competence was defined historically through an analysis of statutory syllabuses and nursing textbooks 1874-1977. Competence was perceived by nursing textbook writers to have four facets. Firstly, it involved the moral character of the nurse; secondly, it required technical knowledge, practical skill and procedure; thirdly, it depended on the role of the ward sister; and fourthly, it relied on the professional etiquette of right relationships. The analysis shows that the traditional system of nursing competence presumed a clearly defined purpose: the production of the bedside nurse, whose function was to care for the sick person. This raises a fundamental question for nursing today: what is the purpose of the modern nurse?

Elevated levels of Ca(II) modulate the activity and inhibition of serine proteases: implication in the mechanism of apoptosis

Elevated levels of intracellular Ca(II) are a prominent feature of apoptosis, a natural form of cell death involved in many physiological and pathological processes. Serine proteases play crucial roles in apoptosis and have been implicated in the genomic DNA degradation and the massive protein degradation that occur during apoptosis. In this study, the effects of the elevated level of Ca(II) on the activity and inhibition of serine proteases were examined by spectrophotometric methods. The effects of the elevated levels of Ca(II), Mg(II), K(I), and Na(I) on the activity and inactivation of three representative members of serine proteases were determined. The level of serine protease activity in CEM-C7-14 leukemic cells was also evaluated in the presence and absence of dexamethasone-induced apoptosis, and also in the presence of A23187, a Ca(II)-ionophore. Among the four metal-ions studied, only Ca(II) was found to significantly enhance the activity of mammalian serine proteases. Ca(II) was also found to significantly protect the enzymes from inhibition, while the other three metal-ions showed no significant effect on the inactivation of the enzymes. Compared to the control sample, the enzymic activity was found to be higher during apoptosis, and in the presence of the Ca(II)-ionophore. Results of this study indicate that Ca(II) can significantly enhance the catalytic efficiency of serine proteases during apoptosis.

Thrombocytopenia and absent radii (TAR) syndrome associated with horseshoe kidney

The TAR syndrome is an inherited disorder characterized by limb abnormalities, especially absent radii, and hypomegakaryocytic thrombocytopenia. Previous reports have included two infants with genitourinary abnormalities. We report a newborn with bilaterally absent radii and foreshortened ulnae, hypoplastic humeri, a left clubfoot, a ventricular septum defect, and persistent thrombocytopenia. This constellation of abnormalities is consistent with the TAR syndrome. In addition, he had a horseshoe kidney with parenchyma of normal appearance. This is the first report of horseshoe kidney in association with the TAR syndrome.

The virtue of nursing: the covenant of care

It is argued that the current confusion about the role and purpose of the British nurse is a consequence of the modern rejection and consequent fragmentation of the inherited nursing tradition. The nature of this tradition, in which nurses were inducted into the moral virtues of care, is examined and its relevance to patient welfare is demonstrated. Practical suggestions are made as to how this moral tradition might be reappropriated and reinvigorated for modern nursing.

Disruption of the Sparc locus in mice alters the differentiation of lenticular epithelial cells and leads to cataract formation

SPARC (secreted protein acidic and rich in cysteine) is a matricellular protein that regulates cellular adhesion and proliferation. In this report, we show that SPARC protein is restricted to epithelial cells of the murine lens and ends abruptly at the equatorial bow region where lens fiber differentiation begins. SPARC protein was not detected in the lens capsule or in differentiated lens fibers. SPARC-null mice developed cataracts at approximately 3-4 months after birth, at which time posterior subcapsular opacities were observed by slit lamp ophthalmoscopy. Histological analyses of ocular sections from 3-month old animals revealed several microscopic abnormalities present in the SPARC-null mice but absent from the wild-type animals. Fiber cell elongation was incomplete posteriorly and resulted in displacement of the lenticular nucleus to the posterior of the lens. Nuclear debris was present in the posterior subcapsular region of the lens, an indication of the abnormal migration and elongation of either fetal or anterior epithelial cells, and the bow region was disrupted and vacuolated. In the anterior lens, the capsule appeared to be thickened and was lined by atypical, plump cuboidal epithelium. Moreover, anterior cortical fibers were swollen. Polyacrylamide gel electrophoresis of the epithelial, cortical and nuclear fractions of wild-type and SPARC-null lenses indicated no significant differences among the alpha-, beta-, and gamma-crystallins. Expression of alphaB-crystallin appeared similar in fiber cells of wild-type and SPARC-null lenses, although the distribution of alphaB-crystallin was asymmetric in SPARC-null lenses as a result of abnormal lens fiber differentiation. No evidence of atypical extracellular matrix deposition in areas other than the capsule was detected in wild-type or SPARC-null lens at 3 months of age. We conclude that the disruption of the Sparc locus in mice results in the alteration of two fundamental processes of lens development: differentiation of epithelial cells and maturation of fiber cells.

Defining 'competency' in nursing (Part II): An analytical review

The reason for the present uncertainty in defining nursing competency is analysed. The prevailing educational philosophy underpinning nursing preparation for competence is subjected to a critique. The effect and outcome of this philosophy on clinical supervision, PREP and the law are considered in relation to nursing competence. It is concluded that because nursing competency is only vaguely and broadly defined, preparation and assessment of competency is haphazard and unstructured; and hence a potential safety hazard for both patient and nurse. It is suggested that the UKCC needs to assume responsibility for ascertaining nursing competence; and a four-point framework is proposed for setting and testing national standards of nursing competency.

Defining 'competency' in nursing (Part I): A policy review

How the nursing profession in England defines the basic competency of the registered general nurse is crucial for the safety of the patient and the protection of the nurse. It is also essential for determining advanced practice, extended practice and specialist practice in nursing. An historical overview of documentation from the United Kingdom Central Council for Midwifery and Health Visiting, the English National Board for Nursing, Midwifery and Health Visiting and the Royal College of Nursing shows a profound change in educational policy during the 1980s regarding the interpretation of nursing competency. The effects of this policy change on the current methods developed to define, teach and test nursing competency are examined. Preliminary conclusions show shortcomings and uncertainty in the present preparation and evaluation of nursing competency.

The spiritual dimension of hospice: the secularization of an ideal

There is increasing concern that the original hospice ethos is becoming subject to routinization and bureaucratization. Authors, drawing on Weber's concept of rationalization, have suggested that this has resulted from the loss of the original charismatic impetus and the commitment to care for the terminally ill and dying as inspired by the spiritual 'calling'. This paper argues that this original ethical ideal has been fundamental to the humane care of the dying and terminally ill. Using Alasdair MacIntyre's analysis it is suggested that as the ideal attenuates there are inevitable shifts in the ethos and culture of care. An emotivist culture in which the aesthete, the therapist and the manager are dominant characters, may seem to be occurring in palliative care. The focus on management skills and the values of efficiency and effectiveness influence attitudes to death. This brings increased medicalization, a reliance on psychosocial techniques, a predominant focus on education, research and audit and most particularly redefined attitudes to the spiritual component of care. The paper asks the question whether the original ethic has a place in preventing palliative care becoming merely a technique for professional empowerment.

Yes! There is an ethics of care: an answer for Peter Allmark

This paper is a response to Peter Allmark's thesis that 'there can be no "caring" ethics'. It argues that the current preoccupation in nursing to define an ethics of care is a direct result of breaking nursing tradition. Subsequent attempts to find a moral basis for care, whether from subjective experimental perspectives such as described by Noddings, or from rational and detached approaches derived from Kant, are inevitably flawed. Writers may still implicitly presuppose a concept of care drawn from the Judaeo-Christian tradition but without explicit recourse to its moral basis nursing is left rudderless and potentially without purpose. The very concept of 'care' cut off from its roots becomes a meaningless term without either normative or descriptive content.

Effect of arterial cannulation and contrast agents on blood coagulation

RATIONALE AND OBJECTIVES

Nonionic contrast media have been considered by some to have thrombogenic properties. We prospectively assessed the effect of femoral artery catheterization and both nonionic and ionic contrast media on the coagulation parameters--fragment 1 + 2 (F1 + 2) and fibrinopeptide A (FpA)--during clinical angiography.

METHODS

Seventeen patients undergoing aortography were included. Blood samples were obtained before and after arterial puncture and before and up to 30 min after contrast administration.

RESULTS

An increase in FpA was observed after arterial puncture (range = 8.4 +/- 1.9 to 13.6 +/- 2.3 ng/ml, p < .004; data are written as mean +/- standard error of the mean). There was an observed increase in F1 + 2 after arterial puncture that was not statistically significant (2.0 +/- 0.4 to 2.3 +/- 0.4 nmol/l). No further increase was observed in either FpA or F1 + 2 levels after nonionic or ionic contrast media administration.

CONCLUSION

The increased activity of the coagulation system during angiography is related to the arterial puncture, and nonionic and ionic contrast media have no thrombogenic potential in vivo.

Has nursing lost its way? Nursing and medicine: cooperation or conflict?

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