Clinical relevance of laboratory-reported antibiotic resistance in acute uncomplicated urinary tract infection in primary care

OBJECTIVES

To determine whether patients with an uncomplicated community-acquired urinary tract infection (UTI) and an isolate resistant to trimethoprim had worse clinical outcomes following empirical treatment with trimethoprim 200 mg twice daily for 3 days than did those with a susceptible isolate.

PATIENTS AND METHODS

This was a prospective cohort study of clinical outcome. We enrolled 497 women (>or=18-70 years) presenting to general practitioner surgeries in Norwich and Gloucester with at least two symptoms of acute (<7 days) uncomplicated UTI. Significant bacteriuria was defined as >or=10(4) cfu/mL from a mid-stream urine (MSU).

RESULTS

Of enrolled patients 75% (334/448) had significant bacteriuria, and trimethoprim resistance was present in 13.9% (44/317) of isolates. Patients with resistant isolates had a longer median time to symptom resolution (7 versus 4 days, P=0.0002), greater reconsultation to the practice (39% versus 6% in first week, P<0.0001), more subsequent antibiotics (36% versus 4% in first week, P<0.0001) and higher rates of significant bacteriuria at 1 month (42% versus 20% with susceptible isolate, P=0.04). Half of patients reconsulting in the first week had a resistant organism.

CONCLUSIONS

Patients with uncomplicated UTI caused by trimethoprim-resistant organisms had significantly worse clinical outcomes than those with trimethoprim-susceptible organisms. Nevertheless, trimethoprim resistance was rarer than predicted from routine laboratory submissions and we calculate that 23 women require microbiological investigation to prevent one reconsultation arising from resistance-based treatment failure. We therefore suggest empirical antibiotic treatment in acute, uncomplicated UTIs. If patients reconsult in the first week, we suggest a change of antibiotic treatment with urine culture and susceptibility testing then done. More generally, laboratory resources should concentrate on resistance surveillance to inform empirical antibiotic choice.

Interactions between attention and perceptual grouping in human visual cortex

Freeman et al. demonstrated that detection sensitivity for a low contrast Gabor stimulus improved in the presence of flanking, collinearly oriented grating stimuli, but only when observers attended to them. By recording visual event-related potentials (ERPs) elicited by a Gabor stimulus, we investigated whether this contextual cueing effect involves changes in the short-latency afferent visual signal from V1 that have a stimulus onset latency between 60 and 80 ms and/or longer-latency changes from visual cortex. Under dual-task conditions, the subjects performed contrast discrimination for a central Gabor and an orientation judgment for a pre-specified subset of the flanking Gabors. On random trials, the central Gabor could be collinearly or orthogonally oriented with respect to the attended flankers. Subjects showed improvements in discriminating the contrast of the central grating when it was oriented collinearly with the attended flankers. The ERP difference between attending to collinear versus orthogonal flankers manifested as a positive polarity response at occipital electrodes with a latency of 180-250 ms after stimulus onset. No shorter-latency contextual cueing differences were observed in the ERPs. The ERP latency profile of the contextual cueing effect argues against the hypothesis that short-latency afferent activity from V1 is the stage of processing at which attention can influence neuronal lateral interactions. However, the scalp voltage distribution of the longer-latency contextual cueing effect is similar to the one generated by the early phasic stimulus onset activity from V1. These findings leave open the possibility that V1 is involved in the attentional modulation of lateral interactions but that this has a longer time course, likely being mediated by re-afferent inputs from later stages of the visual pathway.

Urinary catheterization in care homes for older people: self-reported questionnaire audit of catheter management by care home staff

A self-administered questionnaire was used to determine care home staff's reported knowledge of the urinary catheter care standards published by the National Institute for Clinical Excellence (NICE) and the Association of Continence Care, and to see whether this differed in homes with higher catheterization rates. Seven hundred and fifty out of 1438 (52%) nursing and care staff from 37 randomly selected care homes with high, medium and low catheterization rates responded. There was no difference in reported practice in care homes in the three health districts sampled or those with differing catheterization rates. Eighty-three percent of the nursing staff and 40% of the other care staff received formal catheter care training. However, at least 10% of all staff reported not washing their hands before handling a catheter, and delaying emptying a urine bag until it was full, rather than three-quarters full. Only 45% of nursing staff and 40% of other care staff encouraged residents to empty their own catheter bags. Routine use of catheter maintenance solutions or bladder washouts was reported by 50% of all staff. Nursing staff (29%) and other care staff (54%) took urine specimens from the catheter bag tap. Compliance with standards has improved greatly since an audit in 1998. However, some non-compliance remains. There is a need for ongoing local audit and formal training in urinary catheter care, particularly for non-qualified care staff. Education is needed to ensure local implementation of NICE guidance.

Variation in the use of H. pylori tests in UK general practice--a qualitative study

BACKGROUND

Although serology is the main Helicobacter pylori test used by general practitioners in the UK, there is no information available on variation in requesting rates.

AIM

To explore the reasons for any variation in H. pylori serology testing by general practices in the UK using qualitative methods.

METHODS

Serology requesting rates were determined using laboratory and population data. Staff from randomly selected practices in the lowest and highest quintiles of testing attended focus groups to discuss the management of H. pylori and dyspepsia. Transcribed data were analysed using an interpretative phenomenological approach.

RESULTS

Serology submission varied 600-fold (0.1-59/1000 population/year) and H. pylori positivity rate 17-100%. Low-testing practices were less aware of the benefits of H. pylori testing and had shorter endoscopy waiting times. They preferred endoscopy diagnosis over serology test. Three high-testing practices had a high non-white population with high H. pylori positivity. Most staff knew little about the predictive value of serology, the availability of urea breath test on prescription or the existence of a stool test.

CONCLUSIONS

Seroprevalence of H. pylori is still high in dyspeptics, especially in non-white populations. Laboratories and primary care trusts should audit H. pylori requests and endoscopy referrals, target education at high endoscopy referrers and low H. pylori testers and inform clinicians of the more accurate H. pylori tests and NICE dyspepsia guidance.

Electrophysiological correlates of lateral interactions in human visual cortex

Detection thresholds for visually presented targets can be influenced by the nature of information in adjacent regions of the visual field. For example, detection thresholds for low-contrast Gabor patches decrease when flanked by patches that are oriented collinearly rather than orthogonally with the target. Such results are consistent with the known microanatomy of primary visual cortex, where long-range horizontal connections link cortical columns with common orientation preferences. To investigate the neural bases of collinearity effects, we recorded event-related brain potentials (ERPs) together with psychophysical measures for targets flanked by collinear vs. orthogonal gratings. Human volunteers performed a contrast discrimination task on a target grating presented at a perifoveal location. For targets flanked by collinear stimuli, we observed an increased positive polarity voltage deflection in the occipital scalp-recorded ERPs between 80 to 140 ms after stimulus onset. Such a midline occipital scalp voltage distribution of this ERP collinearity effect is consistent with a generator in primary visual cortex. Two later negative voltage ERP deflections (latencies of 245-295 and 300-350 ms) were focused at lateral occipital scalp sites, a pattern consistent with activity in extrastriate visual cortex. These ERP effects were correlated with improved contrast discrimination for central targets presented with collinear flanks. These results demonstrate that the integration of local flanking elements with a central stimulus can occur as early as 80 ms in human visual cortex, but this includes processes occurring at longer latencies and appears to involve both striate and extrastriate visual areas.

Diagnosis of genital chlamydia in primary care: an explanation of reasons for variation in chlamydia testing

OBJECTIVES

To explore the reasons for the 40-fold variation in diagnostic testing for genital Chlamydia trachomatis by general practices.

METHODS

A qualitative study with focus groups. We randomly selected urban and rural high and low testing practices served by Bristol, Hereford, and Gloucester microbiology laboratories. Open questions were asked about the investigation of C trachomatis in men and women in different clinical contexts.

RESULTS

The high and low testing practices did not differ in their age/sex make-up or by deprivation indices. There were major differences between high and low chlamydia testing practices. Low testing practices knew very little about the epidemiology and presentation of genital chlamydia infection and did not consider it in their differential diagnosis of genitourinary symptoms until patients had consulted several times. Low testers were less aware that chlamydia was usually asymptomatic, thought it was an inner city problem, and had poor knowledge of how to take diagnostic specimens. High testing practices either had a general practitioner with an interest in sexual health or a practice nurse who had completed specialist training in family planning. High testing practices were more cognizant of the symptoms and signs of chlamydia and always considered it in their differential diagnosis of genitourinary symptoms, including patients attending family planning clinics.

CONCLUSIONS

Any programme to increase chlamydia testing in primary care must be accompanied by an education and awareness programme especially targeted at low testing practices. This will need to include information about the benefits of testing and who, when, and how to test.

Prevalence of urinary catheterization in UK nursing homes

A postal questionnaire survey was undertaken in registered nursing homes in three different health districts in England: Gloucestershire, North Staffordshire and Leeds. Nursing homes may be registered as general nursing or mental health homes. If homes also have provision for residential beds these are defined as dual registered homes. Overall, 9% (438/4900) of residents, with an equal male:female split, had urinary catheters. There was no significant difference in the overall urinary catheterization rate in the three districts (P=0.9). There was a wide range of urinary catheterization prevalence between homes, with some homes of all three categories having no catheterized residents and several with a prevalence of over 40%. The wide range of prevalence may be due to differences in residents' underlying medical conditions or to differences in attitudes towards urinary catheterization by nursing home staff. Almost all homes (114/124, 92%) stated they had an infection control policy, but 31% (38/124) did not have a written policy on urinary catheter care. In view of the potential for morbidity, infection control policies should include a section on the care of urinary catheters and this should form part of the continuing training of nursing home staff.

Laboratory diagnosis of urinary symptoms in primary care--a qualitative study

The use of the microbiology laboratory for the investigation of urinary symptoms and the test positivity rate for the urine specimens varies considerably. We used qualitative methods to explore how and why primary care staff make diagnostic and management decisions in patients presenting with urinary symptoms. Stratified random sampling was used to include general practitioner (GP) practices that were heavy and light users of the microbiology service. The data were analysed using a modified grounded theory approach utilising the constant comparative method. Frequent users of the laboratory, with low specimen positivity, did not use near patient tests (NPTs) and sent urines from most patients with urinary symptoms to confirm their clinical diagnosis. Frequent users with high positivity advise patients with negative NPTs and send all specimens with positive NPTs for antibiotic susceptibility testing. Infrequent users did not value the laboratory for diagnosis, made great use of NPTs, and tended to prescribe empirical antibiotic treatment even in patients with minimal symptoms. Guidance on the management of urinary symptoms, the use of near patient tests and laboratory culture should form part of the ongoing education of primary care staff.

Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial

BACKGROUND

Functional breathing disorders may complicate asthma and impair quality of life. This study aimed to determine the effectiveness of physiotherapy based breathing retraining for patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing.

METHODS

33 adult patients aged 17-65 with diagnosed and currently treated asthma and Nijmegen questionnaire scores > or =23 were recruited to a randomised controlled trial comparing short physiotherapy breathing retraining and an asthma nurse education control. The main outcome measures were asthma specific health status (Asthma Quality of Life questionnaire) and Nijmegen questionnaire scores

RESULTS

Of the 33 who entered the study, data were available on 31 after 1 month and 28 at 6 months. The median (interquartile range) changes in overall asthma quality of life score at 1 month were 0.6 (0.05-1.12) and 0.09 (-0.25-0.26) for the breathing retraining and education groups, respectively (p=0.018), 0.42 (0.11-1.17) and 0.09 (-0.58-0.5) for the symptoms domain (p=0.042), 0.52 (0.09-1.25) and 0 (-0.45-0.45) for the activities domain (p=0.007), and 0.50 (0-1.50) and -0.25 (-0.75-0.75) for the environment domain (p=0.018). Only the change in the activities domain remained significant at 6 months (0.83 (-0.10-1.71) and -0.05 (-0.74-0.34), p=0.018), although trends to improvement were seen in the overall score (p=0.065), the symptoms domain (p=0.059), and the environment domain (p=0.065). There was a correlation between changes in quality of life scores and Nijmegen questionnaire scores at 1 month and at 6 months. The number needed to treat to produce a clinically important improvement in health status was 1.96 and 3.57 at 1 and 6 months.

CONCLUSION

Over half the patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing show a clinically relevant improvement in quality of life following a brief physiotherapy intervention. This improvement is maintained in over 25% 6 months after the intervention.

Parents' perspectives on the MMR immunisation: a focus group study

BACKGROUND

The uptake of the combined measles, mumps and rubella immunisation (MMR) in Britain has fallen since 1998, when a link was hypothesised with the development of bowel disorders and childhood autism. Despite reassurances about the safety of MMR, uptake levels remain lower than optimal. We need to understand what influences parents' decisions on whether to accept MMR or not so that health professionals can provide a service responsive to their needs.

AIM

To investigate what influences parents' decisions on whether to accept or refuse the primary MMR immunisation and the impact of the recent controversy over its safety.

DESIGN

Qualitative study using focus group discussions.

SETTING

Forty-eight parents, whose youngest child was between 14 months and three years old, attended groups at community halls in six localities in Avon and Gloucestershire.

METHODS

Purposive sampling strategy was used to include parents from a variety of socioeconomic backgrounds. Three groups comprised parents who had accepted MMR and three groups comprised parents who had refused MMR. Data analysis used modified grounded theory techniques incorporating the constant comparative method.

RESULTS

All parents felt that the decision about MMR was difficult and stressful, and experienced unwelcome pressure from health professionals to comply. Parents were not convinced by Department of Health reassurances that MMR was the safest and best option for their children and many had accepted MMR unwillingly. Four key factors influenced parents' decisions: (a) beliefs about the risks and benefits of MMR compared with contracting the diseases, (b) information from the media and other sources about the safety of MMR, (c) confidence and trust in the advice of health professionals and attitudes towards compliance with this advice, and (d) views on the importance of individual choice within Government policy on immunisation.

CONCLUSIONS

Parents wanted up-to-date information about the risks and benefits of MMR to be available in advance of their immunisation appointment. Many parents did not have confidence in the recommendations of health professionals because they were aware that GPs needed to reach immunisation targets. Most parents would, however, welcome more open discussion about immunisation with health professionals.

Lateral interactions between targets and flankers in low-level vision depend on attention to the flankers

Detection of an oriented visual target can be facilitated by collinear visual flankers. Such lateral interactions are thought to reflect integrative processes in low-level vision. In past studies, the flankers were task-irrelevant, and were typically assumed to be unattended. Here we manipulated attention to the flankers directly, by requiring observers to judge the relative alignment of two flankers while ignoring a second flanker-pair. Under identical stimulus conditions, attended flankers produced typical lateral interactions, but ignored flankers did not. These data show that lateral interactions can depend on attention to the flanking context, revealing the functional consequences of attentional modulation in low-level vision.

Unilateral spatial neglect: new treatment approaches with potential application to occupational therapy

Unilateral spatial neglect is one of the most common symptoms of stroke. It has important implications for occupational therapy because of its clinical manifestations, which include problems with activities of daily living, mobility, and reading. This article reviews neurophysiological theories pertaining to unilateral spatial neglect and focuses on two new treatment approaches with potential application to occupational therapy practice. Both approaches--constraint-induced therapy and partial visual occlusion--involve a form of restraint of the less affected side. These approaches are discussed in the context of current neurophysiological theories and the application to occupational therapy treatment for neglect.

Segmentation, attention and phenomenal visual objects

Issues concerning selective attention provoke new questions about visual segmentation, and vice-versa. We illustrate this by describing our recent work on grouping under conditions of inattention, on change blindness for background events and the residual processing of undetected background changes, on modal versus amodal completion in visual search, and the differential effects of these two forms of completion on attentional processes, and on attentional modulation of lateral interactions thought to arise in early visual cortex. Many of these results indicate that segmentation processes substantially constrain attentional processes, but the reverse influence is also apparent, suggesting an interactive architecture. We discuss how the 'proto-objects' revealed by studies of segmentation and attention (i.e. the segmented perceptual units which constrain selectivity) may relate to other object-based notions in cognitive science, and we wrestle with their relation to phenomenal visual awareness.

Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey

OBJECTIVES

To estimate the prevalence of dysfunctional breathing in adults with asthma treated in the community.

DESIGN

Postal questionnaire survey using Nijmegen questionnaire.

SETTING

One general practice with 7033 patients.

PARTICIPANTS

All adult patients aged 17-65 with diagnosed asthma who were receiving treatment.

MAIN OUTCOME MEASURE

Score >/=23 on Nijmegen questionnaire.

RESULTS

227/307 patients returned completed questionnaires; 219 (71.3%) questionnaires were suitable for analysis. 63 participants scored >/=23. Those scoring >/=23 were more likely to be female than male (46/132 (35%) v 17/87 (20%), P=0.016) and were younger (mean (SD) age 44.8 (14.7) v 49.0 (13.8, (P=0.05). Patients at different treatment steps of the British Thoracic Society asthma guidelines were affected equally.

CONCLUSIONS

About a third of women and a fifth of men had scores suggestive of dysfunctional breathing. Although further studies are needed to confirm the validity of this screening tool and these findings, these prevalences suggest scope for therapeutic intervention and may explain the anecdotal success of the Buteyko method of treating asthma.

Combined homicide-suicide in Galveston County

Combined homicide-suicides have been classified based on the psychopathology of the perpetrator and the nature of the relationship between perpetrator and victim(s). To further understand the nature of this tragic phenomenon and to test the validity and practicality of a previously suggested classification system, investigators systematically collected data on all combined homicide-suicide events that occurred in Galveston County, Texas over a continuous 18-year period (n = 20). The most common psychopathological finding for perpetrators was high serum alcohol levels that suggested intoxication. Most combined homicide-suicides fell into one of the relational categories and most of these, as predicted, were of the consortial type, possessive subtype. As expected, due to the small sample size, the less common types of combined homicide-suicide were not represented in this sample.

Inter-rater reliability of stroke sub-type classification by neurologists and nurses within a community-based stroke incidence study

The stroke classification developed for use in the Oxfordshire Community Stroke Project (OCSP) is simple, clinically meaningful and requires no investigations. However, its inter-rater reliability in a community setting is unknown. We aimed to assess the inter-rater reliability of this classification among neurologists and nurses within a community-based stroke incidence study. Fifty-four stroke patients with cerebral infarction who were registered in the North East Melbourne Stroke Incidence Study (NEMESIS) were assigned OCSP classifications by two neurologists and one of seven research nurses. There was moderate agreement between neurologists (kappa = 0.53), fair agreement between neurologist 1 and nurse (kappa = 0.31) and moderate agreement between neurologist 2 and nurse (kappa = 0.45). Disagreement about the neurological signs was an important reason for classification differences. The OCSP classification can be easily applied in a community setting with moderate inter-rater reliability and is thus a useful instrument for commun ity-based epidemiological studies.

Changes in cerebral blood flow associated with premenstrual syndrome: a preliminary study

The purpose of this study was to determine changes in regional cerebral blood flow (rCBF) associated with premenstrual syndrome (PMS). Regional CBF was examined using single photon emission computed tomography (SPECT) in seven women who sought treatment for PMS and seven control subjects. Confirmation of PMS was based on the Daily Symptom Report (DSR) of 17 common symptoms associated with PMS. A first SPECT scan was performed near the peak of premenstrual symptoms based on DSR reports from the two previous cycles. A second scan was performed in the postmenstrual period. Prior to scanning, each subject had a Hamilton Depression Rating Scale (Ham-D) obtained. Regions of interest were drawn on the images to generate mean counts per pixel, and normalized to the cerebellum. Activity in the frontal, temporal and parieto-occipital cortices, and the thalami and basal ganglia, were compared between the two scans. Correlations between activity in each region of interest and Ham-D values were also determined. There were marked decreases in rCBF in the temporal lobes on the premenstrual scan compared to the postmenstrual scan in PMS patients. Significant correlations were observed between the change in rCBF in the right and left temporal lobes and the changes in Ham-D scores (r = 0.91, p < 0.01 and r = 0.86, p = 0.01 respectively). No rCBF changes were observed in controls. We conclude that SPECT imaging demonstrates modest decreases in rCBF in the temporal lobes that correlate with the level of depression in subjects with PMS.

British general practitioners' attitudes toward abortion

CONTEXT

Women in Great Britain may obtain abortions only if they meet certain criteria and the procedure is approved by two physicians. Since seeing a general practitioner is typically a woman's first step toward obtaining an abortion, these doctors' attitudes about the procedure are very important.

METHODS

In 1999, a random sample of 702 general practitioners participated in a mailed survey regarding their attitudes toward abortion and the British Abortion Act.

RESULTS

Four in five respondents considered themselves broadly prochoice, and three in five believed that the current law should be liberalized to give women the right to obtain an abortion without regard as to reason. Three-quarters of doctors favored government provision of free abortions, and one-quarter thought that the current law places an unreasonable burden on general practitioners. However, physicians' opinions about whether the abortion decision should be the woman's alone depended on the pregnancy's gestation, and three-fifths of respondents said that the law was appropriate. Among doctors who were broadly antiabortion, one-fifth favored women's right to choose, and two-thirds supported the current law; however, nearly half opposed government funding of abortion services, and one-quarter did not feel that physicians need to reveal their antiabortion stance to patients.

CONCLUSIONS

Although Great Britain's abortion law is more restrictive than those in many other developed countries, general practitioners have largely positive attitudes toward women's access to abortion and toward the existing law. Their occasionally contradictory views, however, suggest that some areas are potentially problematic.

The effect of dehydroepiandrosterone supplementation to symptomatic perimenopausal women on serum endocrine profiles, lipid parameters, and health-related quality of life

Dehydroepiandrosterone (DHEA), an androgenic steroid hormone, exhibits an age-related decline. Perimenopausal women have only approximately 50% of peak DHEA levels. Despite limited scientific data, DHEA has gained recognition as a dietary supplement to reduce the symptoms of aging and improve well-being. This randomized, double-blind placebo-controlled trial examined the effects of 50 mg/day of oral DHEA supplementation, for 3 months, on 60 perimenopausal women with complaints of altered mood and well-being. Changes in the serum endocrine profile of women in the DHEA group were significantly greater than the placebo group, including a 242% [95% confidence interval (CI) +60.1, +423.9] increase in DHEAS, a 94.8% (95% CI +34.2, +155.4) increase in testosterone, and a 13.2% (95% CI -27.88, +0.5) decline in cortisol compared to baseline. Women receiving DHEA had a 10.1% (95% CI -15.0, -5.1) decline in high-density lipoprotein and an 18.1% (95% CI -32.2, -3.9) decline in Lp(a) from baseline, but these declines did not significantly differ from women who received placebo. Women receiving DHEA did not have any improvements significantly greater than placebo in the severity of perimenopausal symptoms, mood, dysphoria, libido, cognition, memory, or well-being. DHEA supplementation significantly effects the endocrine profile, may affect the lipid profile, but does not improve perimenopausal symptoms or well-being compared to placebo.

The role of low progesterone and tension as triggers of perimenstrual chocolate and sweets craving: some negative experimental evidence

Approximately half of the 40-50% of North American women who crave chocolate or sweets do so principally in the perimenstrum, the part of the menstrual cycle surrounding the onset of menstruation. We test two hypotheses about the events that trigger these cravings: 1) the premenstrual drop in progesterone levels; or 2) dysphoria or tension in the perimenstruum. Chocolate craving, sweets craving, and other perimenstrual symptoms were rated daily for six menstrual cycles by a sample of women with severe premenstrual syndrome (PMS). Forty-four women satisfied criteria for cyclicity in chocolate craving, and 44 for sweet craving, determined during the first two cycles. Thirty-four subjects satisfied criteria for craving of both chocolate and sweets. After placebo treatments during the third cycle, subjects were randomly assigned, double blind, to administration of placebo, oral micronized progesterone, or alprazolam (a tranquillizer). Treatments were administered from the beginning of the third week to the second day postonset of menstruation during the fourth to sixth months of study. Neither progesterone nor alprazolam decreased chocolate or sweets craving.

Is premenstrual dysphoric disorder a distinct clinical entity?

Does the evidence now available support the concept of premenstrual dysphoric disorder (PMDD) as a distinct clinical disorder such that the relative safety and efficacy of potential treatment can be evaluated? In a roundtable discussion of this question, a wealth of information was reviewed by a panel of experts. The key characteristics of PMDD, with clear onset and offset of symptoms closely linked to the menstrual cycle and the prominence of symptoms of anger, irritability, and internal tension, were contrasted with those of known mood and anxiety disorders. PMDD displays a distinct clinical picture that, in the absence of treatment, is remarkably stable from cycle to cycle and over time. Effective treatment of PMDD can be accomplished with serotinergic agents. At least 60% of patients respond to selective serotonin reuptake inhibitors (SSRIs). In comparison with other disorders, PMDD symptoms respond to low doses of SSRIs and to intermittent dosing. Normal functioning of the hypothalamic-pituitary-adrenal (HPA) axis, biologic characteristics generally related to the serotonin system, and a genetic component unrelated to major depression are further features of PMDD that separate it from other affective (mood) disorders. Based on this evidence, the consensus of the group was that PMDD is a distinct clinical entity. Potential treatments for this disorder can now be evaluated on this basis to meet the clear need for effective therapy.

Rapid amperometric verification of PCR amplification of DNA

Amplification of an 800-base template was verified in a 10-min test on a 2-microL sample of the PCR product solution. For verification, digoxigeninylated primers and biotinylated d-UTP-16-biotin were added to the amplification solution. The resulting amplified product was digoxigeninlabeled at its 3'-end and was also labeled with multiple biotin functions along its chain. The detecting electrode was coated with an electron-conducting redox hydrogel to which anti-digoxin monoclonal antibody was covalently bound. The amplified DNA was captured by the electrode through conjugation of its 3'-digoxigenin with the antibody. Exposure to a solution of horseradish peroxidase-labeled avidin led to capture of the enzyme and switched the redox hydrogel from a noncatalyst to catalyst for H2O2 electroreduction. The switching resulted in an H2O2 electroreduction current density of 2.1 +/- 0.9 microA cm-2 in 10-4 M H2O2 at Ag/AgCl potential and at 25 degrees C.

Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. Sertraline Premenstrual Dysphoric Collaborative Study Group

CONTEXT

Premenstrual dysphoric disorder is an important cause of symptoms and functional impairment in menstruating women.

OBJECTIVE

To evaluate the efficacy of sertraline hydrochloride for treatment of premenstrual dysphoria by measuring changes in symptom expression and functional impairment.

DESIGN

Two screening cycles followed by 1 single-blind placebo cycle and 3 cycles of randomized, double-blind, placebo treatment.

SETTING

Twelve university-affiliated outpatient psychiatry and gynecology clinics.

PATIENTS

Of the 447 women who requested participation, 243 met criteria for premenstrual dysphoric disorder and were randomized; 200 women completed the study.

INTERVENTION

A flexible (50-150 mg) daily dose of sertraline hydrochloride.

MAIN OUTCOME MEASURES

The Daily Record of Severity of Problems, Hamilton Rating Scale for Depression, Clinical Global Impression Scale, and Social Adjustment Scale.

RESULTS

Mean (+/-SD) total daily symptom scores decreased significantly (P<.001) in the sertraline-treated (64+/-22 to 44+/-19) compared with the placebo-treated (62+/-22 to 54+/-24) groups. Significant improvement (P<.05) was found for all clinically derived symptom clusters (depressive, physical, and anger/irritability symptoms). Hamilton Rating Scale for Depression scores decreased by 44% and 29% in the sertraline and placebo groups, respectively (P<.002). End-point global ratings showed much or very much improvement in 62% of the active treatment group and 34% of the placebo treatment group (P<.001). Reported functional impairment was substantial at baseline. Improvement in psychosocial functioning with treatment was similar to what is found in studies of major depression.

CONCLUSIONS

Sertraline was significantly better than placebo for treatment of premenstrual dysphoria as reflected by symptomatic improvement and change in reported functional impairment. Serotonin reuptake inhibitors such as sertraline are useful therapeutic options for women with premenstrual dysphoria.

Surgically assisted rapid orthodontic lengthening of the maxilla in primates--a pilot study

Orthodontic and surgical treatment of patients with maxillary retrusion and/or midface hypoplasia is challenging. This study was designed to show that the maxilla can be successfully lengthened by surgical assisted rapid orthopedic movement, using the principles of distraction osteogenesis. Three experimental and three control adolescent cynomolgus primates were used in this study. Metallic markers were placed in the cranial base and the maxilla and cephalometric x-ray films were taken. An orthodontic appliance was constructed with a Glen-Ross screw (Dentaurum, Newtown, Pa.) oriented anteroposteriorly. Anterior supraapical osteotomies of the maxilla were carried out. Bilateral horizontal and interdental osteotomies were created between the first premolars and the canine; the anterior six tooth dental-osseo segment was completely mobilized in all animals. Beginning 1 week after surgery, the orthodontic appliance was opened a quarter turn every 2 days until the anterior segment was advanced by 4 mm in two animals and 6 mm in one animal. Animals were killed at 6, 8, and 12 weeks after completion of the maxillary orthopedic advancement. Computerized tomographic scans of the maxillae were completed, and the specimens were then prepared by routine histologic methods for examination by light microscopy. The computerized tomographic scans showed bone deposition in the osteotomy sites, which was confirmed by histologic observations. Since this technique demonstrated repair by bone rather than soft connective tissue in the osteotomy sites, this procedure could be a useful method of treating midface retrusion.

Radiology on the information superhighway

PURPOSE

To explore the potential for the information superhighway to provide radiologists with new opportunities.

MATERIALS AND METHODS

The Internet was used as the communication and distribution medium. MOSAIC, a graphical interface, provided access for clients, and a computer was used to serve text, images, sound, and cine onto the Internet.

RESULTS

The system can be used to send reports and images to referring physicians or consulting radiologists; to provide a large database that is constantly available; to provide an increasing collection of teaching files; and to distribute interactive, multimedia teaching tools that can be used on any computer system. The use of the MOSAIC interface facilitates interaction, which allows users with limited computer experience to access the system.

CONCLUSION

The Internet can dramatically expand the ways radiologists interact with their colleagues. These preliminary results indicate that there will be great challenges and opportunities for improving care and teaching in the future.

Surgically assisted-rapid orthopedic lengthening of the maxilla in primates--relapse following distraction osteogenesis

A recent study has shown that the maxilla in primates can be successfully lengthened (0.5 mm every other day up to 6.0 mm) by means of surgically assisted-rapid orthopedic movement, using the principles of distraction osteogenesis. The present study was designed to determine if the maxilla can be advanced at a faster rate and if relapse would occur after removal of the orthodontic appliance. Metallic markers were placed in the cranial base and maxilla of two Cynomolgus primates, and cephalometric radiographs were taken. Bilateral horizontal and interdental osteotomies were created between in the first premolars and the canines, and the anterior segment was completely mobilized. An orthodontic appliance was bonded to the teeth and the screw was closed, compressing the osteotomy site. One week postoperatively the appliance was opened four quarter turns every day until the anterior segment was advanced by 10 mm. Cephalometric radiographs were taken at 6, 8, and 12 weeks postadvancement. At 12 weeks, the orthodontic appliance was removed, and at that time and 2, 4, and 6 weeks later, cephalometric radiographs were taken and study models fabricated. At the end of the postretention period, the animals were sacrificed, and the maxillae were evaluated by light microscopy. Results showed that the maxilla can be successfully advanced at a faster rate and for longer distances, and that the advanced maxilla does not relapse during the 6-week postretention period.

Rapid orthopedic lengthening of the mandible in primates by sagittal split osteotomy and distraction osteogenesis: a pilot study

This study proposes the development of an intraoral surgical approach to distraction osteogenesis to treat maxillofacial defects. Bilateral sagittal split osteotomies were made in the ascending ramus and body of the mandible of two adult cynomologus primates, and the dento-osseous segment was completely mobilized. A distraction device was fabricated from a Glen-Ross screw soldered between two mini bone plates. The bone plates were fixed by self-tapping screws to both right and left proximal and distal mandibular segments. Beginning 1 week postoperatively, both distraction plates were opened 1 mm every day until the mandible was advanced a total of 10 mm. Comparison of cephalometric radiographs and study casts prepared preoperatively, at the completion of the mandibular orthopedic advancement, and up to 12 weeks postdistraction, showed that mandibular advancement was successful and stable. There was radiographic evidence of bone filling the osteotomy sites, and there was no scar tissue formation or evidence of relapse.

Implications of the community education and practice project

A key feature of the Community Education and Practice (CEP) Project (UKCC, 1991) was the recognition that nurses should be appropriately trained if they choose to work in the community. The University of Central England (UCE) in Birmingham has developed a Diploma in Professional Studies in Nursing (Community Health Studies) course in order to fulfil this goal.

Potential predictors of information-seeking behavior by homosexual/bisexual (gay) men with a human immunodeficiency virus seropositive health status

Seeking ways to improve their health, gay men with human immunodeficiency virus (HIV) infections living in San Francisco are developing information networks and patterns of self-care behavior. Drawing from a set of explanatory theories, this cross-sectional survey with retrospective elements examined patterns and potential predictors of information-seeking activity in a cohort or 162 HIV seropositive (HIV+) men, 60 of whom provided complete data sets. The study suggests that 1 year after becoming aware of an HIV+ health status, most patients have developed multifaceted information networks. The amount of tangible aid acquired from these networks and frequency of consultation is positively related to patterns of HIV self-care behaviors and "feeling calm" (p less than 0.01), suggesting that these variables may be important markers for the need of supportive-educative nursing care. Suggestions for nursing practice and research are also described.

Gingival crevicular fluid concentration and side effects of minocycline: a comparison of two dose regimens

The purpose of this study was to conduct a direct comparison of two dose regimens of minocycline to determine 1) whether they achieved crevicular fluid concentrations in a therapeutic range; and 2) the frequency of side effects. In a double-blind design, 30 patients divided into 2 groups were given either 100 mg minocycline or 200 mg minocycline per day for an 8-day period. The concentration of minocycline in the gingival clevicular fluid (GCF) at 8 days was 4.77 micrograms/ml for the 100 mg a day group and 5.97 micrograms/ml for the 200 mg a day group and at 15 days was 4.30 micrograms/ml for the 100 mg a day group and 4.17 micrograms/ml for the 200 mg a day group. There was no significant difference in the antibiotic concentration in the gingival crevicular fluid between the 2 groups. Reported adverse experiences to the minocycline were greater in the 200 mg a day group. Short-term changes in periodontal health as measured by plaque index, gingival index, pocket depth, and bleeding upon probing showed improvements in all parameters over the 15 day period. There were no significant differences in these parameters between the 100 mg a day and 200 mg a day group. At 8 days reduced levels of Porphyromonas gingivalis and Prevotella intermedia were achieved but they were not eliminated from infected subgingival sites in either group. Achieving bacteriostatic concentrations of GCF, fewer side effects, and the potential for better compliance suggests that a single daily dose of 100 mg minocycline should now be investigated for its efficacy in managing periodontal infections manifesting as periodontitis.

Potential correlates of self-care and symptom distress in homosexual/bisexual men who are HIV seropositive

Although treatment of HIV infections is possible, anecdotal data and research suggest that infected homosexual and bisexual men are developing sets of HIV-specific self-care behaviors that they believe will maintain their health or delay progressive disease. However, little is known about frequent use of HIV self-care in relationship to symptom distress or other factors commonly assessed by nurses. These deficits limit the ability of healthcare providers to intervene appropriately. Consequently, the following repeated-measures study retrospectively examined correlates of HIV self-care in 162 outpatients who were attending a major healthcare facility in San Francisco, CA. Standard and HIV-specific instruments created for the study were used in data collection. Results suggest that the men increased their use of 35 of 81 HIV self-care behaviors once they became aware of being HIV seropositive (p less than 0.001). Frequent use of HIV self-care behaviors was related to several variables, including previous patterns of self-care (p less than 0.001), and AIDS diagnosis (p less than 0.01), and a locus of control (LOC) indicator (e.g., the statement "What happens to me is beyond my control") (p less than 0.001). Symptom distress also was related to several variables, including selected LOC and quality-of-life (QOL) indicators, mood states, and recent diagnosis of selected AIDS-related diseases (p less than 0.01). Collectively, these results suggest that taking self-care and selected psychosocial histories will allow nurses to identify ambulatory patients with HIV infections who need intensive care.

Critically ill patients have high basal growth hormone levels with attenuated oscillatory activity associated with low levels of insulin-like growth factor-I

OBJECTIVE

The aim was to study the relationship between growth hormone (GH) and insulin-like growth factor-I (IGF-I) in critically ill patients.

DESIGN

Case-control study of critically ill patients admitted to the intensive care unit was carried out.

PATIENTS

Six critically ill patients (51-78 years) who required ventilation and parenteral nutrition and six age, weight, height, and sex-matched healthy adults were studied.

MEASUREMENTS

The patients and controls were studied for two 24-hour periods; the patients before and after starting parenteral feeding, and the controls during a 36-hour fast and when taking meals equivalent in calories and protein to the patients' parenteral feed. Serum GH was measured at 20-minute intervals and analysed by a pulse detection algorithm (Pulsar) and Fourier transformation. IGF-I was measured at 0, 12, and 24 hours.

RESULTS

Patients had low serum IGF-I levels compared with controls, whether fasted or fed, despite having mean GH levels similar to fasted controls. For fasted patients vs fasted controls the mean (+/- 1 SD) GH levels were 4.5 +/- 2.0 vs 4.0 +/- 2.4 mU/l respectively, and IGF-I levels at the end of the fast were 0.17 +/- 0.11 vs 0.78 +/- 0.29 U/ml (P = 0.003). Patients showed elevated baseline GH levels compared with controls when fasted and during parenteral feeding (patients vs controls fasted 3.1 +/- 1.9 vs 0.8 +/- 0.5 mU/l, P = 0.01; patients vs controls fed 4.2 +/- 4.5 vs 0.5 +/- 0.04 mU/l, P = 0.028). Fourier transformation confirmed oscillatory GH levels in the controls, fasted or fed, but this activity was attenuated in the patients. Parenteral feeding had no effect on the GH profiles or IGF-I levels of patients, but controls showed greater mean GH levels during their fast than when fed.

CONCLUSIONS

We have demonstrated that critically ill patients have low IGF-I levels associated with augmented baseline GH levels which show reduced oscillatory activity. The results would be compatible with the hypothesis that there is an adaptive change in critically ill patients away from the indirect effects of GH (stimulation of IGF-I production and anabolism) and toward the direct effects (lipolysis and insulin antagonism) which increase the availability of energy substrates. The pattern of GH levels seen in our patients may be important in this adaptation.

Pyridostigmine, an Acetylcholinesterase Inhibitor, Stimulates Growth Hormone Release, but has no Effect on Basal Thyrotrophin or Adrenocorticotrophin Levels, or the Thyrotrophin Response to Thyrotrophin-Releasing Hormone

Abstract Pyridostigmine, an acetylcholinesterase inhibitor, stimulates growth hormone (GH) release and is thought to act by inhibiting hypothalamic somatostatin release. There are few data concerning the effect of pyridostigmine on other pituitary hormones apart from GH. We have studied the effect of pyridostigmine on basal GH, thyrotrophin (TSH), prolactin, adrenocorticotrophin and cortisol release, and thyrotrophin-releasing hormone (TRH)-stimulated TSH and prolactin release, in two studies involving nine healthy male subjects. Pyridostigmine stimulated GH release in all subjects but had no effect on adrenocortocotrophin or cortisol levels, or basal or TRH-stimulated TSH and prolactin levels. There are some data to suggest that somatostatin inhibits TRH-stimulated TSH release. Our findings, however, suggest that either endogenous somatostatin tone has little effect on the TSH response to TRH compared to its effects on GH or pyridostigmine acts through a mechanism other than altering somatostatin tone. Pyridostigmine did not alter adrenocorticotrophin or cortisol levels in the presence of a clear action on GH release, providing further evidence that the previously reported effects of cholinergic drugs on cortisol release are stress-related.

Ineffectiveness of progesterone suppository treatment for premenstrual syndrome

Progesterone is the most widely used treatment for premenstrual syndrome. To answer definitely the question of whether progesterone suppositories are effective for the treatment of premenstrual syndrome, a randomized, placebo-controlled, double-blind crossover study of 168 women, receiving progesterone in doses of 400 and 800 mg or placebo, was carried out. Premenstrual symptoms were not significantly improved by progesterone compared with placebo in any measure used in the study, including daily symptom reports maintained throughout treatment, clinician evaluation of improvement, and patient global reports of symptoms severity, relief, and disruption of daily activity. No symptom cluster or individual symptom differed significantly between progesterone and placebo treatment. These treatment results were not significantly affected by fluctuations in response during the placebo washout period, pretreatment levels of depression or anxiety at either postmenstrual or premenstrual times, or any of 19 other background, medical history, or symptom variables examined individually as covariates with treatment.

The Neurobehavioral Rating Scale: an interrater reliability study in the HIV seropositive population

The Neurobehavioral Rating Scale (NRS) has been used in the rapid bedside assessment of closed head-injured and stroke patients in the past and has been found to be highly predictive of long-term outlook. The NRS consists of 27 items in a Likert-type scale and measures cognition and behavioral parameters of brain disease. The NRS was administered to nine human immunodeficiency virus (HIV) positive individuals in a pilot interrater reliability study. Highly significant correlations (r .94 and r .97; p less than .001) were found between interviewers. Content and construct validity had already been established in prior research. To date, no quick, easy assessment tool measuring both cognitive and behavioral manifestations in this population has been widely used. Therefore, it becomes imperative that such a tool be available to nursing staff to aid in monitoring of neurologic deterioration, assist in appropriate placement of acquired immunodeficiency syndrome (AIDS) dementia complex patients and planning of care.

Characteristics of premenstrual syndrome

To characterize the symptoms associated with premenstrual syndrome (PMS), the menstrual symptom calendars of 100 women diagnosed with PMS were factor-analyzed. Scores on 18 symptoms were recorded daily for one menstrual cycle prior to the women's first clinic visits. Two factors were found to predominate throughout the cycle: The first included emotional and behavioral symptoms and the second included physical and cognitive symptoms. The two factors were constant throughout all the phases of the menstrual cycle. Emotional symptoms clustered together throughout the menstrual cycle and were the dominant symptoms on factor I. However, they loaded (correlation of the variable with the factor) on factors I and II during the postmenstrual phase. Behavioral symptoms loaded on factor I throughout the menstrual cycle; however, they were prevalent predominantly in the later half of the intermenstrual and the premenstrual phases. Physical symptoms loaded predominantly on factor II and were less prevalent than the emotional symptoms. The cognitive symptoms loaded on factor II during the premenstrual phase. These findings are relevant for defining PMS criteria for women who seek treatment.

Periodontal Disease Part III: Chemotherapeutics

In Part III of this article, the author deals with chemotherapeutics, systemic and topical antibiotics, and mouth rinses as an adjunct to mechanical therapy.