Suicidal patients and special observation

Special observation is a nursing practice utilized in in-patient psychiatric facilities for patients who are suicidal. Special observation is carried out by an allocated registered nurse remaining continuously at arms length from, or within sight of (as specified), the patient; or a registered nurse observing the patient within a 30 min interval. In this exploratory study, we investigated the role of the registered nurse when caring for patients on special observation. Semistructured interviews were conducted with 10 randomly selected registered nurses from 4 acute psychiatric wards. The 9 themes that emerged were: 1) Safety; 2) Therapeutic relationships; 3) Supporting patients and carers; 4) Consequences of special observation for nurses; 5) Continuity of care concerns; 6) Peer support; 7) Suicide indicators; 8) Responsibilities and rights: nurses and patients; and 9) Nurses, doctors and the hospital hierarchy. Recommendations for alleviation of the concerns about the practice of special observation are outlined and discussed.

The effects of 4-nonylphenol in rats: a multigeneration reproduction study

The alkylphenol breakdown products of alkylphenol ethoxylates have been shown in in vitro studies to be weakly estrogenic, but few in vivo data address this issue in mammals. Because estrogens have been found to be most potent during developmental/perinatal exposures, this study maximized developmental exposure to nonylphenol (NP) by treating 3.5 generations of Sprague-Dawley rats to NP in diet at 200, 650, and 2000 ppm to determine the range and severity of any toxicity. Dose rate was higher for younger rats; calculated dose ranges were 9-35, 30-100, and 100-350 mg/kg/d for the low (200NP), middle (650NP), and high (2000NP) dose groups, respectively. There were adult (F0, F1, F2) and postnatal day (pnd) 21 (F1, F2, F3) necropsies; the oldest F3 rats were killed on pnd 55-58. Body weight gain was reduced by 8-10% in the 650NP and 2000NP groups. Vaginal opening was accelerated by approximately 2 days (650NP) and approximately 6 days (2000NP) in F1, F2, and F3 generations. Uterine weights at pnd 21 were increased in 650NP (14%) and 2000NP (50%) F1 females, but not in other generations. Testis descent, anogenital distance, and preputial separation were not consistently changed. No consistent changes were seen in pup number, weight or viability, litter indices, or other functional reproductive measures. Relative ovary weight in F2 adults was decreased at 650NP and 2000NP by 12%; relative ovary was unchanged in other generations. Follicle counts were unchanged in F2 adults. Sperm indices, including CASA measures, were unchanged in F0 and F1 males. In F2 rats, epididymal sperm density was reduced by 8% and 13% at 650NP and 2000NP, respectively. Testicular spermatid count was reduced by 13% in 2000NP F2 males; testis and epididymis weights were unchanged. Erosion of gastric and duodenal mucosa was monitored grossly and microscopically, and never found. Kidney weights were increased in 650NP and 2000NP males, and renal medullary tubular dilatation and cyst formation were noted in all generations of males, and often at the lowest dose tested. These data show that NP had limited effects on the reproductive system in the presence of measurable nephrotoxicity. The F2 sperm effects are either statistical/biological "noise," or imply heretofore unknown pharmacokinetics or toxicodynamics. These sperm data should be interpreted cautiously until the findings are repeated.

Topiramate as add-on treatment for patients with bipolar mania

OBJECTIVE

Anticonvulsant agents such as carbamazepine and valproate are alternatives to lithium in treating subjects with bipolar disorder. Topiramate (Topamax), a new antiepileptic agent, is a candidate drug for bipolar disorder. We evaluated topiramate as adjunctive treatment for bipolar patients.

METHODS

Eighteen patients with DSM-IV bipolar I disorder [mania (n = 12), hypomania (n = 1), mixed episode (n = 5), and rapid cycling (n = 6)], and two subjects with schizoaffective disorder bipolar type, resistant to current mood-stabilizer treatment were initiated on topiramate, 25 mg/day, increasing by 25-50 mg every 3 7 days to a target dose between 100 and 300 mg/day, as other medications were held constant for 5 weeks. The Young Mania Rating Scale (Y-MRS), Hamilton Depression Rating Scale (Ham-D), and Clinical Global Impression-Bipolar Version Scale (CGI-BP) were used to rate subjects weekly.

RESULTS

By 5 weeks, 12 (60%) subjects were responders, i.e., 50% reduction in the Y-MRS scores and a CGI of 'much' or 'very much improved'. Three subjects were 'minimally improved', four showed no change, and one was 'minimally worse'. Six subjects had parasthesia, three experienced fatigue, and two had 'word-finding' difficulties; in all cases, side effects were transient. All patients lost weight with a mean of 9.4 lb in 5 weeks, and a significant reduction in body mass index (BMI) occurred too.

CONCLUSIONS

Topiramate appears to have efficacy for the manic and mixed phases of bipolar illness. Other preliminary data suggest antidepressant efficacy too. Among obese bipolar subjects, the weight loss potential of topiramate may be beneficial. If controlled trials confirm these initial results, topiramate may be a significant addition to the available treatments for bipolar disorder.

Recombinant rat fibroblast growth factor-16: structure and biological activity

Fibroblast growth factor-16 (FGF-16) is the most recent member of the FGF family to be cloned. Since the biologic activity of rat FGF-16 (rFGF-16) was unknown, and this protein has no apparent signal sequence, we transformed its entire cDNA into Escherichia coli for high-level expression and further characterization of this novel protein. An attempt was made to purify the expressed protein from the supernatant of mechanically lysed cells using sequential cation-exchange chromatography. This resulted in a gradual loss of the protein as precipitate throughout the purification process. In addition to precipitation during purification, sodium dodecyl sulfate polyacrylamide gel electrophoresis revealed that the partially purified materials showed a cluster of protein bands around 20k to 29k. Sequence analysis of the major bands indicated that two N-terminal truncations had occurred, during E. coli fermentation, purification, or both. The largest truncation resulted in the removal of the 34 N-terminal amino acids, including the initiation codon methionine. We cloned d34 rFGF-16, expressed the gene in E. coli, and developed a purification process for this form. Even with this truncated form, precipitation was a problem. We were largely able to overcome this problem, however, by including EDTA throughout the purification process. We have characterized the structure of purified d34 rFGF-16 extensively using circular dichroism, Fourier transform infrared spectroscopy, and sedimentation velocity analysis. These studies revealed that the protein has a distinct tertiary structure, consists primarily of beta-strands, has a weak tendency to self-associate, and is fairly extended. We then performed biologic assays which showed that d34 rFGF-16 induces oligodendrocyte proliferation in vitro, and induces hepatocellular proliferation and increased liver weight in vivo. In summary, FGF-16, a novel FGF family member, has both unique structural and biological properties.

Biochemical, biophysical, and pharmacological characterization of bacterially expressed human agouti-related protein

The agouti-related protein gene (Agrp) is a novel gene implicated in the control of feeding behavior. The hypothalamic expression of Agrp is regulated by leptin, and overexpression of Agrp in transgenic animals results in obesity and diabetes. By analogy with the known actions of agouti, these data suggest a role for the Agrp gene product in the regulation of melanocortin receptors expressed in the central nervous system. The availability of recombinant, highly purified protein is required to fully address this potential interaction. A nearly full-length form of AGRP (MKd5-AGRP) was expressed in the cytosolic or soluble fraction of Escherichia coli and appeared as large intermolecular disulfide-bonded aggregates. Following oxidation, refolding, and purification, this protein was soluble, and eluted as a single symmetric peak on RP-HPLC. Circular dichroism studies indicated that the purified protein contains primarily random coil and beta-sheet secondary structure. Sedimentation velocity studies at neutral pH demonstrated that MKd5-AGRP is monomeric at low micromolar concentrations. Mobility shifts observed using SDS-PAGE under reducing and nonreducing conditions for bacterially expressed and mammalian expressed AGRP were identical, an indication of a similar disulfide structure. The purification to homogeneity of a second, truncated form of AGRP (Md65-AGRP) which was expressed in the insoluble or inclusion body fraction is also described. Both forms act as competitive antagonists of alpha-melanocyte stimulating hormone (alpha-MSH) at melanocortin-3 (MC-3) and melanocortin-4 receptors (MC-4). The demonstration that AGRP is an endogenous antagonist with respect to these receptors is a unique mechanism within the central nervous system, and has important implications in the control of feeding.

Osteoprotegerin ligand is a cytokine that regulates osteoclast differentiation and activation

The ligand for osteoprotegerin has been identified, and it is a TNF-related cytokine that replaces the requirement for stromal cells, vitamin D3, and glucocorticoids in the coculture model of in vitro osteoclastogenesis. OPG ligand (OPGL) binds to a unique hematopoeitic progenitor cell that is committed to the osteoclast lineage and stimulates the rapid induction of genes that typify osteoclast development. OPGL directly activates isolated mature osteoclasts in vitro, and short-term administration into normal adult mice results in osteoclast activation associated with systemic hypercalcemia. These data suggest that OPGL is an osteoclast differentiation and activation factor. The effects of OPGL are blocked in vitro and in vivo by OPG, suggesting that OPGL and OPG are key extracellular regulators of osteoclast development.

GFRalpha-2 and GFRalpha-3 are two new receptors for ligands of the GDNF family

The receptor for glial cell line-derived neurotrophic factor (GDNF) consists of GFRalpha-1 and Ret. Neurturin is a GDNF-related neurotrophin whose receptor is presently unknown. Here we report that neurturin can bind to either GFRalpha-1 or GFRalpha-2, a novel receptor related to GFRalpha-1. Both GFRalpha-1 and GFRalpha-2 mediate neurturin-induced Ret phosphorylation. GDNF can also bind to either GFRalpha-1 or GFRalpha-2, and activate Ret in the presence of either binding receptor. Although both ligands interact with both receptors, cells expressing GFRalpha-1 bind GDNF more efficiently than neurturin, while cells expressing GFRalpha-2 bind neurturin preferentially. Cross-linking and Ret activation data also suggest that while there is cross-talk, GFRalpha-1 is the primary receptor for GDNF and GFRalpha-2 exhibits a preference for neurturin. We have also cloned a cDNA that apparently codes for a third member of the GFRalpha receptor family. This putative receptor, designated GFRalpha-3, is closely related in amino acid sequence and is nearly identical in the spacing of its cysteine residues to both GFRalpha-1 and GFRalpha-2. Analysis of the tissue distribution of GFRalpha-1, GFRalpha-2, GFRalpha-3, and Ret by Northern blot reveals overlapping but distinct patterns of expression. Consistent with a role in GDNF function, the GFRalphas and Ret are expressed in many of the same tissues, suggesting that GFRalphas mediate the action of GDNF family ligands in vivo.

A survey of women with HIV about their expectations for care

As an increasing number of women become infected with the human immunodeficiency virus (HIV), it is important to understand their expectations regarding the health care services they receive. In 1995 a new centre was opened at an academic centre in St Louis, Missouri, to provide comprehensive care to women with HIV. To assist in the Centre's development, we interviewed 50 of 119 enrolled clients (42%) using a survey instrument focusing on what they consider important in their care. In response to open-ended questions, clients most often mentioned wanting a sense of personalized caring and respect by medical staff (n = 28, [56%]), having someone to talk to about problems (n = 28, [56%]), honest answers about their condition (n = 23, [46%]), medical follow-up (n = 21, [42%]), reduced barriers to care (n = 20, [40%]), and education about their condition (n = 15, [30%]). The highest-ranked aspects of care were seeing the doctor, learning about their condition, and being seen in a pleasant environment (92% [n = 46%]). Significant differences were found in some responses when analysed according to race, educational level, and severity of disease. It is important that programmes delivering health care services to women with HIV provide services that take into account their individualized needs. Ideally, this requires incorporation of a multidisciplinary team to provide psychological and social support, patient education, and medical management.

Molecular cloning and characterization of a novel p38 mitogen-activated protein kinase

The p38 mitogen-activated protein kinases (MAPK) are activated by cellular stresses and play an important role in regulating gene expression. We have isolated a cDNA encoding a novel protein kinase that has significant homology (57% amino acid identity) to human p38alpha/CSBP. The novel kinase, p38delta, has a nucleotide sequence encoding a protein of 365 amino acids with a putative TGY dual phosphorylation motif. Dot-blot analysis of p38delta mRNA in 50 human tissues revealed a distribution profile of p38delta that differs from p38alpha. p38delta is highly expressed in salivary gland, pituitary gland, and adrenal gland, whereas p38alpha is highly expressed in placenta, cerebellum, bone marrow, thyroid gland, peripheral leukocytes, liver, and spleen. Like p38alpha, p38delta is activated by cellular stress and proinflammatory cytokines. p38delta phosphorylates ATF-2 and PHAS-I, but not MAPK-activated protein kinase-2 and -3, known in vivo and in vitro substrates of p38alpha. We also observed that p38delta was strongly activated by MKK3 and MKK6, while p38alpha was preferentially activated by MKK6. Other experiments showed that a potent p38alpha kinase inhibitor AMG 2372 minimally inhibited the kinase activity of p38delta. Taken together, these data indicate that p38delta is a new member of the p38 MAPK family and that p38delta likely has functions distinct from that of p38alpha.

Role of cytochrome P450 in hydrazine toxicity in isolated hepatocytes in vitro

1. Hepatocytes, isolated from the control, diethyldithiocarbamate (DEDC), acetone, isoniazed and hydrazine pretreated rat, were incubated with hydrazine (8-20 mM) for 3 h. Hydrazine caused a dose-dependent loss of viability, leakage of LDH, depletion of GSH and ATP and an inhibition of the incorporation of 3H-leucine into protein. 2. Pretreatment with DEDC increased, whereas hydrazine and acetone pretreatments decreased the cytoxicity and biochemical effects of hydrazine. Pretreatment with isoniazid slightly increased hydrazine cytotoxicity. Acetone pretreatment reduced the inhibition of protein synthesis caused by hydrazine compared to the control. 3. 4-Nitrophenol hydroxylase activity (P4502E1) correlated with viability, LDH leakage, ATP and GSH depletion in cells from the control, DEDC, acetone and hydrazine pretreated rats. 4. The activities of PROD (P4502B1) and EROD (P4501A1/1A2) also correlated with the above parameters for all treatments. The results suggest that three isoenzymes may be involved in the detoxication of hydrazine. Protein synthesis inhibition did not correlate with the activities of any of the enzymes measured.

Home abatement and blood lead changes in children with class III lead poisoning

We studied the effect of home abatement on blood lead (PbB) levels in children from central Massachusetts who had not undergone chelation therapy and whose homes were abated between 1987 and 1990, when stricter abatement guidelines were enacted. One hundred and thirty-two children with a mean preabatement PbB of 25.9 micrograms/dL (1.25 mumol/L) were studied: their mean postabatement PbB (up to 1 year later) was 21.1 micrograms/dL (1.02 mumol/L) (P < .001). This reduction correlated with preabatement PbB; 32 of 33 (97%) with preabatement PbB > or = 30 micrograms/dL (> or = 1.45 mumol/L) were lower postabatement, and 64 of 79 (81%) with PbB 20 to 29 micrograms/dL (0.97-1.40 mumol/L) were lower. However, in children with preabatement PbB < 20 micrograms/dL (< 0.97 mumol/L), only seven of 20 (35%) were lower postabatement and, in fact, there was a significant rise in PbB from 16.8 to 19.3 micrograms/dL (0.81 to 0.93 mumol/L) (P = 0.05). Continued improvement in home abatement technology is needed if that strategy is to be effective in achieving the lower PbB levels now mandated in the 1991 Centers for Disease Control guidelines. Primary prevention of the initial blood lead level elevation remains the most desirable strategy.

The prevalence of akathisia in patients receiving stable doses of clozapine

BACKGROUND

Akathisia is a common side effect of traditional neuroleptic drugs and is associated with medication refusal and impulsive behavior. While our previous experience indicates that clozapine is effective in treating persistent akathisia, two controlled studies indicate vastly different prevalence rates of akathisia (7% vs. 40%) in patients receiving clozapine.

METHOD

We used the Barnes Rating Scale for Drug-Induced Akathisia to estimate the prevalence of akathisia in patients receiving stable doses of clozapine alone (N = 29) in a state hospital. Measurements were also made of manifest psychopathology (Brief Psychiatric Rating Scale) and tardive dyskinesia (Abnormal Involuntary Movement Scale).

RESULTS

Two patients (6.8%) receiving clozapine were rated as having akathisia. Only 4 (28.6%) of the 14 subjects with a history of moderate-to-severe tardive dyskinesia on traditional neuroleptic drugs continued to show current evidence of tardive dyskinesia, and in 10 patients (71.4%) there was no evidence of the syndrome (p < .002). In the 4 subjects with tardive dyskinesia there was amelioration to a milder form of the syndrome. There were no new cases of tardive dyskinesia among clozapine-treated subjects.

CONCLUSION

These data support the low prevalence of akathisia in patients receiving stable doses of clozapine monotherapy. There is further support that clozapine has an ameliorating effect on tardive dyskinesia associated with traditional neuroleptic drugs. These and other data indicate the need for a controlled trial of clozapine in patients experiencing persistent and disabling akathisia on traditional neuroleptic drugs.

Venous stasis ulcers: assessment and treatment in the home care setting

This is a comprehensive article about assessment and treatment of venous stasis ulcers in the home. It includes information regarding the pathophysiology, assessment, treatment, follow-up care, and reimbursement considerations of venous stasis ulcers, and was written for the home health enterostomal therapy nurse and the home health nurse.

The efficacy of metoclopramide in the treatment of migraine headache

STUDY OBJECTIVES

By evaluating the efficacy of metoclopramide alone and in combination with ibuprofen versus placebos, this study was designed to both evaluate the efficacy of metoclopramide and elucidate its mechanism of action in the treatment of migraine headache.

DESIGN

The study was conducted over a two-year period and was a randomized, double-blind, placebo-controlled study.

SETTING

An urban teaching hospital.

PARTICIPANTS

Patients enrolled were at least 18 years old and had recurring headaches with one or more of the following characteristics: unilateral, preceded by neurologic symptoms, significant nausea and vomiting, or mood changes and photophobia.

INTERVENTION

Ten milligrams of metoclopramide or an equal volume of IV normal saline was given and 600 mg of ibuprofen or identical-appearing placebo was given orally at time 0. Patients rated their pain and nausea at time 0, 30 minutes, and 60 minutes using visual-analog scales.

RESULTS

The differences in pain and nausea scores for the metoclopramide + placebos group versus the other three groups were tested using exact nonparametric (Mann-Whitney) statistical procedures. The metoclopramide + placebos group had significantly better relief of pain compared with the placebos + ibuprofen and placebos + placebos groups. The metoclopramide + placebos group had significantly better relief of nausea than the ibuprofen + placebos group; nausea scores for the placebos + placebos group could not be analyzed due to excessive variance from the other groups at baseline. The differences between the metoclopramide + placebos group and the metoclopramide + ibuprofen group were not statistically significant with regard to either pain or nausea.

CONCLUSION

Metoclopramide is efficacious in the treatment of both the pain and nausea of migraine headache. This is a direct action that is not dependent on the concomitant administration of another agent.

Hemicorporectomy for acute aortic occlusion: a case study

Hemicorporectomy has been done for potentially curable pelvic malignancy and for intractable pelvic sepsis with bone involvement. In this report, the authors describe the first use of hemicorporectomy to treat ischemic gangrene of the limbs and pelvic soft tissues secondary to acute aortic occlusion.

Syringomyelia presenting as shoulder instability

Three middle-aged women presented with shoulder instability as the first sign of syringomyelia. The patients' symptoms were unilateral in each case. Two patients had posterior shoulder instability, and one patient had anterior instability. Two patients had undergone surgery to stabilize the shoulder before referral to our center. In both cases the surgery had been unsuccessful. Review of two of the patients' plain radiographs after referral demonstrated radiographic changes highly suggestive of neuropathic arthropathy. The diagnosis of syringomyelia was confirmed by myelography, computed tomographic scanning, and magnetic resonance imaging. One patient had an associated Arnold-Chiari malformation that was treated by a syringosubarachnoid shunt. Each patient's shoulder disability, although significant, remained static throughout a follow-up period averaging 79 months. Shoulder instability can be a presenting symptom and sign of syringomyelia. Patients over age 40 presenting with a glenohumeral dislocation may, in addition to having a high probability of rotator cuff injury, have neuropathic arthropathy. Syringomyelia should be included in the differential diagnosis of shoulder instability so that unnecessary and unsuccessful surgery can be avoided.

Quality assurance and quality of care: II. Monitoring treatment

The absence of meaningful linkages between quality assurance programs and quality of care has alienated them from each other, especially in psychiatry, where standards of care and process and outcome of treatment are vaguely defined and vigorously debated. This paper describes several factors contributing to the gap between quality assurance and quality of care as well as a treatment-monitoring process that attempts to bridge the gap. The form and review process described are criteria-based and concurrent, and they use methodology that both assesses documentation and promotes an interactive clinical review. Preliminary data that demonstrate the clinical usefulness of the process and its impact on a treatment service are presented.

The tamper effect: environmental influence on electron tunneling

The time constants for electron transfer from the singlet excited state of the small cavity conformer of the tetrabridged coplanar zinc porphyrin quinone (ZnPQ) average 2.4 times as fast in solvents containing XCCl3 group as in solvents of similar dielectric properties. Solvent molecules containing this bulky group cannot fit in the small cavity of conformer ZnPQa. We assign the effect to the increase of the electron wave function in the porphyrin-quinone space by increased exclusion from the electron dense solvent as compared to more usual solvents. We name this property the tamper effect.