Electronic reminding technology for cognitive impairment

Demographic changes highlight the need to address disabilities associated with the costly morbidities of old age, such as dementia. Memory impairment associated with dementia represents a significant challenge for many older people. Difficulties occur in carrying out activities in their entirety or in commencing them at all. Technology has the potential to help individuals overcome the barriers created by cognitive disability in terms of performing activities of daily living and therefore help to maintain independence and enhance quality of life (Czaja, 2005). This literature review examines the current reported research, which employs electronic reminding technology to support individuals with cognitive impairment. These devices range from everyday technologies, such as phones, to sophisticated interactive devices with specifically designed software. A summary of the current evidence base is presented and recommendations for future practice are made.

A Comparative Analysis of the SF-12 and the SF-36 among Ischaemic Heart Disease Patients

This paper investigated whether the SF-12 could replace the SF-36 in the measurement of health status among ischaemic heart disease patients. The SF-36 and SF-12 were administered to 105 cardiac patients. The SF-36 summary scores were strongly correlated and similar to the SF-12 summary scores. Also, the SF-12 scores were as powerful as the SF-36 summary scores in discriminating between subgroups of patients categorized according to their self-reported health status or angina classification. It is suggested that when there is a need to collect routine information about cardiac patients' general physical and mental health, the SF-12 is preferable to the SF-36 because of its brevity and acceptability to patients.

An inconvenient truth: treatment of displaced paediatric supracondylar humeral fractures

The need for emergent management of displaced paediatric supracondylar humeral fractures is being questioned in the literature. Open reduction rates of up to 46% have been reported in the non-emergent management of these injuries. At our institution these fractures are managed as operative emergencies by senior personnel. To examine the ongoing need for this policy we reviewed our results. All patients managed over a five year period with Gartland type IIB or III paeditric supracondylar humeral fractures were identified and a comprehensive chart and radiographic review undertaken. The mean time from injury to fracture reduction and stabilization was 6.6 h. Consultants performed or supervised 90% of cases. Open reduction was necessary in 5% of cases. Complications included a perioperative nerve injury rate of 6% and a superficial pin site infection rate of 3%. This study suggests that, despite the challenge to trauma on-call rostering, the emergency management of these injuries is advantageous to patients in units of our size. Based on the data presented here we continue our practice of emergent management. We suggest that units of a similar size to our own would show a benefit from an analogous policy albeit an inconvenient truth.

Nonconvulsive seizures are common in critically ill children

BACKGROUND

Retrospective studies have reported the occurrence of nonconvulsive seizures in critically ill children. We aimed to prospectively determine the incidence and risk factors of nonconvulsive seizures in critically ill children using predetermined EEG monitoring indications and EEG interpretation terminology.

METHODS

Critically ill children (non-neonates) with acute encephalopathy underwent continuous EEG monitoring if they met institutional clinical practice criteria. Study enrollment and data collection were prospective. Logistic regression analysis was utilized to identify risk factors for seizure occurrence.

RESULTS

One hundred children were evaluated. Electrographic seizures occurred in 46 and electrographic status epilepticus occurred in 19. Seizures were exclusively nonconvulsive in 32. The only clinical risk factor for seizure occurrence was younger age (p=0.03). Of patients with seizures, only 52% had seizures detected in the first hour of monitoring, while 87% were detected within 24 hours.

CONCLUSIONS

Seizures were common in critically ill children with acute encephalopathy. Most were nonconvulsive. Clinical features had little predictive value for seizure occurrence. Further study is needed to confirm these data in independent high-risk populations, to clarify which children are at highest risk for seizures so limited monitoring resources can be allocated optimally, and to determine whether seizure detection and management improves outcome.

The epidemiology of red cell transfusion

BACKGROUND AND OBJECTIVES

Understanding of the clinical usage of red cells is limited despite its importance in transfusion practice improvement and planning for blood supply requirements. Previous studies have described red cell use based upon ICD and hospital discharge codes; however, such approaches are open to misclassification. This study addresses this limitation by undertaking an epidemiological analysis of red cell use using case note review.

MATERIALS AND METHODS

Patient, disease and contextual factors were extracted from the medical records of a randomly selected sample of hospital patients in Northern Ireland who received a red cell transfusion during 2005 (n=1474).

RESULTS

Transfused patients received a total of 3804 units (median of two units per transfusion episode). Most transfusions occurred in a medical setting (71%). Patients undergoing treatment for gastrointestinal conditions were responsible for the majority of the demand (29% of transfusion episodes; 34% of red cell units). The presence of bleeding and abnormal tests of coagulation were associated with receiving larger transfusions (≥ 3 units), while patients undergoing orthopaedic surgery and those with a haemoglobin level over 7 g/dl had the lowest risk of receiving ≥ 3 units in any one transfusion episode.

CONCLUSION

The majority of red cells are now prescribed in a medical setting. With an ageing population and increasing therapeutic interventions, the demand for blood is likely to increase despite efforts to reduce usage by eliminating inappropriate transfusions through education and behaviour change. The post-transfusion target (and therefore the number of units to transfuse) for any given clinical situation as well as guidance on a 'safe' transfusion threshold should be considered in future guidelines.

Electroencephalographic monitoring during hypothermia after pediatric cardiac arrest

BACKGROUND

Hypoxic ischemic brain injury secondary to pediatric cardiac arrest (CA) may result in acute symptomatic seizures. A high proportion of seizures may be nonconvulsive, so accurate diagnosis requires continuous EEG monitoring. We aimed to determine the safety and feasibility of long-term EEG monitoring, to describe electroencephalographic background and seizure characteristics, and to identify background features predictive of seizures in children undergoing therapeutic hypothermia (TH) after CA.

METHODS

Nineteen children underwent TH after CA. Continuous EEG monitoring was performed during hypothermia (24 hours), rewarming (12-24 hours), and then an additional 24 hours of normothermia. The tolerability of these prolonged studies and the EEG background classification and seizure characteristics were described in a standardized manner.

RESULTS

No complications of EEG monitoring were reported or observed. Electrographic seizures occurred in 47% (9/19), and 32% (6/19) developed status epilepticus. Seizures were nonconvulsive in 67% (6/9) and electrographically generalized in 78% (7/9). Seizures commenced during the late hypothermic or rewarming periods (8/9). Factors predictive of electrographic seizures were burst suppression or excessively discontinuous EEG background patterns, interictal epileptiform discharges, or an absence of the expected pharmacologically induced beta activity. Background features evolved over time. Patients with slowing and attenuation tended to improve, whereas those with burst suppression tended to worsen.

CONCLUSIONS

EEG monitoring in children undergoing therapeutic hypothermia after cardiac arrest is safe and feasible. Electrographic seizures and status epilepticus are common in this setting but are often not detectable by clinical observation alone. The EEG background often evolves over time, with milder abnormalities improving and more severe abnormalities worsening.

Oesophageal cancer: caregiver mental health and strain

OBJECTIVE

To investigate strain and mental health among family caregivers of oesophageal cancer patients and possible factors associated with caregiver mental health and strain.

METHODS

Patients with oesophageal adenocarcinoma in Ireland were recruited into the FINBAR study (the main aim of which was to investigate factors influencing the Barrett's adenocarcinoma relationship). Carers completed the 13-item Caregiver Strain Index and the General Health Questionnaire-30 (GHQ) in the context of a brief interview with trained research staff that was undertaken separately from the interview with each cancer patient.

RESULTS

Two hundred and twenty-seven patients participated in the FINBAR study. A total of 39 patients did not have a family carer or the carer could not be identified. Fifty percent (94/188) of carers completed the questionnaires. Mean (SD) scores for strain (6.65, SD=3.63) and mental health status (10.21, SD=7.30) were high and 71% of carers scored >5 on the GHQ indicating psychological distress. There was a statistically significant positive relationship between level of strain experienced by caregivers and the severity of their mental health status and whether or not carers scored >5 on the GHQ. Relatives were 1.70 (95% CI 1.34-2.15) times more likely to be defined as high scorers with each unit increase in the CSI score.

CONCLUSIONS

A significant proportion of caregivers experienced high levels of strain and psychological distress. There is a need to provide appropriate support and services targeted specifically at reducing the considerable strain of caring for patients with oesophageal cancer, particularly for carers of patients from lower socioeconomic groups.

Travel time and cancer care: an example of the inverse care law?

INTRODUCTION

There is growing evidence that in rural areas cancer mortality is higher and referral occurs later, indicating different patterns of care. In Scotland services to rural areas have been organized through 'managed clinical networks'. In some cases, these organizational networks have been structured so that the referral hospital is not the one nearest to the patient's home. This study set out to discover if access to cancer specialist care in mainland Scotland altered with distance to tertiary care facilities. The aim was to explore the relationship between hospital admission rates, type of hospital and travel time.

METHODS

Retrospective analysis of all registered cancers in Scotland over the three-year period 2000-2002, examining incidence rates and accessibility of care over 3 years, measured by hospital discharge rates (equivalent to admission rates) and mean bed days for cancer patients.

RESULTS

The type of hospital to which a cancer patient was admitted and the duration of admission varied with travel distance from a patient's home. All patients travelling more than one hour had lower admission rates to a specialist cancer centre. Those travelling more than 3 hours were not always admitted to the facility nearest their home address and were admitted for significantly fewer days than all other groups.

CONCLUSION

Differences in tertiary cancer care obtained may explain some of the reasons behind late presentation and higher mortality rates. This study provides evidence that the recognized increased cancer mortality in rural patients is indeed compounded by an increased travel burden.

'Minor' morbidity after parotid surgery via the modified Blair incision

OBJECTIVE

To assess the 'minor' morbidities subjectively experienced by the patient after parotid surgery; these include scar cosmesis and pain, 'contour' deformity following removal of parotid bulk, numbness of the pinna and gustatory sweating.

DESIGN

Retrospective study

SETTING

Tertiary Referral Centre.

PATIENTS

28 patients were included in the study.

RESULTS

Contour deformity, scarring and paraesthesia of the pinna secondary to great auricular nerve sacrifice are the most noticeable sequelae following parotidectomy.

DISCUSSION

Although facial nerve injury is the most serious morbidity following parotidectomy, it is relatively uncommon. Other 'minor' morbidities are more likely to cause post-operative problems. Despite there being a number of different approaches to the parotidectomy, with or without reconstruction, these have not been satisfactorily compared.

The evolution of trauma services at Beaumont Hospital

OBJECTIVE

To review and examine the epidemiology, severity and management of trauma admissions at the national neurosurgical teaching hospital.

METHODS

An extensive audit of volume, type and severity of injury and the management requirements of the trauma population admitted to the hospital.

RESULTS

The vast majority of severely injured patients were referred from outside the catchment area of the hospital with only 26% being admitted directly through the Emergency Department. As a consequence, 73% of patients arrived out of normal working hours, which posed problems in providing skilled trauma specialists.

CONCLUSIONS

The management of patients with serious injury is complex. The large proportion of patients with critical injuries, some of whom were paediatric, highlighted the need for 24 h cover by senior trauma personnel and the provision of radiology and operating facilities to meet their needs. The inclusion of indicators of alterations in innate or adaptive immune responses may improve the predictive power of severity of injury scores.

Parapharyngeal abscess in an insulin dependant diabetic patient following an elective tonsillectomy

OBJECTIVES

To demonstrate a potentially life-threatening complication following tonsillectomy in a diabetic patient and discuss the possible pathogenesis.

METHODS

Case report and review of the world literature concerning parapharyngeal abscess post-tonsillectomy.

CASE REPORT

A 20-year-old female patient underwent an uneventful tonsillectomy following a history of recurrent tonsillitis. She re-presented 14 days post-surgery with a large erythematous tender right mid cervical neck swelling. Clinical and radiological evaluation confirmed a parapharyngeal abscess. She proceeded to have an incision and drainage of the abscess through a horizontal skin crease incision and subsequent intravenous antibiotic therapy. She was discharged home well three days post-surgery.

CONCLUSION

Diabetes mellitus is a well-recognised systemic disease that may leave an individual more susceptible to infection. We report the first case in a young healthy diabetic patient and highlight a potential serious complication following a routine tonsillectomy.

Towards a web-based knowledge management system for cardiovascular disease

The objective of this paper is to examine the efficacy of the Knowledge Management (KM) paradigm for a web-based patient administration system (PAS) for cardiovascular disease (CVD). We discuss the role of contemporary information and communication technologies (ICTs) for the management of electrocardiographic information and how this can act as a foundation for a KM-based system.

Otogenic pneumocephalus: case report and review of the literature

We report a case of a 70 year old lady who presented to the accident and emergency department with a three day history of left sided otalgia, drowsiness and confusion. On admission her temperature was 39 degrees C, glascow coma scale was 14/15 and otoscopy revealed a left sided otitis media. There was no sign of CSF otorrhoea or mastoiditis. Neuro-otological examination was normal. High resolution CT scan of temporal bones and brain showed evidence of pneumocephalus near the left cerebello-pontine angle and posterior to the left petrous bone. No focal parenchymal pathology, intra-cranial bleed or defect in the tegmen was noted. The patient responded very well to conservative management in the form of high dose intravenous antibiotics. We would like to emphasise that this complication of otitis media should be borne in mind when an elderly patient presents with otalgia and confusion.

Routine nasopharyngeal biopsy in adults presenting with isolated serous otitis media: is it justified?

Nasopharyngeal malignancy accounts for less than 2 per cent of all head and neck cancers. Serous otitis media (SOM) causing deafness is a recognized indicator of nasopharyngeal obstruction and the possibility of a nasopharyngeal malignancy must be considered in all adults. Examination under anaesthesia (EUA) and biopsy of the nasopharynx is routinely undertaken in many centres to rule out nasopharyngeal malignancy in adults with SOM. The purpose of this 10-year retrospective study was to evaluate the case records of all adult cases of SOM, including their presentation, clinical findings, management and nasopharyngeal biopsy results.

Eighty-five patients were included in the study. Fifty-nine presented with unilateral SOM and 26 with bilateral SOM. The primary presenting complaint in all cases was hearing loss. A nasopharyngeal mass was documented in 55 patients (69 per cent). Four nasopharyngeal masses were noted to have irregular or exophytic mucosa on flexible nasendoscopy. All patients underwent a EUA of the ears and a nasopharyngeal biopsy. The four patients with suspicious-looking masses were all found to have malignancies (two squamous cell carcinomas, one B-cell non-Hodgkin lymphoma and one adenocarcinoma). Three of these patients presented with unilateral SOM and one with bilateral SOM. All other patients with masses were found to have benign lymphoid hyperplasia. In total, 4.7 per cent of the adults with conductive hearing loss secondary to SOM were found to have a malignancy on nasopharyngeal biopsy.

We would advocate a high index of suspicion of a nasopharyngeal tumour in adults presenting with SOM. If a mass is found in the nasopharynx then it should be biopsied. If no mass is found then it is not necessary to biopsy; however, close follow up, with repeat fibre-optic nasendoscopy, is advised.

Validation of rat endometriosis model by using raloxifene as a positive control for the evaluation of novel SERM compounds

Approximately 10% of women of reproductive age suffer from endometriosis, a potentially painful disease process and important cause of female infertility. Raloxifene, a commercially available SERM (selective estrogen receptor modulator) compound, used for the treatment of postmenopausal osteoporosis, has preclinically demonstrated its estrogen antagonist effect on uterine tissue in rats. There is potential that SERM compounds may become a viable treatment option for human endometriosis, although more investigation is needed. In this study, raloxifene was administered at various doses to determine the efficacy and an appropriate dose level for use as a positive control in a rat model of endometriosis. Prior to dose administration, all rats underwent a bilateral ovariectomy, autologous transplantation of uterine tissue onto the peritoneal surface of the abdominal wall, and implantation of a subcutaneous estrogen pellet (E2). Two separate postsurgical experiments were performed. In experiment 1, following a 4-wk recovery, the rats bearing implants were assigned to three groups: (1) removal of the E2 pellet and dosing vehicle only (n = 7); (2) E2 and vehicle (n = 6); and (3) E2 and raloxifene at 10.0 mg/kg (n = 6). In experiment 2, also following a 4-week recovery, the rats bearing implants were assigned to five groups (n = 8/group): (1) E2 and vehicle only; (2) E2 and raloxifene, 0.3 mg/kg/d; (3) E2 and raloxifene, 1.0 mg/kg/d; (4) E2 and raloxifene, 3.0 mg/kg/d; (5) E2 and raloxifene, 10.0 mg/kg/d. All rats were dosed orally BID for 14 d. At the end of the study, the implanted endometrium was remeasured and compared to the pretreatment measurement. The results from both studies demonstrated that Raloxifene at only one dose (10.0 mg/kg) displayed significant implant regression (p < .05). Subsequently, our rat endometriosis experimental model consistently uses the exogenous E2 pellet and raloxifene at 10 mg/kg, BID, as a positive control to help screen and compare novel SERM compounds.

Changes in trauma service workload since the introduction of the penalty points system

With the introduction of the penalty points system (PPS) has come many media reports indicating a reduction in road traffic accident (RTA) rates. We hypothesised that reduced RTAs would result in a reduction in hospital trauma workloads. To study this we examined the numbers of RTA related femoral shaft fracture presentations to the six Dublin teaching hospitals and Waterford regional hospital within the six months since the introduction of the PPS and the two previous corresponding six month periods. We also analysed all RTA related discharges from Beaumont hospital during these three time periods. Whilst a slight reduction in RTA related femoral shaft fracture numbers was observed a dramatic reduction in total RTA related discharges from Beaumont hospital was identified with 70 patients discharged in the first six months since the introduction of the PPS compared to 124 and 125 discharges in the same two preceding six month periods. This reduction was greatest for head and thoracic injuries which were halved, while total numbers of limb injuries were maintained, resulting in no reduction in orthopaedic RTA related discharges or workload.

Intelligent analysis of EMG data for improving lifestyle

In the tragic situation when a person loses his or her hand, they are usually faced with only one option if they wish to regain a good level of mobility; learn to control an artificial hand. It has been suggested that our brain stores a "body map" of the different parts in our body. Thus, if a person loses a hand, their "body map" remains intact and produces phantom sensations that permit the person to feel like they still have their hand. Some discomfort is felt during these sensations; nevertheless, there is a positive side to them as they enable patients to control prosthetic replacements. Sensations experienced can be measured using a method known as Electromyography (EMG) and can be acquired and processed to control an artificial hand. This research involved the acquisition, analysis and classification of EMG signals through construction of a recording device and the development of classification models based on heuristic approaches and Artificial Intelligence classifiers based on Neural Networks to control artificial hands.

Anatomical variation at the saphenofemoral junction

Background

This study was designed to document the surgical anatomy of the saphenofemoral junction (SFJ).

Methods

The anatomy of the SFJ was recorded diagrammatically in 2089 consecutive groin dissections performed to treat primary varicose veins. The number of primary tributaries, bifid systems, junctional tributaries and the relationship of the external pudendal artery (EPA) to the long saphenous vein (LSV) were recorded.

Results

The LSV was bifid in 18·1 per cent of legs. The number of tributaries at the SFJ varied from one to ten. In 33·4 per cent one or more (junctional) tributaries joined the LSV or common femoral vein deep to the deep fascia. The EPA crossed anterior to 16·8 per cent of LSVs. In 4·6 per cent it passed posterior to one large tributary or trunk of a bifid LSV and anterior to the second trunk, making identification of the second trunk particularly difficult.

Conclusion

A thorough understanding of the anatomical variations of the SFJ is important in ensuring that the junction is managed safely and adequately in patients with varicose veins. Failure to appreciate these variations may account for a significant proportion of inadequate primary varicose vein surgery.

What influences physiotherapy use by children with cerebral palsy?

AIM

To investigate factors that influence the frequency of physiotherapy currently used by a population of children with moderate to severe cerebral palsy (CP).

METHODS

A survey using a postal questionnaire was sent to 212 parents of children with moderate to severe CP. The families were identified from a geographically defined case register of children with CP in Northern Ireland (the Northern Ireland Cerebral Palsy Register). Eighty-five per cent of parents responded. One-third of parent responses regarding their child's use of physiotherapy were validated with their child's physiotherapist and the level of agreement was high.

RESULTS

Ninety-four per cent (169/180) of children received conventional physiotherapy from a statutory source during the school term. Of these, 61% (104/169) used 'intense' levels of physiotherapy (defined as at least twice a week). A higher proportion of intense users were children with severe CP compared with moderate CP (69% vs. 47%; P < 0.01); with moderate intellectual impairment (IQ </= 70 > 50) compared with severe (IQ </= 50) or no intellectual impairment (IQ > 70) (81% vs. 64% vs. 39% respectively; P < 0.01) and at schools for physical disability (PD) compared with severe learning disability (SLD) or mainstream (MS) schools (82% vs. 66% vs. none respectively; P < 0.001). After controlling for severity of motor impairment and the presence and severity of intellectual impairment, children with CP at MS schools used on average significantly less physiotherapy compared with children with similar levels of motor impairment at PD schools (P < 0.001).

CONCLUSIONS

Children with CP in MS schools use less physiotherapy compared with children with similar levels of disability in special schools. Organizing services around special schools may limit the degree to which children with CP and other disabilities are successfully integrated into MS education.

Patients' recall of clinical information following laparoscopy for acute abdominal pain

Background

Failures in doctor–patient communication and patients' understanding continue to confound improvements in the delivery of quality healthcare. In the context of acute abdominal pain managed by means of laparoscopy, it was hypothesized that patients are either not adequately informed, or do not reliably retain simple relevant information transmitted at the time of the procedure. This study was designed to evaluate the reliability of information transfer between doctor and patient in this setting, including the diagnosis and whether or not the appendix was removed.

Methods

A retrospective study of 350 consecutive patients who had undergone laparoscopy for acute abdominal pain over 3·5 years was designed. Each patient completed a telephone questionnaire that was used to evaluate the accuracy of patients' information.

Results

In total, 26·9 per cent of patients did not know or were incorrect regarding the surgical procedure performed. Similarly, 20·0 per cent of all patients did not know or were incorrect regarding the status of their appendix after surgery and 30·0 per cent of patients were incorrect regarding the diagnosis. Despite all of these statistics, 91·4 per cent of patients were happy with the information they had received regarding the procedure.

Conclusion

Some 26·9 per cent of patients who underwent laparoscopy for acute abdominal pain were incorrect or did not know about the procedure that had been performed. This could lead to a further unnecessary operation should they re-present with similar symptoms.

Use of physiotherapy and alternatives by children with cerebral palsy: a population study

OBJECTIVES

To describe the use of physiotherapy services and alternative therapies by a population of children with moderate to severe cerebral palsy (CP).

DESIGN

Descriptive cross-sectional survey.

SUBJECTS

A total of 212 parents of children aged 4-14 years with moderate to severe CP were identified from the Northern Ireland Cerebral Palsy Register (NICPR) and a random subsample of their paediatric physiotherapists.

MAIN MEASURES

A standardized description of motor impairment or assessment form; a postal questionnaire to parents and paediatric physiotherapists (to validate parents' reports of service use). RESPONSE RATES: In total, 85% of parent questionnaires were returned and 100% of paediatric physiotherapists responded.

RESULTS

Service use among families was high; on average the families had contact with approximately seven services in a 6-month time interval. The overwhelming majority of children (96%) received physiotherapy during the school term and most (59%) received treatment at least twice a week for 30 min; 43% of children had their physiotherapy discontinued over the summer holidays. Over one-quarter (28%) of families had opted out of the NHS and bought alternatives like conductive education (21%) or private forms of conventional physiotherapy (16%). Children with more severe forms of CP, in special education, particularly at schools for physical disability, were high-intensity users of the physiotherapy service. Despite this, 74% of parents wanted more physiotherapy for their child.

CONCLUSIONS AND IMPLICATIONS

The demand for physiotherapy services is likely to continue given the relatively stable prevalence rate of CP, the proportion of children with disabling CP and the level of parent interest in the service. A number of quality aspects and gaps in the service have been identified.

High dependency care: impact of lack of facilities for high-risk surgical patients

BACKGROUND

The difference between the level of care available on general ward areas and intensive care units (ICUs) has resulted in the development of high dependency units (HDUs).

AIMS

This study examined the current perioperative management techniques and clinical care settings of high-risk surgical patients in a hospital without a HDU.

METHODS

A prospective audit of high-risk surgical patients was performed over an eight-week period. Using a pre-operative questionnaire, the anaesthetist categorised patient suitability for one of three post-operative care areas. In addition, desired and actual post-operative monitoring, pain management and organ support were indicated.

RESULTS

Seven (25%) of 28 patients admitted to ICU were rated HDU suitable indicating inappropriate use of resources, while 27 (75%) of 36 patients admitted to the general ward were categorised as fulfilling HDU admission criteria. A total of 21/27 (78%) and 12/27 (44%) of this latter group had alteration of idealised post-operative pain management and haemodynamic invasive monitoring plans respectively.

CONCLUSIONS

The absence of an intermediate care area facility in a tertiary hospital without an acute pain team impacts on the type of perioperative care provided to patients and the optimal use of resources.

Analysis of betamethasone in rat plasma using automated solid-phase extraction coupled with liquid chromatography-tandem mass spectrometry. Determination of plasma concentrations in rat following oral and intravenous administration

A method is described for the determination of betamethasone in rat plasma by liquid chromatography-tandem mass spectrometry (LC-MS-MS). The analyte was recovered from plasma by solid-phase extraction and subsequently analyzed by LC-MS-MS. A Packard Multiprobe II, an automated liquid handling system, was employed for the preparation and extraction of a 96-well plate containing unknown plasma samples, standards and quality control samples in an automated fashion. Prednisolone, a structurally related steroid, was used as an internal standard. Using the described approach, a limit of quantitation of 2 ng/ml was achieved with a 50 microl aliquot of rat plasma. The described level of sensitivity allowed the determination of betamethasone concentrations and subsequent measurement of kinetic parameters of betamethasone in rat. Combination of automated plasma extraction and the sensitivity and selectivity of LC-MS-MS offers a valuable alternative to the methodologies currently used for the quantitation of steroids in biological fluids.

T/NK cell non-Hodgkin's lymphoma of the sinonasal tract

Non-Hodgkin's lymphoma of the sinonasal tract is now recognized as an important cause of destructive midfacial lesions formally designated as idiopathic inflammatory processes, and commonly treated with local radiotherapy in a bid to halt the destructive process. However, left untreated, the natural history of this disease remains largely unknown. We report a case which demonstrates the slow and apparently indolent natural course that these lymphomas, if left untreated, may display, before finally evolving into overwhelming and fatal disease. We also take the opportunity to present a brief synopsis of the evolution of our understanding of this condition and to review the modern literature on it.

Nurse endoscopists in United Kingdom health care: a survey of prevalence, skills and attitudes

OBJECTIVES

To assess the prevalence and potential benefits of attitudes towards nurse endoscopy in the United Kingdom (UK).

DESIGN

Postal questionnaire.

SUBJECTS

All hospitals in the UK with accident and emergency, general medical and general surgical services in October 2000.

MAIN OUTCOME MEASURES

Number of teaching or district general hospitals employing nurse endoscopists, range of diagnostic and therapeutic endoscopic skills and potential benefits to the endoscopy unit and patients.

RESULTS

Seventy-six hospitals employed 102 nurse endoscopists. Forty-four nurse endoscopists performed both oesophago-gastroduodenoscopy (OGD) and flexible sigmoidoscopy with solitary OGD and flexible sigmoidoscopy performed by 17 and 31, respectively. Three performed full colonoscopy while seven could perform all three procedures. Nurse endoscopists were found to provide good patient care in the majority of endoscopy units with no compromise in safety. Lead clinicians were keen to restrict nurse endoscopy to diagnostic OGD and flexible sigmoidoscopy only in the majority of units.

CONCLUSIONS

Nurse endoscopy is widely practised in the UK and is not limited to one procedure or solely for diagnostic purposes. Benefits include good patient acceptability, improved care and safety. Most clinicians predict an important but restricted role for nurse endoscopy in contributing to endoscopic services.

Clinical features of newly presenting cases of chronic otitis media

The clinical features of 58 consecutive patients presenting with a new case of chronic otitis media were prospectively collected over a 15-month period. Twenty-three ears had a keratin filled marginal or attic defect (14 with cholesteatoma), 20 had a self-clearing marginal or attic defect, and 21 had a central tympanic membrane perforation (including one cholesteatoma). Twenty patients (35 per cent) had an abnormal finding in the opposite ear. The patients' ages were dispersed over a wide range of age groups with a mean age of 34 years. Hearing loss was the most common presenting symptom (78 per cent), followed by otorrhoea (64 per cent). A significant proportion of patients denied any history of otorrhoea. Our findings should alert the clinician to suspecting a new case of COM in patients with hearing loss of any age, with, or without, a history of otorrhoea, regardless of their background ear history or the duration of their symptoms.

The impact of indoor residual spraying with malathion on malaria in refugee camps in eastern Sudan

An exploratory trial of the efficacy of indoor spraying with malathion on morbidity and mortality in refugee camps in eastern Sudan was conducted during the rainy season of 1997. The interior walls of houses from a randomly selected group of five camps were sprayed with malathion in mid-September and morbidity and mortality rates in the camps for the months October to December compared with rates in five controls. Pyrethrum spray collection and human landing catches were performed in two collection rounds. An exophagic but endophilic population of Anopheles arabiensis was the most common mosquito collected. The mean human blood index of 242 mosquitoes from eight camps was 0.51. Only two of 1040 mosquitoes examined harboured sporozoites. Blood samples of 83 putative malaria patients were examined for parasites by PCR. Mortality rates in the 3 months following spraying were significantly lower in sprayed camps although differences in clinical malaria incidence between sprayed and non-sprayed camps were not significant.

Assessing the impact of national anti-HIV sexual health campaigns: trends in the transmission of HIV and other sexually transmitted infections in England

OBJECTIVE

To assess the impact of the sexual component of AIDS and HIV campaigns on transmission of HIV and other sexually transmitted infections (STIs).

DESIGN

Comparison of time series data.

SETTING

England, 1971-1999.

OUTCOME MEASURES

HIV transmission and diagnoses among men who have sex with men (MSMs), rates of attendances and specific STI diagnoses (per 100 000 total population) at genitourinary medicine (GUM) clinics.

RESULTS

Awareness of AIDS and campaigns in 1983-4 among homosexual men coincided with substantial declines in transmission of HIV and diagnoses of syphilis among MSMs. During general population campaigns in 1986-7 new GUM clinic attendances requiring treatment fell by 117/10(5) in men and 42/10(5) in women. Rates for gonorrhoea fell by 81/10(5) and 43/10(5) and genital herpes by 6/10(5) and 4/10(5), respectively. Previous rises in genital wart rates were interrupted, while rates of attendances not requiring treatment (the "worried well") increased by 47/10(5) and 58/10(5) for men and women, respectively. Since 1987 diagnoses of HIV among MSMs have not declined, averaging 1300-1400 annually. Following a period of unchanging rates there have been substantial increases in GUM attendances requiring treatment, notably for gonorrhoea, syphilis, and viral STIs since 1995.

CONCLUSIONS

Self help initiatives and awareness among homosexual men in 1983-4 contributed significantly to a fall in HIV transmission among MSMs, and the general campaigns of 1986-7 were associated with similar effects on all STI transmission. Both effects seem to have occurred through changing sexual behaviour, and probably contributed to the UK's low national HIV prevalence. Bacterial STI incidence has increased significantly since 1995 and there is no evidence that recent prevention initiatives have reduced HIV transmission among MSMs, hence sexual health initiatives need to be comprehensively reinvigorated in England.

Computational analysis of the autocatalytic posttranslational cyclization observed in histidine ammonia-lyase. A comparison with green fluorescent protein

Density functional calculations using hybrid functionals (B3LYP) have been performed to study the mechanism of the autocatalytic posttranslational cyclization observed in histidine ammonia-lyase. Two mechanisms were analyzed, the commonly accepted mechanism in which cyclization precedes dehydrogenation (reduced mechanism) and a mechanism in which dehydrogenation precedes cyclization (oxidized mechanism). The reduced pathway is not supported by the calculations, while the alternative oxidized mechanism where a dehydration occurs prior to the formation of the ring yields reasonable energetics for the system. Database searches showed that the oxidative mechanism in which the formation of the dehydro amino acids in residue i + 1 precedes the cyclization is also structurally advantageous as it results in shorter distances between the carbonyl carbon of residue i and the amide nitrogen of residue i + 2 and, therefore, preorganizes the protein for cyclization. Conformational searches showed that these distances were also unusually short and exhibited very little variation in the Delta-Ala143 HAL tetramer, indicating that like GFP the tetrameric form of HAL is rigidly preorganized for cyclization. The monomeric form of HAL is less preorganized than the tetrameric form of HAL. Dehydro amino acids aid in the preorganization, but the main driving force in the rigid tight turn formation is the influence of the surrounding protein.

Nuclear localization and shuttling of herpes simplex virus tegument protein VP13/14

The herpes simplex virus type 1 gene UL47 encodes the tegument proteins referred to collectively as VP13/14, which are believed to be differentially modified forms of the same protein. Here we show that the major product of the UL47 gene during transient expression is VP14, suggesting that some feature of virus infection is required to produce VP13. We have tagged VP13/14 with green fluorescent protein and have demonstrated that the protein is targeted efficiently to the nucleus, where it often localizes in numerous punctate domains. Furthermore, we show that removal of the N-terminal 127 residues of the protein abrogates nuclear accumulation, and we have identified a 14-amino-acid peptide from this region that is sufficient to function as a nuclear targeting signal and transport a heterologous protein to the nucleus. This short peptide contains two runs of four arginine residues, suggesting that the VP13/14 nuclear localization signal may behave in a manner similar to that of the arginine-rich nuclear localization signals of the retrovirus transactivator proteins Tat, Rev, and Rex. In addition, by using heterokaryon assays, we show that VP13/14 is capable of shuttling between the nucleus and cytoplasm of the cell, a property that may be attributed to three leucine-rich stretches in the C-terminal half of the protein that again bear similarity to the nuclear export signals of Rev and Rex. This is the first demonstration of a tegument protein that is specifically targeted to the nucleus, a feature which may be relevant both during virus entry, when VP13/14 enters the cell as a component of the tegument, and at later times, when large amounts of newly synthesized VP13/14 are present within the cell.

Fluorescent tagging of herpes simplex virus tegument protein VP13/14 in virus infection

The cellular site of herpesvirus tegument assembly has yet to be defined. We have previously used a recombinant herpes simplex virus type 1 expressing a green fluorescent protein (GFP)-tagged tegument protein, namely VP22, to show that VP22 is localized exclusively to the cytoplasm during infection. Here we have constructed a similar virus expressing another fluorescent tegument protein, YFP-VP13/14, and have visualized the intracellular localization of this second tegument protein in live infected cells. In contrast to VP22, VP13/14 is targeted predominantly to the nuclei of infected cells at both early and late times in infection. More specifically, YFP-13/14 localizes initially to the nuclear replication compartments and then progresses into intense punctate domains that appear at around 12 h postinfection. At even later times this intranuclear punctate fluorescence is gradually replaced by perinuclear micropunctate and membranous fluorescence. While the vast majority of YFP-13/14 seems to be targeted to the nucleus, a minor subpopulation also appears in a vesicular pattern in the cytoplasm that closely resembles the pattern previously observed for GFP-22. Moreover, at late times weak fluorescence appears at the cell periphery and in extracellular virus particles, confirming that YFP-13/14 is assembled into virions. This predominantly nuclear targeting of YFP-13/14 together with the cytoplasmic targeting of VP22 may imply that there are multiple sites of tegument protein incorporation along the virus maturation pathway. Thus, our YFP-13/14-expressing virus has revealed the complexity of the intracellular targeting of VP13/14 and provides a novel insight into the mechanism of tegument, and hence virus, assembly.