Patients' problems with new medication for chronic conditions

OBJECTIVES

To assess patients' adherence to new medication for a chronic condition (and whether non-adherence was intentional), patients' problems with their medication, and their further information needs.

METHODS

A longitudinal survey with data collection at 10 days and 4 weeks was performed on 258 patients recruited from 23 community pharmacies in south east England. Patients were eligible to participate if they were starting a new chronic medication and were either 75 years or older or had one of the following chronic conditions: stroke, coronary heart disease, asthma, diabetes, and rheumatoid arthritis. At each time point a semi-structured telephone interview was conducted and a postal questionnaire was sent.

MAIN OUTCOME MEASURES

Self-reported adherence, causes of non-adherence, problems with medication, information needs.

RESULTS

Sixty seven (30%) of 226 patients still taking their medication at 10 days and 43 of 171 (25%) still taking their medication at 4 weeks were non-adherent. At 10 days 55% of the non-adherence was unintentional and the remainder was intentional; these proportions were similar at 4 weeks. 138 of 208 (66%) participants still taking their new medication at 10 days reported at least one problem with it. 137 of 226 patients (61%) expressed a substantial and sustained need for further information at 10 days and 88 of 171 (51%) at 4 weeks. Several patients who were adherent or reported no problems at 10 days were non-adherent or had problems at 4 weeks.

CONCLUSIONS

A significant proportion of patients newly started on a chronic medication quickly become non-adherent, often intentionally so. Many have problems with their medication and information needs. Patients need more support when starting on new medication for a chronic condition and new services may be required to provide this.

Patients' problems with new medication for chronic conditions

OBJECTIVES

To assess patients' adherence to new medication for a chronic condition (and whether non-adherence was intentional), patients' problems with their medication, and their further information needs.

METHODS

A longitudinal survey with data collection at 10 days and 4 weeks was performed on 258 patients recruited from 23 community pharmacies in south east England. Patients were eligible to participate if they were starting a new chronic medication and were either 75 years or older or had one of the following chronic conditions: stroke, coronary heart disease, asthma, diabetes, and rheumatoid arthritis. At each time point a semi-structured telephone interview was conducted and a postal questionnaire was sent.

MAIN OUTCOME MEASURES

Self-reported adherence, causes of non-adherence, problems with medication, information needs.

RESULTS

Sixty seven (30%) of 226 patients still taking their medication at 10 days and 43 of 171 (25%) still taking their medication at 4 weeks were non-adherent. At 10 days 55% of the non-adherence was unintentional and the remainder was intentional; these proportions were similar at 4 weeks. 138 of 208 (66%) participants still taking their new medication at 10 days reported at least one problem with it. 137 of 226 patients (61%) expressed a substantial and sustained need for further information at 10 days and 88 of 171 (51%) at 4 weeks. Several patients who were adherent or reported no problems at 10 days were non-adherent or had problems at 4 weeks.

CONCLUSIONS

A significant proportion of patients newly started on a chronic medication quickly become non-adherent, often intentionally so. Many have problems with their medication and information needs. Patients need more support when starting on new medication for a chronic condition and new services may be required to provide this.

British HIV Association (BHIVA)/British Association for Sexual Health and HIV (BASHH) guidelines on provision of adherence support to individuals receiving antiretroviral therapy (2003)

The widespread use of highly active antiretroviral therapy (HAART) has dramatically reduced HIV-associated morbidity and mortality where treatment has been made available. Very high levels of adherence to HAART are a prerequisite for a successful virological and immunological response. Low adherence increases the risk of treatment failure and disease progression. It is also likely to lead to further transmission of resistant viruses, and to have a negative impact on the cost effectiveness of HAART. Low adherence is difficult to predict, and this has two key implications for service provision. Firstly, HAART should not be withheld on the basis of assumptions about adherence. Secondly, support with adherence should be provided to all patients prescribed HAART. Our understanding of barriers to and enablers of high adherence, and the evidence base regarding effective interventions, is limited. Meta-analysis of randomized controlled trials available from the general literature suggests multiple interventions are required to maintain high adherence to chronic therapy. This document recommends a series of measures for adoption within HIV clinical care settings, based on evaluation of existing data. High adherence is a process, not a single event, and therefore adherence support must be integrated into clinical follow up. Every prescribing unit should have a written policy on provision of adherence support, and ensure that staff are appropriately trained to make delivery of such services possible.

Factors associated with cardiac rehabilitation attendance: a systematic review of the literature

BACKGROUND

Many eligible patients fail to attend cardiac rehabilitation courses.

OBJECTIVE

To undertake a systematic literature review of studies that have investigated factors associated with cardiac rehabilitation attendance.

METHODS

Literature published between 1978 and 2001 was searched using the MEDLINE, PSYCINFO and CINAHL computerized databases. Studies were sought that examined course attendance in eligible patient samples. Studies had to include at least one baseline predictor variable.

RESULTS

Fifteen studies were identified and predictor variables were usually categorized as sociodemographic, medical and psychological. Nonattenders are more likely to be older, to have lower income/greater deprivation, to deny the severity of their illness; they are less likely to believe they can influence its outcome or to perceive that their physician recommends cardiac rehabilitation. Job status, gender and health concerns play an indirect role in attendance behaviour. Comparison of results between studies could be influenced by different case-mix, measurement instruments and country of origin.

CONCLUSION

A number of factors predict cardiac rehabilitation attendance and some of these are potentially modifiable.

Perceptions of HAART among gay men who declined a treatment offer: preliminary results from an interview-based study

As part of a prospective study of treatment decision making among people with HIV infection, we explored perceptions of HAART in a cohort who declined a treatment offer. This was a qualitative study in which 26 gay men were interviewed in relation to their views about HAART soon after treatment was recommended by their HIV physician. Fifteen themes were associated with the decision to decline HAART. These were grouped under three broad categories: doubts about personal necessity for HAART, concerns about potential adverse effects of taking HAART and satisfaction with the amount of personal control over the decision. These findings provide new insights into the type of beliefs that might inform people's evaluation of their perceived need for HAART and their concerns about HAART. Initiatives to support informed decisions should take account of these perceptions.

Reasons for non-adherence to antiretroviral therapy: patients' perspectives provide evidence of multiple causes

The objective of the study was to define common reasons for non-adherence (NA) to highly active antiretroviral therapy (HAART) and the number of reasons reported by non-adherent individuals. A confidential questionnaire was administered to HIV-seropositive patients taking proteinase inhibitor based HAART. Median self-reported adherence was 95% (n = 178, range = 60-100%). The most frequent reasons for at least 'sometimes' missing a dose were eating a meal at the wrong time (38.2%), oversleeping (36.3%), forgetting (35.0%) and being in a social situation (30.5%). The mean number of reasons occurring at least 'sometimes' was 3.2; 20% of patients gave six or more reasons; those reporting the lowest adherence reported a significantly greater numbers of reasons (rho = - 0.59; p < 0.001). Three factors were derived from the data by principal component analysis reflecting 'negative experiences of HAART', 'having a low priority for taking medication' and 'unintentionally missing doses', accounting for 53.8% of the variance. On multivariate analysis only the latter two factors were significantly related to NA (odds ratios 0.845 and 0.849, respectively). There was a wide spectrum of reasons for NA in our population. The number of reasons in an individual increased as adherence became less. A variety of modalities individualized for each patient are required to support patients with the lowest adherence.

The design and evaluation of a simulated-patient teaching programme to develop the consultation skills of undergraduate pharmacy students

OBJECTIVES

This study aimed to identify the key skills and knowledge required for the delivery of an ideal patient consultation in order to develop a training programme (using simulated-patients) to teach consultation skills to undergraduate pharmacy students.

METHODS

Participants included all third year undergraduate Pharmacy students (MPharm, level III) at the School of Pharmacy & Biomolecular Sciences, University of Brighton (from October 1999 to March 2000). Working in groups of 12, students participated in two 4 hour seminars. A structured questionnaire was designed to assess students' perceptions of the difficulty of conducting a consultation and their confidence in delivering a structured consultation.

MAIN OUTCOME MEASURES

Questionnaires were administered before and after delivery of the teaching programme to assess changes in students' confidence and ability to consult with patients.

RESULTS

Twelve volunteers satisfied the criteria set to serve as simulated patients and then received appropriate training. Six scenarios were developed which focused on the key skills and knowledge identified from the adherence and consultation skills literature. A total of 91 students participated in the programme (mean age = 23 years, SD = 4.5). Following participation in the programme students' perceived 'confidence' for conducting an effective consultation significantly increased (t = -5.9, p < 0.01) while a statistically significant decrease was seen in students' perceived level of 'difficulty' when conducting a consultation (t = 4.0, p < 0.01).

CONCLUSION

This study has shown that the use of a structured teaching programme improves students' perceptions of their ability and confidence in conducting an effective consultation. Providing skills training around the consultation process, using simulated patients, provides pharmacists with a good framework around which to practice pharmaceutical care.

The Satisfaction with Information about Medicines Scale (SIMS): a new measurement tool for audit and research

OBJECTIVE

To develop and examine the psychometric properties of the Satisfaction with Information about Medicines Scale (SIMS), a new 17-item tool designed to assess the extent to which patients feel they have received enough information about prescribed medicines.

METHODS

Patients from eight diagnostic categories were recruited at hospitals in London and Brighton and completed the SIMS questionnaire during hospital admission or attendance at outpatient clinic appointments. The SIMS was evaluated in terms of its ease of use, internal consistency, test-retest reliability, and criterion related validity using existing self-report measures of adherence and patient beliefs about medicines.

RESULTS

The SIMS was well accepted by patients in a variety of clinical settings and showed satisfactory internal consistency and test-retest reliability. As predicted, higher levels of satisfaction with medicines information were associated with higher levels of reported adherence, and lower levels of satisfaction were associated with stronger concerns about the potential adverse effects of medicines, providing evidence of criterion related validity.

CONCLUSION

The SIMS performed well on a number of psychometric indicators and shows promise as a tool for audit (measuring patients' satisfaction with information about their prescribed medicines), research (evaluating current or new forms of information provision), and clinical practice (identifying the information needs of individual patients and as an aid to planning medicine related consultations).

Living with Marfan syndrome II. Medication adherence and physical activity modification

We investigated the perceptions of and adherence to medication and physical activity guidelines in 174 adults with Marfan syndrome. Over 80% of those prescribed beta- and Ca2+-channel blockade reportedly adhere well to their medication regimen. The presence of cardiovascular symptoms and fatigue were positively correlated with the medication use. Medication-takers reported that they are psychologically receptive to the use of medication for prophylactic treatment of their cardiovascular problems. However, all do not view their medication as essential for their health. Duration of the medication regimen, type of medication, and perception of controllability of the condition were each independently associated with respondents' perceptions of the necessity of taking beta- or Ca2+-channel blockers. Over 80% of the respondents reported that they choose their physical activities with their diagnosis in mind. Modifying exercise activities was significantly correlated with an increased perception of Marfan syndrome as having negative consequences on the respondents' lives. Genetic counseling should address beliefs about medication use and physical activity restrictions, as perceptions of these health behaviors may have significant impact on how adults with Marfan syndrome adhere to these recommendations and cope with their condition.

Living with Marfan syndrome I. Perceptions of the condition

We present data from an exploratory study of 174 adults with Marfan syndrome regarding their cognitive perceptions of the condition as postulated by the self-regulatory model (Leventhal H, Benyamini Y, Brownlee S et al. In: Petrie KI, Weinman JA, eds. Perceptions of Health and Illness: Current Research and Applications. Amsterdam, The Netherlands: Harwood Academic, 1997: 19-45; Leventhal H, Nerenz DR, Steele DJ. In: Baum A, Taylor SE, Singer JE, eds. Handbook of Psychology and Health. Hillsdale, NJ: Lawrence Erlbaum Associates, 1984: 219-252). The vast majority of the respondents had adequate general knowledge about Marfan syndrome. Eighty-three percent of the respondents perceived Marfan syndrome as having had significant adverse consequences on their lives. Having striae, pain (sore joints), and depression were each independently correlated with this view. Fifty-eight percent of the respondents indicated that they felt they had low to moderate control over their condition, demonstrating variability. History of aortic dissection, pain (sore joints), and depressive symptoms were each negatively correlated with the view that Marfan syndrome is a curable/controllable condition. Moreover, approximately 28% view the condition as a lethal condition, whereas 67% view it as a serious condition. Forty-four percent of the cohort were found to have significant symptomatology of depression independent of beta- and Ca2+-channel blockade use. Respondents cited both advantages and disadvantages of being affected. Genetic counseling that addresses patients' perceptions of Marfan syndrome, and its associated pain, fatigue, and depressive symptoms, may enhance patient adaptation to the condition.

The Satisfaction with Information about Medicines Scale (SIMS): a new measurement tool for audit and research

OBJECTIVE

To develop and examine the psychometric properties of the Satisfaction with Information about Medicines Scale (SIMS), a new 17-item tool designed to assess the extent to which patients feel they have received enough information about prescribed medicines.

METHODS

Patients from eight diagnostic categories were recruited at hospitals in London and Brighton and completed the SIMS questionnaire during hospital admission or attendance at outpatient clinic appointments. The SIMS was evaluated in terms of its ease of use, internal consistency, test-retest reliability, and criterion related validity using existing self-report measures of adherence and patient beliefs about medicines.

RESULTS

The SIMS was well accepted by patients in a variety of clinical settings and showed satisfactory internal consistency and test-retest reliability. As predicted, higher levels of satisfaction with medicines information were associated with higher levels of reported adherence, and lower levels of satisfaction were associated with stronger concerns about the potential adverse effects of medicines, providing evidence of criterion related validity.

CONCLUSION

The SIMS performed well on a number of psychometric indicators and shows promise as a tool for audit (measuring patients' satisfaction with information about their prescribed medicines), research (evaluating current or new forms of information provision), and clinical practice (identifying the information needs of individual patients and as an aid to planning medicine related consultations).

Shared care: a qualitative study of GPs' and hospital doctors' views on prescribing specialist medicines

BACKGROUND

Shared care schemes have mainly centred on chronic diseases, such as asthma and diabetes. However, with increasing government emphasis on primary and secondary care integration and the effects of budget restraints, general practitioners (GPs) have been asked to take on the prescribing of specialist medicines.

AIM

To elicit the views and experiences of GPs and hospital doctors about existing arrangements for shared care applied to the prescribing of specialist medicines. To identify a set of quality indicators for prescribing specialist medicines at the interface between primary and secondary care.

DESIGN OF STUDY

A qualitative study based on semi-structured interviews.

SETTING

Forty-eight GPs and 13 hospital doctors in the former South Thames region.

METHOD

The interviews focused on how far experiences with shared care compare with the arrangements currently in place for prescribing specialist medicines and identified the barriers to facilitators of effective shared care.

RESULTS

A number of key themes were identified and these formed the basis for eight quality indicators relating to the prescribing of specialist medicines where treatment is shared between primary and secondary care. The themes centred around issues of clinical responsibility, 'cost-shifting', availability of medicines, GP satisfaction, and the nature of the prescribing relationship.

CONCLUSION

Overall, GPs appeared dissatisfied with arrangements for prescribing specialist medicines, while hospital doctors were generally satisfied. The quality indicators will form the basis of a more extensive quantitative survey of GPs' perceptions of the arrangements for prescribing specialist medicines.

The influence of health beliefs on the presentation and consultation outcome in patients with chemical sensitivities

OBJECTIVE

This study was carried out to investigate the impact of the physical effects of a chemical exposure, health and chemical beliefs, and chemical sensitivities treatment preferences on the consultation outcome at a tertiary liaison clinic.

METHOD

Eighty-five patients exposed to a range of chemicals were assessed at a joint medical toxicology and psychiatric clinic. Patient's beliefs about chemicals and health, chemical sensitivities and their treatment preferences were assessed using a 23-item questionnaire.

RESULTS

Fifty-seven patients (69%) had suffered from a range of initial or delayed symptoms that were probably a clear physical consequence of the exposure (Group A), whereas 26 patients (31%) had not (Group B). There were no significant differences found between groups A and B in terms of their diagnosis and their beliefs about health, food, chemicals and chemical sensitivities treatment preferences. However, patients in Group A were significantly more likely to report moderate to severe symptoms in comparison to Group B. Consultation outcome too did not differ between the two groups. The only predictors of consultation outcome were the patients' chemical sensitivities treatment preferences. Patients who at the outset thought that their treatment should comprise of complete avoidance to chemicals, regular monitoring and the use of alternative rather than conventional medicine were significantly less likely to achieve a favourable consultation outcome. Patients' chemical sensitivities treatment preferences were related to the more general beliefs on health, food and the harmful nature of chemicals and were not related to the chemical exposure variables.

CONCLUSION

These findings suggest that addressing patients' treatment preferences and the general beliefs on chemicals, food and health may enhance outcome and perhaps ought to be the target for intervention in context of such a liaison clinic.

Treatment-related empowerment: preliminary evaluation of a new measure in patients with advanced HIV disease

This paper presents a novel method for assessing patients' perceptions of empowerment in the context of drug therapy, the Treatment-related Empowerment Scale (TES). The 10-item TES was specifically constructed to address components of communication, treatment choice, decision-making and satisfaction. Evaluation of the scale in a cross-sectional anonymous survey of 43 patients with advanced HIV infection revealed acceptable internal reliability (Cronbach's alpha=0.85) and evidence of both criterion and discriminant validity. Patients who perceived a high degree of treatment-related empowerment were less likely to view doctors as overly reliant on prescribing medicines and reported lower rates of intentional noncompliance. The TES has scope as a concise measure of patients' degree of control over the selection and use of drug therapy, and may be of particular value for current combination therapy regimens.

Patients' interpretation of symptoms as a cause of delay in reaching hospital during acute myocardial infarction

OBJECTIVE

To examine whether the association between expected symptoms of acute myocardial infarction and actual symptoms predicted delay in reaching hospital and help seeking behaviour.

DESIGN

During hospital convalescence, participants completed a structured interview designed to measure symptom experience and help seeking behaviour following the onset of symptoms of acute myocardial infarction.

PATIENTS

88 patients admitted to hospital with their first myocardial infarction

MAIN OUTCOME MEASURES

Delay in reaching hospital from onset of worst symptoms, obtained from ambulance and hospital records.

RESULTS

The most common symptoms expected by patients with myocardial infarction were central chest pain (76%), radiating arm or shoulder pain (34%), and collapse (26%). The most common symptoms experienced were sweats or feeling feverish (78%), chest pain (64%), and arm, shoulder, or radiating pain (66%). A mismatch between symptoms experienced and those expected occurred in 58% of patients, and was associated with delay. Patients who experienced a mismatch between expectation and actual symptoms also were more likely to have a third party decide to call for help.

CONCLUSIONS

The experience and interpretation of symptoms is an important source of delay and help seeking following onset of myocardial infarction symptoms.

Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness

The aim of this cross-sectional study was to quantify patients' personal beliefs about the necessity of their prescribed medication and their concerns about taking it and to assess relations between beliefs and reported adherence among 324 patients from four chronic illness groups (asthma, renal, cardiac, and oncology). The findings revealed considerable variation in reported adherence and beliefs about medicines within and between illness groups. Most patients (89%) believed that their prescribed medication was necessary for maintaining health. However, over a third had strong concerns about their medication based on beliefs about the dangers of dependence or long-term effects. Beliefs about medicines were related to reported adherence: higher necessity scores correlated with higher reported adherence (r=0.21, n=324, p<0.01) and higher concerns correlated with lower reported adherence (r=0.33, n=324, p<0.01). For 17% of the total sample, concerns scores exceeded necessity scores and these patients reported significantly lower adherence rates (t=-4.28, p<0.001). Stepwise multiple linear regression analysis showed that higher reported adherence rates were associated with higher necessity-concerns difference scores (beta=0.35, p<0.001), a diagnosis of asthma (beta= -0.31, p<0.001), a diagnosis of heart disease (beta=0.19, p<0.001), and age (beta=0.22, p<0.001). Gender, educational experience, or the number of prescribed medicines did not predict reported adherence. Medication beliefs were more powerful predictors of reported adherence than the clinical and sociodemographic factors, accounting for 19% of the explained variance in adherence. These data were consistent with the hypothesis that many patients engage in an implicit cost-benefit analysis in which beliefs about the necessity of their medication are weighed against concerns about the potential adverse effects of taking it and that these beliefs are related to medication adherence.

Coccygeal muscle injury in English Pointers (limber tail)

A condition colloquially referred to as "limber tail" and "cold tail" is familiar to people working with hunting dogs, primarily Pointers and Labrador Retrievers. The typical case consists of an adult dog that suddenly develops a flaccid tail. The tail either hangs down from the tail base or is held out horizontally for several inches from the tail base and then hangs straight down or at some degree below horizontal. Initially, the hair on the dorsal aspect of the proximal tail may be raised and dogs may resent palpation of the area 3-4 inches (8-10 cm) from the tail base. Most dogs recover spontaneously within a few days to weeks. Anecdotal reports suggest that anti-inflammatory drugs administered within 24 hours after onset hasten recovery. Less than one half of affected dogs experience a recurrence. Affected Pointers almost always have a history of prolonged cage transport, a hard workout the previous day, or exposure to cold or wet weather Most owners and trainers familiar with the condition do not seek veterinary assistance. In cases where people are not familiar with this disease, other conditions such as a fracture, spinal cord disease, impacted anal glands, or prostatic disease have been incorrectly diagnosed. We examined 4 affected Pointers and found evidence of coccygeal muscle damage, which included mild elevation of creatine kinase early after onset of clinical signs, needle electromyographic examination showing abnormal spontaneous discharges restricted to the coccygeal muscles several days after onset, and histopathologic evidence of muscle fiber damage. Specific muscle groups, namely the laterally positioned intertransversarius ventralis caudalis muscles, were affected most severely. Abnormal findings on thermography and scintigraphy further supported the diagnosis.

Compliance in asthma

Low rates of compliance with medication pose a major challenge to the effective management of most chronic diseases, including asthma. The high medical and social costs of non-compliance, and the apparent lack of effective methods for dealing with it, has stimulated renewed interest in this complex issue. Two broad categories of non-compliance have been identified, namely unintentional (or 'accidental') and intentional (or 'deliberate'). Unintentional non-compliance may result from poor doctor-patient communication or a lack of ability to follow advice. Intentional non-compliance occurs when the patient knows what is required but decides not to follow this to some degree. Healthcare professionals need to be aware of the various issues affecting compliance in all patients. The reasons for non-compliance are many and varied, and include factors such as complexity of the treatment regimen, administration route, patient beliefs about therapy and other psychological factors. Improvement in patient compliance with therapy will require better doctor-patient communication, improved patient education, the tailoring of therapy to the individual and possible novel strategies such as offering feedback to the patients on their level of compliance.

Barriers to optimum management of heart failure by general practitioners

BACKGROUND

Published research offers clear pointers to the management of heart failure; however, the evidence for implementation into practice is sub-optimal.

AIM

To identify the salient barriers to adopting evidence-based management of heart failure in the community.

METHOD

Structured interviews were used to elicit the views of a stratified sample of 100 general practitioners (GPs) about the diagnosis and treatment of heart failure. Responses to three heart failure case scenarios provided an indication of the degree to which GPs' knowledge of heart failure and trial results might be applied to diagnosis and treatment intentions.

RESULTS

Participants were generally well aware of clinical trials that showed that prognosis could be improved by treatment, but trial results appeared to have little influence on treatment intentions in the three case scenarios. The major barriers to optimum management were the difficulties of differential diagnosis and the perceived properties of angiotensin-converting enzyme inhibitors (ACE-I) relative to diuretics. In the case scenarios, less than 30% reported that they would undertake basic investigations, such as chest X-ray or haemoglobin, or prescribe ACE-I. Over 70% perceived diuretics to be a useful diagnostic tool. The most frequent reasons for not prescribing ACE-I were the perceived inconvenience and risks of adverse effects (41%) and the view that most patients can be managed successfully on diuretics alone (27%). Over two-thirds of the sample were dissatisfied with the quality of information accompanying heart failure patients discharged from hospital.

CONCLUSION

Facilitating evidence-based management of heart failure in the community requires further support for GPs in the form of additional training in the diagnosis of heart failure and the optimum use of both ACE-I and diuretics, and by improved communication between GPs and hospital doctors on a case-by-case basis.

Ultrastructural evidence of intestinal mucosal macrophage activation after bone marrow transplantation

Previous studies have demonstrated upregulation of intestinal mucosal macrophage CD16 (an Fc receptor for IgG) in bone marrow transplant (BMT) recipients with graft-versus-host disease (GVHD). We sought to determine whether there was ultrastructural evidence of mucosal macrophage activation in allogeneic BMT recipients and relate appearances to those seen in autologous BMT patients and to immunohistological findings. Sigmoid colonic mucosal biopsies from five allogeneic and three autologous BMT patients were taken prior to, 30 days after transplant and, in three of the allogeneic patients, 120 days after transplant. These were examined by immunohistochemistry and electron microscopy. Immunohistological analysis revealed upregulation of lamina propria macrophage CD16 after transplant in all patients except one autologous BMT recipient; there were no such changes in total macrophage numbers. Ultrastructural evidence of lamina propria macrophage activation was prominent after both allogeneic and autologous BMT. There was an increase in nuclear size accompanied by increased euchromatin and larger nucleoli. In the cytoplasm there were increased numbers of lysosomes, many of which were small and cylindrical, and cytoplasmic flaps were prominent. Phagosomes were less numerous after transplant. These data confirm that after BMT intestinal mucosal macrophages become activated. However changes in macrophage ultrastructure specific to patients at risk of developing clinical GVHD are lacking.

Aspiration of oocytes for in-vitro fertilization

An aspiration system, incorporating a regulated vacuum pump, was used to examine, in vitro, some factors that may affect oocyte collection. In an open aspiration system, as the length of the needle was increased, or the internal diameter decreased, the velocity (and flow rate) of aspirated fluid decreased. There was a difference, however, between experimental flows and those predicted by Hagen-Poiseuille's Law. Upon application of vacuum to a closed aspiration system, employing isolated bovine ovaries, there was an initial rapid increase in the collection tube vacuum to 85% of the selected pump vacuum followed by a more gradual rise to 100%. The vacuum within the needle similarly rose rapidly to approximately half the selected vacuum, while the vacuum at the needle tip was approximately 5% of selected vacuum. The vacuums throughout the system briefly equilibrated as maximum flow/velocity was reached. Flow/velocity slowed dramatically as the follicle collapsed, and stopped as the needle tip was blocked. If vacuum was maintained during the withdrawal of the needle from the follicle, there was a dramatic forward flow of fluid toward the collection tube. The morphological appearance of bovine cumulus after in-vitro aspiration was generally unaltered by vacuums commonly utilized in oocyte collection, providing the cumulus was regular, compact and refractile. The cumulus was less resistant to aspiration if it was damaged or had degenerated. These results suggest that an intact cumulus may offer protection during oocyte collection.

Doctors, pharmacists and the prescribing process

Although there is evidence that collaboration between doctors and pharmacists results in the more cost-effective use of medicines, the input of pharmacists into the prescribing process remains informal and largely retrospective. This article discusses the current problems associated with the prescribing process and suggests a framework to formalise the input of pharmacists.

Interpenetrating polymer network (IPN) as a permanent joint between the elements of a new type of artificial cornea

The combination at the interface between two chemically identical polymers was investigated by light and electron (scanning, transmission) microscopy. The polymers constitute elements of a new type of artificial cornea in which the peripheral skirt is made from spongy poly(2-hydroxyethyl methacrylate) (PHEMA) and the central optical zone from homogeneous, transparent PHEMA. Their two-phase combination along the boundary fulfill formally the requirements for an interpenetrating polymer network (IPN). The procedure for the manufacture of prosthesis was described in detail. Thin and ultrathin sections excised from the interface region were investigated using microscopic techniques. Light microscopy allowed the measurement of the diffusion path length of transparent PHEMA into sponge, which was approximately 0.5 mm. Transmission electron microscopy revealed a cellular-like morphology as well as larger segregated zones, which indicated network interpenetration on a molecular level and also a relatively poor miscibility of the two polymers despite their identical chemical structure. The latter was interpreted as a result of the submicroscopic restraints imposed by polymer I (sponge) upon polymer II. This study provides evidence that the interface combination of the prosthetic elements should be regarded as a gradient homo-IPN. This system offers a union between elements much stronger than those previously reported in artificial corneas.

Purification and characterization of the urease enzymes of Helicobacter species from humans and animals

The urease enzymes of Helicobacter pylori, H. mustelae, H. felis, and H. nemestrinae have been purified to homogeneity by affinity chromatography and characterized. The native urease enzymes of the four organisms were found to be almost identical, with a pI of 6.1 and molecular masses of 480 to 500 kDa, as determined by electrophoretic mobility in nondenaturing polyacrylamide gels. Transmission electron microscopy of the native urease showed it to be a molecule approximately 13 nm in diameter, with hexagonal symmetry. Denaturation studies indicated that each urease enzyme molecule was composed of two nonidentical subunits with molecular masses of approximately 64 and 30 kDa. The subunits were present in a 1:1 ratio, suggesting a hexameric stoichiometry for the native molecule. The predicted molecular mass of H. pylori urease, based on subunit molecular weight and stoichiometry, is 568 kDa. N-terminal amino acid sequencing of the enzyme subunits from the four species revealed high levels of homology. The large subunits (UreB) were found to be 92 to 100% homologous, and the small subunits (UreA) were 75 to 95% homologous over the first 12 to 20 residues. The high degree of homology suggests a common ancestral origin and an important role for the urease enzymes of these organisms.

Respiratory chain defect of myocardial mitochondria in idiopathic dilated cardiomyopathy of Doberman pinscher dogs

Idiopathic dilated cardiomyopathy (IDCM) is a primary myocardial disease of unknown cause. We tested the hypothesis that IDCM was associated with a myocardial metabolic defect by determining a comprehensive biochemical profile of metabolite concentrations and enzyme activities for the major metabolic pathways of the myocardium. We used the Doberman pinscher breed as a naturally occurring canine model of IDCM and compared its myocardial profile with that of healthy adult mongrels. Compared with controls, myocardium in IDCM had markedly reduced mitochondrial electron transport activity and myoglobin concentration, in association with acidosis and energy depletion following anoxic challenge: 60% decreased NADH dehydrogenase and 50% decreased ATP synthetase activities; 90% decreased myoglobin concentration; and 30% reduced ATP and 50% increased lactate and proton concentrations. Sarcoplasmic reticulum Ca(2+)-transport ATPase was decreased by 42%. There was a 15% compensatory increase in fatty acid oxidation and Krebs cycle activity. Other biochemical changes were mild by comparison with the mitochondrial defects. We conclude that IDCM is associated with a marked impairment of mitochondrial production of ATP, arising from decreased activity of the mitochondrial electron transport system, including myoglobin. These changes may be secondary to an underlying genetic defect or may indicate a deficiency of the mitochondrial respiratory chain that predisposes this breed to heart failure.

Phasic respiratory activity in the fetal lamb during late gestation and labour

We quantified the respiratory activity of 9 fetal lambs using computer-analysis of the diaphragmatic electromyogram (EMG) obtained during 2 h recording sessions interspersed over the last 13 days of gestation. The fetuses delivered unassisted at an average gestational age of 145 days (term = 147 days). During the last 2 h of labour the number of phasic EMG bursts (breaths) averaged 3% of the peak recorded earlier in the study. This decline in breathing began at least 2 days before labour and resulted predominantly from the fetus spending an increasing proportion of time in apnoea. Respiratory rate within epochs of breathing also fell significantly 1 day before labour, and the proportion of time spent in the low voltage electrocortical state declined once labour commenced. No significant change occurred in arterial PO2, PCO2 or pH over the study period. We conclude that fetal respiratory activity falls well before the onset of labour, largely as a result of increased apnoea, and that the decline does not result from the development of a progressive hypoxaemia associated with labour.

Follicular dendritic cells and virus-like particles in AIDS-related lymphadenopathy

Follicular labyrinthine foci, consisting of an association of retrovirus-like particles with expanded dendritic reticular ("antigen trapping") cells, are described in lymph nodes from four immunodeficient homosexual men with unexplained persistent lymphadenopathy. One patient has severe acquired immunodeficiency syndrome (AIDS) with complicating Pneumocystis carinii infection, and the others have AIDS-related lymphadenopathy syndrome. The findings support a role for routine electron microscopy as an aid to diagnostic evaluation of nodal tissue from patients with suspected AIDS. Viral non-lymphoid-cell tropism may be a significant factor in the pathogenesis of the disease.

Fetal oxygen consumption, umbilical circulation and electrocortical activity transitions in fetal lambs

Chronically instrumented fetal lambs were employed to test the hypothesis that the high voltage electrocortical activity phase is a state of low fetal oxygen consumption compared with the low voltage electrocortical activity phase. Measurements of umbilical flow (electromagnetic flowmeter) together with oxygen saturations and haemoglobin concentration of umbilical venous and arterial blood were used to calculate oxygen consumption. Significant depression of umbilical flow occurred at the transition from low voltage electrocortical activity to high voltage electrocortical activity; the maximum change averaged 14% 2 min after the onset of the high voltage phase. Significant depressions of oxygen saturation in umbilical venous and arterial blood were found within 5 min of the onset of high voltage electrocortical activity, averaging 2.2% and 5.2% respectively. No depression of oxygen consumption was found during these transient changes in early high voltage electrocortical activity, as the venous-arterial oxygen content difference widened significantly as a consequence of a greater fall in umbilical arterial oxygen content (0.7 ml/dl) than in umbilical venous oxygen content (0.3 ml/dl). Overall, we detected no significant depression of oxygen consumption in high voltage electrocortical activity. However a small but significant depression of oxygen consumption (6%) was found late in the high voltage electrocortical activity phase when the level of oxygen consumption in low voltage electrocortical activity was greater than 7 ml/min per kg. We conclude that the high voltage electrocortical activity in fetal lambs is not associated with a marked depression of oxygen consumption, despite significant transient depressions of umbilical flow and oxygen levels in umbilical venous and arterial blood.(ABSTRACT TRUNCATED AT 250 WORDS)

Regeneration of retinal limiting membranes after chorioretinal biopsy in dogs

After chorioretinal biopsy in dogs, obtained without vitreous loss, accessory glial cells and fibroblasts filled the defect between cortical vitreous and bare sclera. The proliferating glial cells laid down a new basement membrane which was complete both on the internal and external aspects of the defect. After biopsy complicated by vitreous loss, however, cellular proliferation failed to re-establish complete internal and external limiting membranes, and new formed fibroblastic tissue extended into the vitreous. To our knowledge, this is the first report to describe effective regeneration of the internal limiting membrane of the retina in any species. These findings suggest that when vitreous loss can be avoided, healed chorioretinal biopsies are unlikely to lead to delayed pathological complications.

Human chorioretinal biopsy under controlled systemic hypotensive anaesthesia

This paper describes a simplified technique for biopsy of the retina and choroid which had been used in 5 human volunteers. The biopsy was carried out in 4 immediately before enucleation of an eye for malignant melanoma and in 1 patient who was undergoing trabeculectomy for painful glaucoma associated with retinitis pigmentosa. A combination of intravenous mannitol and transient controlled systemic hypotension, induced under general anaesthesia with intravenous sodium nitroprusside, was used in 3 cases and resulted in no vitreous loss and minimal bleeding. In the 2 cases in which hypotension was not used bleeding was a definite problem, but no vitreous loss was experienced.

Chorioretinal biopsy in dogs

A simplified practical technique for biopsy of retina and choroid has been developed in dogs. A 270 degree circular scleral flap of 3 mm diameter is raised. The risks of chorioretinal bleeding and vitreous loss are greatly reduced by intravenous mannitol and controlled hyperventilation, with hyperoxygenation and transient, systemic hypotension under general anesthesia. Rreasonable ultrastructural detail was preserved in chorioretinal specimens of 1 mm diameter. Repeat biopsies in the same eye are feasible without significant complications.