A systematic review of the experiences and perceptions of the newly qualified nurse in the United Kingdom

AIM

A systematic literature review of the experiences and perceptions of newly qualified nurses in the UK during the transition from student to staff nurse.

BACKGROUND

It has been widely recognised that newly qualified nurses experience a period of transition. Over the past decade there has been radical reorganisation of nurse education in the UK which has raised issues of preparation for practice.

DATA SOURCES

Searches were made of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE.

METHODS

A systematic review was carried out. Papers were critically reviewed, relevant data were extracted and synthesised.

RESULTS

Four themes were identified from the empirical evidence base: transition and change, personal and professional development, pre-registration education, preceptorship and support.

CONCLUSION

Transition remains a stressful experience for newly qualified nurses in the UK. Reasons include an increase in personal and professional development, changes in pre-registration education and lack of support once qualified.

RECOMMENDATIONS

Further research is needed to address the current situation in relation to the transition period including pre-registration education, preparation for practice and support in both primary and secondary care.

Precipitation: its acidic nature

A comparison of the free hydrogen ion concentration and the total hydrogen ion concentration of rain samples shows that rain is a weak acid. The weak acid nature of rain casts doubt on the concepts that the acidity of rain is increasing and that these increases are due to strong acids such as sulfuric acid.

Profil épidémiologique et clinique de l’infertilité masculine à l’hôpital général de Grand-Yoff, Sénégal: à propos de 492 cas

Objectif

Décrire le profil général de l’infertilité masculine, au Sénégal, en milieu hospitalier.

Matériels et méthodes

Il s’agit d’une étude rétrospective, descriptive, portant sur 492 dossiers de patients vus en consultation pour infertilité conjugale du couple entre 2000 et 2004. L’ensemble des paramètres étudiés portait sur les éléments cliniques et les explorations paracliniques.

Résultats

L’âge moyen des patients était de 39 ans. La durée d’évolution de l’infertilité était en moyenne de six ans. L’infertilité était de type primaire dans 66,5 % des cas. Sur le plan clinique, la varicocèle était l’anomalie la plus souvent retrouvée, soit dans 64,6 % des cas. Le spermogramme était perturbé dans 84,3 % des cas. Les principales perturbations étaient une oligospermie inférieure à 5 millions de spermatozoïes/ml (35,6 %) et une azoospermie dans 28,6 % des cas.

Conclusion

Le profil général de l’infertilité est polymorphe. L’exploration est limitée par la non-disponibilité de la partenaire et l’absence de coordination entre gynécologues et andrologues. L’amélioration de la prise en charge de l’infertilité doit passer par de nouvelles voies de recherche, notamment génétiques et immunologiques, afin d’identifier les causes habituellement cachées de l’infertilité. Elle doit aussi reposer sur une bonne collaboration entre praticiens de santé de la reproduction et la mise en place d’unités d’assistance médicale à la procréation (AMP).

Pain and analgesic use in men with metastatic prostate cancer

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Background: Pain is an important endpoint in metastatic prostate cancer and was the basis for the 1996 FDA approval of mitoxantrone. Standards for pain assessment have evolved, and a 2006 draft FDA guidance provides new recommendations for patient- reported outcomes. Contemporary palliation models generally require pain reduction starting from baseline worst pain scores of ≥4/10, and progression models require a sufficient proportion of patients’ pain scores to worsen in order to assure an adequate effect size. The prevalence and distribution of pain severity at specific points in the prostate cancer disease continuum are not well defined. Consequently, it is unclear if sufficient numbers of patients are available to conduct prospective studies using pain palliation or prevention as primary endpoints. Methods: A questionnaire that includes the Brief Pain Inventory and additional pain/analgesia items was developed as a collaboration between the DOD/PCF-supported Prostate Cancer Clinical Trials Consortium (PCCTC) and FDA Study Endpoints and Labeling Design (SEALD) team. IRB waivers were obtained for anonymous administration at 5 PCCTC institutions (Sloan-Kettering, Duke, Johns Hopkins, Anderson, OHSU). Administration is ongoing. Results: Between August-December 2008, 325 men with prostate cancers representing different disease states being seen in outpatient clinics of participating centers were each queried once. Median age was 70 (range 49–87). More than half (n=175) self-reported metastatic disease, including 129 with bone metastases. Among those with bone metastases, 76 (59%) reported experiencing any level of pain in the last week; 49 (38%) reported a worst pain score ≥4/10 of which 38 (78%) used analgesics over the past week and 31 (63%) used daily analgesia. In addition, 70 of the 76 (92%) noted that their pain interfered with work, sleep, or enjoyment of life, with 25 (33%) noting severe interference. Among the 49 patients with pain scores ≥4/10, current or past docetaxel use was reported by 32 (65%), androgen deprivation therapy by 47 (96%), and 28 (57%) had been or were currently enrolled in a clinical trial. Conclusions: Pain is sufficiently prevalent in men with metastatic prostate cancer to enable prospective assessment of palliation endpoints in clinical trials.

No significant financial relationships to disclose.

Surveillance results of depleted uranium-exposed Gulf War I veterans: sixteen years of follow-up

As part of a longitudinal surveillance program, 35 members of a larger cohort of 77 Gulf War I veterans who were victims of depleted uranium (DU) "friendly fire" during combat underwent a 3-day clinical assessment at the Baltimore Veterans Administration Medical Center (VAMC). The assessment included a detailed medical history, exposure history, physical examination, and laboratory studies. Spot and 24-h urine collections were obtained for renal function parameters and for urine uranium (U) measures. Blood U measures were also performed. Urine U excretion was significantly associated with DU retained shrapnel burden (8.821 mug U/g creatinine [creat.] vs. 0.005 mug U/g creat., p = .04). Blood as a U sampling matrix revealed satisfactory results for measures of total U with a high correlation with urine U results (r = .84) when urine U concentrations were >/=0.1 mug/g creatinine. However, isotopic results in blood detected DU in only half of the subcohort who had isotopic signatures for DU detectable in urine. After stratifying the cohort based on urine U concentration, the high-U group showed a trend toward higher concentrations of urine beta(2) microglobulin compared to the low-U group (81.7 v. 69.0 mug/g creat.; p = .11 respectively) and retinol binding protein (48.1 vs. 31.0 mug/g creat.; p = .07 respectively). Bone metabolism parameters showed only subtle differences between groups. Sixteen years after first exposure, this cohort continues to excrete elevated concentrations of urine U as a function of DU shrapnel burden. Although subtle trends emerge in renal proximal tubular function and bone formation, the cohort exhibits few clinically significant U-related health effects.

Preparing for the future: nurse education and workforce development

Nurse education needs to be responsive to changes not only within health policy but also those relating to workforce development. Viewed within this context this discussion paper highlights areas of consideration when planning for and responding to such demands.

Health surveillance of Gulf War I veterans exposed to depleted uranium: updating the cohort

A cohort of seventy-four 1991 Gulf War soldiers with known exposure to depleted uranium (DU) resulting from their involvement in friendly-fire incidents with DU munitions is being followed by the Baltimore Veterans Affairs Medical Center. Biennial medical surveillance visits designed to identify uranium-related changes in health have been conducted since 1993. On-going systemic exposure to DU in veterans with embedded metal fragments is indicated by elevated urine uranium (U) excretion at concentrations up to 1,000-fold higher than that seen in the normal population. Health outcome results from the subcohort of this group of veterans attending the 2005 surveillance visit were examined based on two measures of U exposure. As in previous years, current U exposure is measured by determining urine U concentration at the time of their surveillance visit. A cumulative measure of U exposure was also calculated based on each veteran's past urine U concentrations since first exposure in 1991. Using either exposure metric, results continued to show no evidence of clinically significant DU-related health effects. Urine concentrations of retinol binding protein (RBP), a biomarker of renal proximal tubule function, were not significantly different between the low vs. high U groups based on either the current or cumulative exposure metric. Continued evidence of a weak genotoxic effect from the on-going DU exposure as measured at the HPRT (hypoxanthine-guanine phosphoribosyl transferase) locus and suggested by the fluorescent in-situ hybridization (FISH) results in peripheral blood recommends the need for continued surveillance of this population.

Teenage conceptions, abortions, and births in England, 1994-2003, and the national teenage pregnancy strategy

BACKGROUND

The aim of this study was to quantify the change in the number of conceptions and abortions among women younger than 18 years in England in relation to the government's national teenage pregnancy strategy.

METHODS

We undertook geographic analysis of data for 148 top-tier local authority areas. The main outcomes were changes in under-18 conceptions, abortions, and births between the 5-year period before implementation of the strategy (1994-98) and the period immediately after implementation (1999-2003).

FINDINGS

The number of teenage conceptions peaked in 1998, then declined after the implementation in 1999 of the teenage pregnancy strategy. Under-18 conception rates fell by an average of 2.0% (95% CI 1.8 to 2.2) per year between 1998 and 2003, below the rate needed to achieve the target of 50% reduction by 2010. The net change between 1994-98 and 1999-2003 was a fall in conceptions of 3.2% (2.6 to 3.9) or 1.4 per 1000 women aged 15-17 years, a rise in abortions of 7.5% (6.5 to 8.6) or 1.4 per 1000, and a fall in births of 10.6% (9.9 to 11.3) or 2.8 per 1000. The change in the number of conceptions was greater in deprived and more rural areas, and in those with lower educational attainment. The change was greater in areas where services and access to them were poorer, but greater where more strategy-related resources had been targeted.

INTERPRETATION

The decline in under-18 conception and birth rates since 1998 and evidence that the declines have been greatest in areas receiving higher amounts of strategy-related funding provides limited evidence of the effect of England's national teenage pregnancy strategy. The full effect of local prevention will be clear only with longer observation, and substantial further progress is needed to remedy England's historically poor international position in teenage conceptions.

An analysis of deficiencies identified during investigational new drug (IND) application reviews by the Division of Drug Oncology Products (DDOP) of the US FDA

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Background: Regulations require IND application review by the FDA prior to initiation of the clinical study. Deficiencies identified in the study protocol require communication between the FDA reviewers and the Sponsor for resolution. If the deficiencies are not adequately resolved, clinical hold and subsequent delay in the start of the clinical study results. To identify and analyze the commonly encountered IND application deficiencies, data from recent reviews were collected. Methods: Eight clinical reviewers analyzed the deficiencies that had been identified in 268 IND applications reviewed in the DDOP FDA from January 2003 to June 2005. All of the study protocol deficiencies leading to a clinical hold, or requiring resolution prior to study initiation were categorized as deficiencies pertaining to: patient eligibility; starting drug dose; study conduct (toxicity management, dose adjustment, stopping criteria); statistical or endpoints; non-clinical; and other issues. Results: 268 IND applications reviewed over a 30-month period by eight medical officers were analyzed. One hundred and twelve (42%) of the applications had no deficiencies; however, 156 (58%) had one (31%) or multiple (69%) deficiencies. Deficiencies pertained to study conduct/scheme (65%), dose (48%), patient eligibility (46%), others (31%), statistics or endpoints (15%), and non-clinical (4%) issues. In 141 (90%) of the deficient applications the deficiencies were adequately addressed by FDA reviewer-Sponsor communication and the trials could start as scheduled. Fifteen (10%) deficient trials were placed on clinical hold. Fourteen (93%) of these trials had multiple deficiencies that pertained to patient eligibility in 12 (80%), starting drug dose in 12 (80%), study conduct in 11 (73%), other in 7 (47%), and non-clinical and statistical issues in 2 (13%) each. Conclusions: Deficiencies were identified in 58% of the reviewed IND applications: 90% of these were resolved by FDA-Sponsor communication. Only 10% of deficient studies were placed on clinical hold; all except one had multiple deficiencies. The most common deficiencies leading to clinical hold pertained to eligibility of study population and proposed starting drug dose.

No significant financial relationships to disclose.

Leaving the professional tennis circuit: exploratory study of experiences and reactions from elite female athletes

In 2002, Tennis Australia commissioned a report into the experiences of elite female past players on leaving the professional tennis circuit. Australian players who were in the top 800 of the Women's Tennis Association (WTA) end of year rankings and who had left the professional circuit within the previous 15 years were asked by mail to respond to a questionnaire. The questionnaire asked players to describe their feelings about leaving the tour during the time leading up to leaving the tour to two years after retirement. The main findings of the study suggested that those who planned to leave the tour found the transition process easy, whereas those who did not plan to leave the tour found the process difficult. Most players (66%) did not regret leaving the tour, and, although the remaining players responded that they regretted leaving, none attempted a comeback. Tennis Australia has implemented strategies to assist current players on the professional tour based on the results of this study.

Gremlin gene expression in bovine retinal pericytes exposed to elevated glucose

AIM

To assess the influence of high extracellular glucose on the expression of the bone morphogenetic protein (BMP) antagonist, gremlin, in cultured bovine retinal pericytes (BRPC).

METHODS

BRPC were cultured under conditions of 5 mM and 30 mM d-glucose for 7 days and total RNA was isolated. Gremlin mRNA levels were correlated, by RT-PCR, with other genes implicated in the pathogenesis of diabetic retinopathy and the signalling pathways in high glucose induced gremlin expression were probed using physiological inhibitors. Gremlin expression was also examined in the retina of streptozotocin induced diabetic mice.

RESULTS

High glucose stimulated a striking increase in BRPC gremlin mRNA levels in parallel with increases in mRNA for the growth factors vascular endothelial growth factor (VEGF), transforming growth factor beta (TGFbeta), and connective tissue growth factor (CTGF) and changes in other genes including fibronectin and plasminogen activator inhibitor-1 (PAI-1). High glucose triggered gremlin expression was modulated by anti-TGFbeta antibody, by the uncoupler of oxidative phosphorylation, CCCP, and by inhibition of MAP-kinase (MAPK) activation. Striking gremlin expression was observed in the outer retina of diabetic mice and also at the level of the vascular wall.

CONCLUSIONS

Gremlin gene expression is induced in BRPC in response to elevated glucose and in the retina of the streptozotocin induced diabetic mouse. Its expression is modulated by hyperglycaemic induction of the MAPK, reactive oxygen species, and TGFbeta pathways, all of which are reported to have a role in diabetic fibrotic disease. This implicates a role for gremlin in the pathogenesis of diabetic retinopathy.

Combination therapy with ribavirin and interferon in a cohort of children with hepatitis C and haemophilia followed at a pediatric haemophilia treatment center

Nearly all children with bleeding disorders who received factor concentrates prior to the late 1980s were infected with hepatitis C. Treatment of adults infected with hepatitis C with combination therapy consisting of ribavirin and interferon has shown sustained response rates of 30-60%. Little data is available on the response of children infected with hepatitis C treated with combination therapy, especially those with bleeding disorders. We wish to report a single paediatric haemophilia treatment center's results of treatment of adolescents with haemophilia and hepatitis C infection with combination therapy. All patients followed at the haemophilia treatment center with hepatitis C, who were human immunodeficiency virus (HIV) negative and had a measurable hepatitis C viral load were eligible. Study patients received at least 6 months of 3 MU interferon-alpha via subcutaneous injection three times per week and 1000 mg day(-1) of ribavirin. Eleven patients agreed to participate in the study. Three patients had an un measurable viral load after 6 months of combination therapy. All three completed 12 months of medication and continued to remain free of hepatitis C for 12 months after discontinuation of therapy. Side-effects of combination therapy were significant but tolerable. The sustained response rate in this study is similar to the historical response rate seen in adults but less than the other reported response rates seen in children treated with combination therapy. Given the toxicity of combination therapy, and natural history of hepatitis C infection in children, consideration of a liver biopsy to evaluate disease progression prior to considering antiviral medications is warranted.

The utility of computerized neuropsychological assessment of cognitive dysfunction in patients with relapsing-remitting multiple sclerosis

Traditional paper-and-pencil neuropsychological batteries used to document cognitive deficits in multiple sclerosis (MS) patients lack timing precision. This makes it difficult to accurately measure psychomotor slowing, a central cognitive symptom of MS. Additionally, traditional batteries lack multiple alternate forms necessary to control for practice effects when assessing cognition over time. Finally such batteries are lengthy and expensive. Computerized neuropsychological batteries address many of these shortcomings. They measure response time more precisely, require less administration time, include alternate forms, and are ideal for rapid screening/triage. Although there are normative data on the reliability and validity of computerized measures, there have been no controlled validation studies with MS patients. The current study was designed to validate a computerized neuropsychological battery (ANAM) for use with relapsing-remitting (RR) MS patients. Prior to initiation of interferon-beta-1a (Avonex) treatment, subjects participated in a neuropsychological evaluation consisting of traditional and computerized measures. Moderate-to-high correlations were found between computerized and traditional measures. Computerized tests accurately predicted performance on key traditional tests. The battery was also concordant with traditional measures in identifying RR MS patients with and without neurocognitive impairment. Findings are discussed with respect to increased accuracy and accessibility of neuropsychological evaluations for MS patients.

Fragmentation of care for frail older people--an international problem. Experience from three countries: Israel, Canada, and the United States

Cross-national comparisons of healthcare systems can help us to better understand them and to offer possible solutions for problems identified within these jurisdictions. Because multiple discontinuities present in most healthcare systems interfere with the appropriate clinical care of frail older people, we were interested in comparing the situation in three countries with markedly different healthcare systems. At one end of the spectrum we find Canada, with an almost fully socialized system. At the other stands the United States, where market forces are allowed the freest rein in any developed nation. Israel offers an intermediate model with elements held in common with both the U.S. and Canadian systems. Although the problems outlined in this paper can be addressed at the "micro" level, it is through an improvement in the structuring and organization of national systems of care that the appropriate conditions for the care of frail older people can be truly bettered. This international comparison offers insights for policy makers in these three states in particular and other countries in general.

Surveillance of depleted uranium exposed Gulf War veterans: health effects observed in an enlarged "friendly fire" cohort

To determine clinical health effects in a small group of US Gulf War veterans (n = 50) who were victims of depleted uranium (DU) "friendly fire," we performed periodic medical surveillance examinations. We obtained urine uranium determinations, clinical laboratory values, reproductive health measures, neurocognitive assessments, and genotoxicity measures. DU-exposed Gulf War veterans with retained metal shrapnel fragments were excreting elevated levels of urine uranium 8 years after their first exposure (range, 0.018 to 39.1 micrograms/g creatinine for DU-exposed Gulf War veterans with retained fragments vs 0.002 to 0.231 microgram/g creatinine in DU exposed but without fragments). The persistence of the elevated urine uranium suggests ongoing mobilization from the DU fragments and results in chronic systemic exposure. Clinical laboratory outcomes, including renal functioning, were essentially normal. Neurocognitive measures showing subtle differences between high and low uranium exposure groups, seen previously, have since diminished. Sister chromatid exchange frequency, a measure of mutation in peripheral lymphocytes, was related to urine uranium level (6.35 sister chromatid exchanges/cell in the high uranium exposure group vs 5.52 sister chromatid exchanges/cell in the low uranium exposure group; P = 0.03). Observed health effects were related to subtle but biologically plausible perturbations in central nervous system function and a general measure of mutagen exposure. The findings related to uranium's chemical rather than radiologic toxicity. Observations in this group of veterans prompt speculation about the health effects of DU in other exposure scenarios.

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.

Transcription factor NF 1 expression in involuting mammary gland

Transcripts of each of the four NF1 genes (NF1 A, B, C (CTF/NF1) and X) are expressed in both lactating and involuting mouse mammary gland but there is an indication that increased expression of an NF1 C (CTF/NF1) transcript accompanies early involution. The involution-associated 74 kD NF1 and the 114 kD lactation-associated NF1 are recognised by an anti-NF1 C-specific antibody that does not cross-react with other NF1 proteins. It is most likely that this lactation/involution switch in NF1 factors represents a change in expression of NF1 C (CTF/NF1) proteins.

Implementing the second generation social health maintenance organization

BACKGROUND

In 1996 the Health Care Financing Administration implemented a second generation of the Social HMO demonstration. This model retained the chronic care benefits of the original Social HMOs while attempting to develop a geriatric service model integrated into primary care and a screening and assessment process focused directly on healthcare risk factors. Other refinements included risk-adjusted capitation payment, broadened eligibility for expanded care benefits, low co-payments for these benefits, and no caps on the expanded care benefits expenditures.

OBJECTIVES

The geriatric approach is designed to facilitate integration among providers and levels of care. This includes timely application of primary care monitoring and treatment to reduce illness and disability as well as a geriatric education and consultation program to provide specialty support for complex cases. Care management is designed for those requiring home-based care, those discharged from hospitals or nursing homes, and those having difficulty with treatment regimens.

DESIGN

A case study of the Social HMO implementation through the Fall of 1999.

SETTING

Health Plan of Nevada (HPN), with locations in Las Vegas, Reno, and surrounding areas.

PARTICIPANTS

More than 25,000 Medicare beneficiaries participated during the study period.

MEASUREMENTS

Administrative reports, charts, and interviews with administrators and clinicians.

RESULTS

Within 12 months of operation under this authority, HPN succeeded in putting in place most of the components of the planned geriatric approach: a screening program to identify patients "at risk" for high service costs and disability and timely application of primary care treatment to reduce illness and disability. Geriatric education and a consultation program for complex cases were available, but full implementation was delayed until the plan was able to hire a full time geriatrician.

CONCLUSIONS

Health Plan of Nevada's Social HMO program reflects current perspectives on how to integrate chronic care into an HMO. The accomplishments affirm that the provision of risk-adjusted reimbursement, along with the 5 % supplement to the normal Medicare capitation payment, are sufficient incentives for a health plan to restructure itself so that it places a priority on retaining and serving populations at risk for high expenditures.

Managed care and multilevel long-term care providers: reluctant partners

Managed care is reshaping our health care system, although long-term care is only beginning to feel its effects. We report on the managed care involvement of 492 multilevel, long-term care facilities (MLFs; including skilled nursing and assisted/independent living) nationally. Organizational structure and culture and especially environmental characteristics are associated with whether facilities have contracts with managed care organizations (MCOs), plan to have contracts, are only gathering information on MCOs, or intend to do nothing in the near future. Resource dependence theory best explains MCO contracting patterns with MLFs appearing to be responding more to survival than to growth.

Health effects of depleted uranium on exposed Gulf War veterans

A small group of Gulf War veterans possess retained fragments of depleted uranium (DU) shrapnel, the long-term health consequences of which are undetermined. We evaluated the clinical health effects of DU exposure in Gulf War veterans compared with nonexposed Gulf War veterans. History and follow-up medical examination were performed on 29 exposed veterans and 38 nonexposed veterans. Outcome measures employed were urinary uranium determinations, clinical laboratory values, and psychiatric and neurocognitive assessment. DU-exposed Gulf War veterans with retained metal shrapnel fragments are excreting elevated levels of urinary uranium 7 years after first exposure (range 0.01-30.7 microg/g creatinine vs 0.01- 0.05 microg/g creatinine in the nonexposed). The persistence of the elevated urine uranium suggests on-going mobilization from a storage depot which results in a chronic systemic exposure. Adverse effects in the kidney, a presumed target organ, are not present at this time, though other effects are observed. Neurocognitive examinations demonstrated a statistical relationship between urine uranium levels and lowered performance on computerized tests assessing performance efficiency. Elevated urinary uranium was statistically related to a high prolactin level (>1.6 ng/ml; P=0.04). More than 7 years after first exposure, DU-exposed Gulf War veterans with retained metal fragments continue to excrete elevated concentrations of urinary uranium. Effects related to this are subtle perturbations in the reproductive and central nervous systems.

Trends in teenage pregnancy in England and Wales: how can we explain them?

Teenage pregnancy is associated with adverse social and physical outcomes for both mother and child. We drew on various sources--birth and abortion statistics from the Office for National Statistics, data from the National Survey of Sexual Attitudes and Lifestyles, and routinely collected data from family planning clinics--to identify trends in England and Wales and their possible determinants. The rate of teenage sexual activity has increased steadily and consistently over the past four decades, whilst the rate of teenage fertility has shown greater variation. When the teenage fertility rate is calculated against the denominator of sexually active women, rather than the total sample of teenage women, the underlying trend in teenage fertility over the past four decades has been downwards, though not consistently so. Fluctuations in the teenage fertility rate seem to track intervention-related factors such as access to, and use of, contraceptive services and the general climate surrounding the sexual health of young people.

Transjugular intrahepatic portosystemic shunt (TIPS) for Budd-Chiari syndrome or portal vein thrombosis: review of indications and problems

OBJECTIVE

The aim of this study was to evaluate the role of transjugular intrahepatic portosystemic shunt (TIPS) in patients who present with portal vein thrombosis (PVT) or Budd-Chiari Syndrome (BCS).

METHODS

Nine patients with recent PVT and four patients with BCS underwent TIPS. The diagnosis was confirmed by color Doppler ultrasound and by angiogram in most patients. Patients were followed clinically and had TIPS checked periodically for patency. The end point was mortality, subsequent surgical shunting or orthotopic liver transplantation (OLT).

RESULTS

TIPS was placed in 13 of 15 (87%) patients with BCS or PVT. The mean decrease in pressure gradient was 56%. Median and mean follow-up were 14 months and 16.9 months. Procedure related complications occurred in two of 13 (15%), both in the PVT group. Direct procedural mortality was one of 13 (8%). The majority of patients with PVT (five of eight) underwent OLT. Of the remaining three, one patient subsequently developed a cavernous transformation of portal vein but is stable, one patient is stable, without further variceal bleeding, and one patient died because of multiple organ failure. In patients with BCS, three of four (75%) did well with TIPS, but one patient required immediate surgical shunting after occlusion of the TIPS. Two patients underwent OLT and the fourth patient is stable 2 yr later but has cirrhosis on biopsy.

CONCLUSIONS

In patients with BCS, TIPS placement is effective and can be used as a bridge to liver transplantation. TIPS in the noncavernous PVT group should only be recommended when cirrhosis and uncontrollable variceal bleeding are present.

Long-term functional status and quality of life after lower extremity revascularization

OBJECTIVE

The objective of this study was to assess the longer term (up to 7 years) functional status and quality of life outcomes from lower extremity revascularization.

METHODS

This study was designed as a cross-sectional telephone survey and chart review at the University of Minnesota Hospital. The subjects were patients who underwent their first lower extremity revascularization procedure or a primary amputation for vascular disease between January 1, 1989, and January 31, 1995, who had granted consent or had died. The main outcome measures were ability to walk, SF-36 physical function, SF-12, subsequent amputation, and death.

RESULTS

The medical records for all 329 subjects were reviewed after the qualifying procedures for details of the primary procedure (62.6% arterial bypass graft, 36.8% angioplasty, 0.6% atherectomy), comorbidities (64% diabetics), severity of disease, and other vascular risk factors. All 166 patients who were living were surveyed by telephone between June and August 1996. At 7 years after the qualifying procedure, 73% of the patients who were alive still had the qualifying limb, although 63% of the patients had died. Overall, at the time of the follow-up examination (1 to 7.5 years after the qualifying procedure), 65% of the patients who were living were able to walk independently and 43% had little or no limitation in walking several blocks. In a multiple regression model, patients with diabetes and patients who were older were less likely to be able to walk at follow-up examination and had a worse functional status on the SF-36 and a lower physical health on the SF-12. Number of years since the procedure was not a predictor in any of the analyses.

CONCLUSION

Although the long-term mortality rate is high in the population that undergoes lower limb revascularization, the survivors are likely to retain their limb over time and have good functional status.

Comparison of antitumor activity of declopramide (3-chloroprocainamide) and N-acetyl-declopramide

Previous studies have suggested that some of the antitumor activity of declopramide (3-chloroprocainamide) could be due to its metabolites. One metabolite has been identified as N-acetyl-declopramide (N-acetyl-3-chloroprocainamide). The aim of this study is to investigate the bioactivity of N-acetyl-declopramide and to compare it with its parent compound. The data have shown that N-acetyl-declopramide inhibited tumor cell growth in vitro in HL60 and K562 cells, and in vivo in scid mice xenografted with a human brain astrocytoma (T24), which was evaluated after oral doses of 20 and 40 mg/kg given at 0, 24 and 48 hr +/- a single im dose of cisplatin (7.5 mg/kg). The action was presumably by inducing DNA strand breaks and apoptosis. No acute toxic symptoms and no body weight loss were observed. N-acetyl-declopramide given orally or im gave a similar drug level in mouse serum 30 minutes after administration (p > 0.05). It had a greater antitumor activity in vitro in HL60 or K562 cells and a similar efficacy of inhibiting tumor growth in vivo, when compared with declopramide. These data provided an explanation for the primary result obtained in this study, i.e. declopramide administered orally at 40 mg/kg gave the same efficacy of inhibiting tumor growth as im injection although oral administration had a lower bioavailability due to the formulation of N-acetyl-declopramide. Based on these data, it was concluded that the antitumor properties of declopramide administered orally were not compromised by metabolism to N-acetyl-declopramide because the latter also has strong antitumor properties.

Pharmacokinetics and central nervous system toxicity of declopramide (3-chloroprocainamide) in rats and mice

Declopramide (3-chloroprocainamide) has been identified in previous studies as a representative of a new class of chemosensitizers. In this study, the toxicity and pharmacokinetics of declopramide have been investigated and compared with a structural analog, metoclopramide (MCA). Declopramide has not induced central nervous system (CNS)-related side effects in rats at doses up to 200 mg/kg, whereas MCA does at 12.5 mg/kg. In addition, declopramide did not bind to dopamine D2 receptors in subcellular preparations at doses up to 100 microM, whereas MCA showed affinity at 1 microM. Declopramide bound with affinity to 5-hydroxytryptamine3 receptors which are important in controlling vomiting. In contrast to MCA, declopramide has a rapid clearance from serum, a lower tissue concentration (about 15-fold lower than MCA) and a lower oral bioavailability (about 6-fold lower than MCA). However, declopramide was shown in vitro to possess a higher tumor cell absorption rate. One of the main metabolites of declopramide was identified as N-acetyl declopramide. Taken together, these data suggest that the clinical development of declopramide as a sensitizer of radio- and chemotherapies is an improvement over MCA, because it can be administered in a high dose and is devoid of CNS side effects.

The effects of clinical pathways for renal transplant on patient outcomes and length of stay

OBJECTIVES

Clinical pathways have been implemented nationwide but little is understood about their effects on efficiency of care and patient outcomes. The present study examined the effects of both development and implementation of two renal transplant pathways.

METHODS

Cohorts of patients at a university hospital were compared before, during, and after the development and implementation of two renal transplant clinical pathways: isolated renal transplant from cadaveric donors (n = 170) or from living donors (n = 178). Clinical pathways for cadaveric and living related donor renal transplants were developed and implemented. Hospital length of stay and complications and infections after renal transplant were determined.

RESULTS

Mean length of hospital stay decreased after development and implementation of the cadaveric donor pathway (11.8 days after implementation versus 17.5 days before development). Cadaveric kidney recipients also had statistically fewer complications and infections after both guideline development and guideline implementation (57.1% before, 24.5% during, 18.5% after), but the greatest effect occurred during development. All of these findings persisted after control for demographic and comorbid factors. There were no changes in hospital stay, complications, or infections in the patients who received kidneys from living donors.

CONCLUSIONS

The development and use of a clinical pathway for cadaveric donor renal transplant patients was associated with a significant decline in length of stay, complications, and infections, but much of the effect was seen during development rather than during implementation, and a closely related pathway for living related donor patients had no effect. Further understanding of what factors predict an effective pathway and what elements (ie, development or implementation) have an effect should be undertaken.

The effect of HMO status on the outcomes of home-care after hospitalization in a Medicare population

OBJECTIVE

The literature suggests that Medicare health maintenance organization (HMO) patients may have poorer outcomes with formal home-health care than do fee-for-service (FFS) patients, but it is unclear whether this is related to case-mix or quality. Our objective was to compare the home-health care outcomes for HMO and FFS Medicare patients after hospitalization for stroke, COPD, CHF, hip replacement, or hip fracture with fixation or replacement while controlling for site of discharge and other patient characteristics.

DESIGN

Patients were identified before hospital discharge with data collected at that time and then prospectively for 1 year.

SETTING

Nineteen acute general hospitals in Minneapolis/St. Paul, Minnesota.

PATIENTS

All Medicare patients in the above hospitals identified predischarge with stroke, COPD, CHF, hip replacement, or hip fracture with fixation or replacement.

MEASURES

OUTCOME

weighted ADL scale and hospital readmission. Independent factors: site of discharge, HMO status, comorbidity, severity, and demographic factors.

RESULTS

A total of 970 subjects were studied, 211 of whom were discharged to home-care. HMO patients were more likely to be discharged to a nursing home than to home-care after controlling for other factors (OR = 1.7; P = .015). After controlling for site of discharge and patient characteristics through either propensity scores or regression analysis, there was no statistically significant difference in ADL function at 6 weeks or at 6 months between HMO and FFS patients. Nor was there was a statistically significant difference in hospital readmission rates at 6 weeks and 6 months between HMO and FFS home-care patients.

CONCLUSIONS

The outcomes of Medicare HMO patients discharged to home-care are not worse than those of FFS patients.

The Caregiver Activity Survey (CAS): development and validation of a new measure for caregivers of persons with Alzheimer's disease

BACKGROUND

Most instruments that measure the impairments associated with Alzheimer's disease assess symptom severity. Little attention has been paid to the illness's impact on the time formal and informal caregivers spend caring for Alzheimer's individuals. A tool that measures the time spent caregiving would help to determine the economic impact of the illness. The Caregiver Activity Survey (CAS) was developed to measure the time caregivers spend aiding Alzheimer's patients with their day-to-day activities.

METHODS

The test-retest reliability of the CAS was assessed during a 3-week study with 42 Alzheimer's patients and their caregivers. The CAS was validated with the Alzheimer's Disease Assessment Scale Cognitive Subscale (ADAS-Cog), the Mini Mental State Exam (MMSE) and the Physical Self Maintenance Scale (PSMS).

RESULTS

The final version of the CAS consists of six items (communicating with the person, using transportation, eating, dressing, looking after one's appearance and supervising the person). The six-item CAS total score has high test-retest reliability, with ICC = 0.88 between weeks 1 and 3. The scale has strong convergent validity with the ADAS-Cog (r = 0.61), MMSE (r = -0.57) and PSMS (r = 0.43). Efforts to include a dimension that reflects caregiver burden were not successful, in part due to the reluctance of caregivers to acknowledge that caregiving is bothersome.

CONCLUSIONS

The CAS provides a new tool that measures time spent caring for Alzheimer's individuals. The instrument may be used to augment existing clinical assessments that measure the efficacy of potentially therapeutic agents for persons with Alzheimer's disease.

Epidemiological and genetic observations on human schistosomiasis in Kinshasa, Zaire

A survey for Schistosoma intercalatum conducted in Kinshasa, Zaire, in September 1994 revealed a prevalence of 3.6% (n = 167). Three isolates of schistosomes were made by exposing Bulinus wrighti to miracidia hatched from eggs collected from 2 infected children. Characterization of the isolates by biochemical (isoenzymes of phosphoglucomutase), molecular (restriction fragment length polymorphism and randomly amplified polymorphic deoxyribonucleic acid analysis) and morphological (egg measurements) techniques confirmed the existence of an autochthonous transmission focus of S. intercalatum in Kinshasa. The study also provided evidence of the occurrence of natural hybridization between S. intercalatum and S. haematobium. No potential snail host for either species was found in the 2 rivers examined. Apart from Bu. globosus from Zambia and Bu. wrighti, snail infection experiments showed an incompatible relationship between the parasite isolates and snails belonging to the Bu. forskalii group, the Bu. iruncatus/Bu. tropicus complex, and the Bu. africanus group.

The prevalence and clinical significance of lymphadenopathy in primary biliary cirrhosis

We present the results of a retrospective review of abdominal computed tomography, ultrasound, and magnetic resonance examinations of 12 patients with primary biliary cirrhosis undertaken to determine the prevalence and clinical significance of previously reported coexistent intra-abdominal lymphadenopathy in patients with this disorder. Lymphadenopathy, in the form of bulky periportal and retroperitoneal nodes, was identified in a single patient secondary to an occult metastatic adenocarcinoma. We conclude that coexistent intra-abdominal lymphadenopathy occurring in patients with primary biliary cirrhosis is uncommon. Although it may represent a benign component of the primary disease, it may equally be due to unsuspected coexistent occult malignancy.

Diagnosis of Budd-Chiari syndrome: comparison between sonography and MR angiography

PURPOSE

To compare findings with color Doppler sonography and magnetic resonance (MR) angiography in the diagnosis of Budd-Chiari syndrome.

MATERIALS AND METHODS

Doppler sonographic scans and MR angiograms in 11 patients (five men and six women; age range, 30-63 years; mean age, 45 years) with proved Budd-Chiari syndrome were subjected to retrospective review.

RESULTS

Occlusion of three hepatic veins was identified in each of two patients, of two hepatic veins in each of four patients, and of one hepatic vein in each of five patients at both Doppler sonography and MR angiography. Dominant intrahepatic venovenous collateral pathways were identified in eight of 11 patients and spider-web collaterals were identified in three of 11 patients at both sonography and MR angiography.

CONCLUSION

Sonography enables noninvasive diagnosis of Budd-Chiari syndrome. MR angiography affords similar diagnostic information and may be of value when the diagnosis is not clear after sonographic examination or when body habitus limits a complete sonographic examination.

Omeprazole treatment of children with peptic esophagitis refractory to ranitidine therapy

OBJECTIVE

To evaluate the cause of chronic abdominal pain lasting more than 3 weeks in 153 patients aged 6 to 18 years (mean, 9.9 years) who had undergone endoscopy.

DESIGN

Those patients with peptic esophagitis as the cause of their chronic pain were treated with high-dose ranitidine hydrochloride, followed by the proton-pump inhibitor, omeprazole, for those who did not respond to a histamine2-receptor antagonist.

RESULTS

Eighty-four percent of patients had peptic esophagitis, 3% had Helicobacater pylori gastritis, and 3% had ulcer disease. Seventy percent of the patients with peptic esophagitis responded to an 8-week course of high-dose ranitidine hydrochloride (4 mg/kg per dose, twice a day or three times a day). Of the 30% of patients who failed to respond to ranitidine therapy, 87% responded to an 8-week course of omeprazole (20 mg/d). The grade of esophagitis at initial endoscopy was a predictive factor for response to ranitidine therapy. Ninety percent of patients with grade 1 esophagitis responded to ranitidine therapy vs only 43% of those with grade 3 or 4 esophagitis. Only five patients (4%) failed to respond to both therapies; three of these subsequently underwent Nissen fundoplications. There were no side effects of either ranitidine or omeprazole therapy.

CONCLUSIONS

These findings indicate that (1) peptic esophagitis was a common cause of chronic abdominal pain in pediatric patients and (2) omeprazole was effective in the treatment of esophagitis in children and adolescents that was resistant to high-dose histamine2-receptor antagonists.

Isolation and characterization of a sea urchin zygote cortex that supports in vitro contraction and reactivation of furrowing

The isolation of the cortex of the sea urchin blastomere by detergent lysis was explored with the aim of analyzing components important in the structure and function of the cortical cytoskeleton, and their relationship to such phenomena as contraction. Buffered EGTA medium supplemented with isotonic glycerol and with magnesium, at a level close to the reported internal cellular concentration, yields stable cytoskeletal cortices that retain their spherical shape. Cortices prepared this way contain actin, myosin, fascin and spectrin, components normally associated with the cortical cytoskeleton in a similar distribution to that in intact zygotes. They retain the organized cortical filamentous structure, including the actin-fascin bundles that form cores of microvilli. ATP and NaCl caused changes in cortical shape, described as either contraction or expansion, respectively. Spectrin, but not myosin, was partially extracted by NaCl, resulting in expansion of the cortex that suggests a role for spectrin in maintenance of cortical structure. ATP (but not ADP nor ATP gamma S), which caused the partial removal of myosin and spectrin, led to the contraction of the cortex, consistent with a role for myosin in cortical tension. In cortices isolated from dividing eggs, the zygotes retained their cleavage furrows and ATP induced continuation of furrow progression. This preparation appears to be a useful in vitro model for cytokinesis.