Managing chronically ill older people in the midst of the health care revolution

The health care revolution is challenging nursing to change, as are the rapidly changing population demographics. The aging of America underlines a need for the health care revolution to address continuum-based care requirements, particularly of the chronically ill older population. They and their families are stressed with the current fragmentation of the health care system. Continuum-based care for the chronically ill is critical in altering the trajectory of health care consumption, and case management is central to it. A model of nurse case management is presented as an emerging solution.

A single photon emission computed tomography scan study of striatal dopamine D2 receptor binding with 123I-epidepride in patients with schizophrenia and controls

The usefulness of 123I-epidepride as a single photon emission computed tomography (SPECT) scan D2 receptor ligand was examined in vivo in 13 medicated patients with schizophrenia and age- and sex-matched normal controls. To establish the effect of endogenous dopamine on 123I-epidepride binding, 4 of the 13 controls also received 20 mg D-amphetamine. The results showed that 123I-epidepride had high specific binding to the striatum in both patients with schizophrenia and normal controls. There was a trend for the total striatal binding of medicated patients with schizophrenia, as measured by total basal ganglia: frontal cortex (TBG:FC) ratios, to be less than the binding of controls (P = 0.053). This trend confirms previous work showing that antipsychotic medication decreases the number of D2 receptors available for binding to the radioligand. Interestingly, there was also a significant relationship between 123I-epidepride binding ratios and global functioning scales (Global Assessment of Functioning scale [GAF]) for schizophrenia (r = 0.56, P = 0.045), although there was no such relationship with the Brief Psychiatric Rating Scale (BPRS). In addition, our results showed that amphetamine-induced dopamine release did not alter 123I-epidepride binding, confirming the high specific binding of 123I-epidepride to the D2 receptor. We conclude that 123I-epidepride appears to be a very useful SPECT ligand for imaging the D2 receptor.

Treatment of a patient with an infected hepatic cyst

Symptomatic hepatic cysts are infrequently seen by family physicians. We review the literature and describe the diagnosis and management of a patient with cystic liver disease and a dominant infected hepatic cyst. The treatment included percutaneous drainage, intravenous antibiotic therapy, and sclerotherapy infusion using sterile alcohol (95% ethanol).

The alpha1 and alpha2 isoforms of the AMP-activated protein kinase have similar activities in rat liver but exhibit differences in substrate specificity in vitro

The AMP-activated protein kinase (AMPK) is a heterotrimeric complex composed of a catalytic subunit (alpha) and two regulatory subunits (beta and gamma). Two isoforms of the catalytic subunit (alpha1 and alpha2) have been identified. We show here that the alpha1- and alpha2-containing complexes contribute approximately equally to total AMPK activity in rat liver. Furthermore, expression of alpha1 or alpha2 with beta and gamma in mammalian cells demonstrates that both complexes have equal specific activity measured with the SAMS peptide. Using variant peptides, however, we show that alpha1 and alpha2 exhibit slightly different substrate preferences, which suggest that the two isoforms could play different physiological roles within the cell.

Burden of care, psychological distress and satisfaction with services in the relatives of acutely mentally disordered adults

This project aimed to examine the views of relatives nominated as the "most significant other person" by acutely mentally disordered patients who were newly referred to either a community-based (n = 24) or a district general hospital based (n = 17) psychiatric service. Relatives were asked about their satisfaction with these services, the psychological impact on them of caring for a mentally disordered relative, and levels of subjective and objective burden of care at the time of referral and 6 months later. The findings of this study suggested that the initial severity of an acute psychiatric disorder rather than the type of psychiatric service provided is more strongly associated with objective and subjective levels of burden. At follow-up, psychological distress as measured on the General Health Questionnaire (GHQ) was associated with the objective burden of caring for a relative with psychosis or major affective disorder, but not other conditions. Dissatisfied relatives tended to be those who remained distressed at 6 months according to GHQ scores or those recording continually high levels of subjective burden on the Burden of Care Schedule (BCS). Interventions to reduce subjective and objective burden should be targeted at the group demonstrating persistent stress.

Inherited diseases of the vasculature

This review focuses on a spectrum of inherited disorders in which recent genetic advances have made a significant contribution to our understanding of vascular pathology and homeostasis. They are discussed according to the type of blood vessel affected and the compounded physiological processes that include angiogenesis, vascular development, and defects in the structure and regulation of the mature vessel. Vascular malformations, arterial aneurysms and dissection, telangiectasia, infiltrative vascular disease, and inherited tumors and disorders of neovascularization are discussed in a variety of settings. Disease roles for endoglin, tissue inhibitor of metalloproteinases 3 (TIMP3), and vascular endothelial growth factor (VEGF) dysregulation are highlighted (175 references).

Hyperhomocysteinaemia is a risk factor for vein graft stenosis

OBJECTIVES

Many infrainguinal vein graft failures are due to progressive vein graft stenosis (VGS) from intimal hyperplasia. Systemic factors have been implicated in the aetiology of intimal hyperplasia. Hyperhomocysteinaemia (HHCA) is established as an independent risk factor for coronary and peripheral arterial disease. The objective of this study was to examine the influence of HHCA and other serological factors upon the development of VGS.

STUDY DESIGN

Thirty-eight patients who had undergone infrainguinal vein bypass were recruited to a case/control study from a graft surveillance program. Nineteen patients with documented VGS were matched against controls without stenosis for age, sex, length of time from surgery, diabetes, smoking history and preoperative symptom score. All patients were recalled for Duplex ultrasound scans, venesection and carbon monoxide estimation which were performed in a blinded fashion.

RESULTS

Statistical analysis of all parameters revealed that plasma homocysteine was significantly elevated in patients with VGS (p < 0.3, Wilcoxon rank sum).

CONCLUSIONS

These results suggest that HHCA is a previously unidentified risk factor for VGS. Patients with HHCA are susceptible to VGS and preoperative investigation would allow identification of patients at risk.

Homocysteine: an independent risk factor for the failure of vascular intervention

Hyperhomocysteinaemia is an independent risk factor for the early development of arterial disease. Homocysteine and cardiovascular risk factors were assessed in 41 young and 25 older patients with vascular disease. As homocysteine may act by the generation of free radicals, total antioxidant capacity was measured. Hyperhomocysteinaemia was found in 29 per cent of patients but there was no difference between young and older patients. Homocysteine level was unrelated to other cardiovascular risk factors. Young age, diabetes and hyperhomocysteinaemia were independent risk factors for the failure of vascular procedures (P = 0.006). Patients with hyperhomocysteinaemia had raised total antioxidant capacity. The potential of identifying and treating a subgroup of patients with a poor prognosis deserves further study.

Factors influencing infections in Rhipicephalus appendiculatus ticks fed on cattle infected with Theileria parva

A large database on the transmission of a stabilate of the Theileria parva Muguga stock from one breed of cattle using two stocks of Rhipicephalus appendiculatus, Muguga and Ol Pejeta was developed and analysed. Factors associated with the ticks and cattle, and the infections developing in cattle were studied in relation to the infection variables in the tick batches harvested daily from cattle. Generalized Linear Interactive Modelling (GLIM) was used to determine the importance of factors and interactions in influencing the levels of tick infection variables using Type I and Type III sums of squares analyses. Analysis of the 6 variables, prevalence (percentage of ticks infected), abundance (mean number of infected salivary gland acini per tick examined) and intensity (mean number of infected salivary gland acini per infected tick) in batches of 30 male and 30 female ticks showed that 24 covariates, factors or interactions had a significant effect (P < 0.05). Certain covariates and factors were particularly important for all 6 tick infection variables; parasitaemia of animal on the day of tick harvest, stabilate dilution administered to animal, month in which tick batch was harvested, minimum packed cell volume of animal over the sampling period, age of animal, and the minimum leukocyte count of the animal over the sampling period. The GLIM analyses were found to be a useful tool in identifying factors that influence infection levels and in devising methods of producing tick batches with more predictable infections.

Apolipoprotein B RNA editing enzyme-deficient mice are viable despite alterations in lipoprotein metabolism

RNA editing in the nucleus of higher eukaryotes results in subtle changes to the RNA sequence, with the ability to effect dramatic changes in biological function. The first example to be described and among the best characterized, is the cytidine-to-uridine editing of apolipoprotein B (apo-B) RNA. The editing of apo-B RNA is mediated by a novel cytidine deaminase, apobec-1, which has acquired the ability to bind RNA. The stop translation codon generated by the editing of apo-B RNA truncates the full-length apo-B100 to form apo-B48. The recent observations of tumor formation in Apobec-1 transgenic animals, together with the fact that Apobec-1 is expressed in numerous tissues lacking apo-B, raises the issue of whether this enzyme is essential for a variety of posttranscriptional editing events. To directly test this, mice were created with a null mutation in Apobec-1 using homologous recombination in embryonic stem cells. Mice, homozygous for this mutation, were viable and made apo-B100 but not apo-B48. The null animals were fertile, and a variety of histological, behavioral, and morphological analyses revealed no phenotype other than abnormalities in lipoprotein metabolism, which included an increased low density lipoprotein fraction and a reduction in high density lipoprotein cholesterol. These studies demonstrate that neither apobec-1 nor apo-B48 is essential for viability and suggest that the major role of apobec-1 may be confined to the modulation of lipid transport.

Employee motivation: new perspectives of the age-old challenge of work motivation

In this qualitative study, the 1950s-1970s work of Frederick Herzberg, the father of work motivational research, was compared, and contrasted with current data study about management effectiveness to explore how employee motivation may have changed. Staff members and managers (N = 38), primarily from healthcare settings, but also from academic, public, and private sector businesses were interviewed. Interpersonal relations now ranks first as a motivating factor in this study. Recognition, the work itself, and responsibility are still ranked as critical motivating factors. These are important to understand as work is redesigned. Supporting positive interpersonal relations among subordinates, supervisors, and peers can be viewed as an effective management strategy to facilitate employee motivation. For employees, developing positive interpersonal relations with co-workers can enhance individual motivation and may improve job satisfaction.

A combined high-performance liquid chromatographic-microbiological assay for serum folic acid

An assay of folic acid in human serum is described involving HPLC fractionation of deproteinized serum prior to Lactobacillus casei assay. High specific activity [3H]folic acid is added as internal standard to 1 ml serum prior to deproteinization with perchlorate and an aliquot is applied to a C18 reverse-phase HPLC column. The folic acid fraction was assayed by L. casei microtiter plate assay. Intra- and interassay variations (CV) were 5.5 and 7.5% respectively for sera (n = 10) spiked with folic acid. The percentage recovery for folic acid additions of 10 and 20 ng/liter were 105.2 and 103.7%, respectively. The lower limit of detection was 1 ng folic acid/ml serum. Folates other than folic acid and 5-methyltetrahydrofolate were not detected. The assay permitted serial measurements to be made of folates in serum following an oral dose.

A meta-analytic evaluation of the polymerase chain reaction for the diagnosis of HIV infection in infants

OBJECTIVE

To evaluate the sensitivity and specificity of the polymerase chain reaction (PCR) for the diagnosis of infection with human immunodeficiency virus (HIV) in infants.

DATA SOURCES

We used studies published between 1988 and 1994 identified in a literature search of 17 databases, including MEDLINE.

STUDY SELECTION

Studies were included if DNA amplification by PCR was performed on peripheral blood mononuclear cells from infants or children.

DATA EXTRACTION

Two investigators independently extracted data. The study design was assessed independently by 2 investigators who were blinded to study results.

DATA SYNTHESIS

Thirty-two studies met the inclusion criteria and were analyzed. The median reported sensitivity was 91.6% (range, 31%-100%), and the median specificity was 100% (range, 50%-100%). A summary receiver operating characteristic curve based on all 32 studies indicated that PCR has a maximum joint sensitivity and specificity between 93.2% and 94.9%. Subgroup analysis indicated that the joint sensitivity and specificity was significantly (P = .04) higher in older infants (98.2%) than in neonates (aged < or = 30 days; 93.3%). For infants at low risk of perinatal transmission (probability of transmission, 8.3%), the positive predictive value for PCR is 55.8% in neonates and 83.2% in older infants. A negative PCR result reduces the probability of HIV infection to less than 3%. No studies met all criteria for study design.

CONCLUSIONS

Although PCR is one of the best available tests for diagnosis of HIV infection in neonates and infants, it is not definitive. Therefore, PCR should be interpreted with the aid of careful clinical follow-up examinations. The sensitivity and specificity of PCR in neonates is lower than in older infants, which results in a low positive predictive value; however, negative tests are informative. Delaying the use of PCR until after the neonatal period or repeating PCR on independent samples obtained 30 to 60 days later will reduce test errors.

Polymerase chain reaction for the diagnosis of HIV infection in adults. A meta-analysis with recommendations for clinical practice and study design

PURPOSE

To do a meta-analysis of studies that have evaluated the sensitivity and specificity of polymerase chain reaction (PCR) assay for the diagnosis of human immunodeficiency virus (HIV) infection in adults. Evaluating the performance of PCR is difficult because in certain clinical situations, the sensitivity or specificity of PCR may exceed those of the current reference standard tests (enzyme immunoassay followed by confirmatory Western blot analysis). Therefore, an additional goal was to develop recommendations for 1) the design of future evaluative studies of PCR and 2) the use of PCR in persons with suspected HIV infection.

DATA SOURCES

Studies published between 1988 and 1994 that were identified in a search of 17 computer databases, including MEDLINE, and abstracts identified from conference proceedings.

STUDY SELECTION

Studies were included if DNA amplification by PCR was done on peripheral blood mononuclear cells from adults. Ninety-six studies met the inclusion criteria.

DATA EXTRACTION

Data were extracted independently by two reviewers. Study design was assessed independently by two investigators blinded to study results.

RESULTS

Reported sensitivities for PCR range from 10% to 100%, and specificities range from 40% to 100%. A summary receiver-operating characteristic curve based on all 96 studies has a maximum joint sensitivity and specificity (upper left point on the curve, where sensitivity equals specificity) of 97.0% to 98.1%. If the threshold value that defines a positive PCR result is chosen so that sensitivity is higher than 98.1%, specificity will decrease to less than 98.1%. Conversely, if the threshold value that defines a positive PCR result is chosen so that specificity is greater than 98.1%, sensitivity will decrease to less than 98.1%. If sensitivity and specificity are chosen to be equal, the corresponding false-positive rate is 1.9% to 3.0%. At the maximum joint sensitivity and specificity, the positive predictive value of PCR ranges from 34% to 85% as the prevalence of HIV increases from 1.0% to 10%. We identified seven areas in which study design could be modified to 1) reduce susceptibility to bias in estimates of the sensitivity and specificity of PCR and 2) to increase the generalizability of the study results. These modifications will also help to overcome methodologic problems created by the lack of a reference standard test.

CONCLUSIONS

The PCR assay is not sufficiently accurate to be used for the diagnosis of HIV infection without confirmation. Use of PCR for the diagnosis of HIV in adults should be limited to situations in which antibody tests are known to be insufficient. Future studies of PCR performance should be sufficiently large and should use adequate reference standard tests and standardized methods for the performance of PCR. Specimens should be evaluated by persons blinded to clinical status and to the results of other diagnostic tests for HIV infection.