Assessment of practice in pre-registration nurse education and the development of a skills acquisition manual

It has been suggested that Project 2000 training has not taken account of the need to assess the development of specific nursing skills. This could result in nurses who may be in a vulnerable position upon qualification regarding the expectations of their skills performance. A new initiative has been developed at the University of Luton, which enables specific skills to be assessed for pre-registration students during the Common Foundation Programme. This document is discussed here and is the precursor to a wider research study proposed to be undertaken upon completion of the evaluation.

Clinical and endocrine effects of a microdose GnRH agonist flare regimen administered to poor responders who are undergoing in vitro fertilization

OBJECTIVE

To assess the endocrine and clinical responses to microdose GnRH agonist (GnRH-a) that was administered in the early follicular phase before controlled ovarian hyperstimulation to poor responders who were candidates for IVF-ET.

DESIGN

Prospective nonrandomized trial with historical controls.

SETTING

Tertiary care university-affiliated infertility practice.

PATIENT(S)

Thirty-four IVF-ET candidates with a prior poor response to a standard long-protocol GnRH-a controlled ovarian hyperstimulation regimen (cycle A). Patients were divided into two groups based on their age at the initiation of cycle A (Group 1: < or = 39 years, n = 15; Group 2: > or = 40 years, n = 19).

INTERVENTION(S)

Low-dose oral contraceptive (x 21 d) followed by GnRH-a (leuprolide acetate; 40 micrograms s.c. b.i.d.) flare and urofollitropin initiated on day 3 of GnRH-a administration (cycle B).

MAIN OUTCOME MEASURE(S)

Comparative analysis of clinical responses (total urofollitropin dose used and number of oocytes retrieved as well as fertilization and clinical and ongoing pregnancy rates) and endocrine responses (serum E2, FSH, LH, T, and P levels) between cycles A and B in the two groups. Early follicular phase serum E2 and FSH changes in groups 1 and 2 were compared with changes in nine normal responder controls who were receiving a standard long-protocol GnRH-a/urofollitropin regimen (group 3).

RESULT(S)

Maximal E2 levels as well as clinical and ongoing pregnancy rates were higher in cycle B patients receiving microdose GnRH-a. Cancellation rates in cycle B were lower than in cycle A. Statistically significant increases in treatment day 6 serum FSH levels were noted during cycle B in both groups 1 and 2 but not in group 3 controls. No abnormal rises in LH, P, or T were noted in any of the groups.

CONCLUSION(S)

Microdose GnRH-a enhances urofollitropin response and clinical outcome in poor responders undergoing IVF-ET. This may be due to enhanced release of early follicular phase endogenous FSH without concomitant deleterious rises in androgen levels or corpus luteum rescue.

Regional variations in deaths from volatile solvent abuse in Great Britain

AIMS

To assess geographical variations in mortality and the relationship of socio-economic correlates to deaths from volatile substance abuse (VSA) in Great Britain.

DESIGN

Analysis of the National Register of deaths from VSA by linking the addresses (postcode) of the deceased to census enumeration districts and hence wards and counties.

SETTING AND PARTICIPANTS

All 775 deaths in Great Britain listed in the national register between 1985-91. Population counts from the 1991 census were used as denominators.

MEASUREMENT

The Poisson heterogeneity test was used to test the null hypothesis that all standardized mortality ratios were from the same population. The t-test was used to compare differences in Townsend Deprivation scores between wards with and without VSA deaths. Multiple regression was used to assess the relationship between indices of deprivation and deaths from VSA.

FINDINGS

One-third of all VSA deaths occurred in six regions of Great Britain which accounted for 17% of the at risk population. There was considerable variation in age standardized mortality ratios (ASMR) across regions. A ward level analysis indicated that wards with a VSA death had significantly higher levels of deprivation. The Townsend deprivation index showed mean deprivation scores of 2.8 and 0.2, respectively, for wards with and without a registered death (p < 0.0001). Multiple regression at county/region level found that 45% of the variation in ASMR was explained by the components of the Townsend deprivation index.

CONCLUSIONS

Factors associated with deprivation are important in VSA deaths and this should be taken into account in planning public health measures to prevent mortality.

High-efficiency transduction of freshly isolated human tumor cells using adenoviral interleukin-2 vectors

Tumor cells genetically modified to express immunostimulatory molecules can produce high levels of antitumor immunity in rodent models. Although a number of clinical trials are currently in progress to assess the value of the approach in human disease, almost all require ex vivo transduction of cultured tumor cells with retroviral vectors. This process is not feasible for many human malignancies, hampering clinical evaluation of the approach. We have used an E1a,1b/E3 deletion mutant of adenovirus containing either the lacZ or the human interleukin-2 (IL-2) gene to transduce human neuroblastoma cells. This vector transduces fresh neuroblastoma cells and neuroblastoma cell lines with an efficiency of 80-90%, compared to an efficiency of 0-14% obtained with retroviral vectors. Cells transduced with the IL-2 adenovector produce up to 12,000 pg of IL-2/10(6) cells/24 hr. IL-2 adenovector-transduced neuroblasts are immunostimulatory; when they are cultured with patient lymphocytes, they increase the proportion of DR+ T cells and generate major histocompatibility complex (MHC) unrestricted cytotoxic effector cells active against parental (nontransduced) tumor cells. We conclude that IL-2 adenovector can be used to transduce freshly isolated human tumor cells efficiently, which will then produce immunomodulatory quantities of the cytokine. The use of adenoviral rather than retroviral vectors facilitates preparation of human tumor "vaccines" and these vectors are now being used in our clinical study of neuroblastoma patients.

Differential effects of external pH alteration on intracellular pH in rat coronary and cardiac myocytes

Changes in extracellular pH (pHo) induce changes in the intracellular pH (pHi) of cardiac myocytes that are slow and attenuated. Little however is known about the effects of changing pHo on the pHi of the coronary smooth muscle cells. We have therefore directly compared the effects of altering pHo on pHi of both coronary and cardiac myocytes. Carboxy-SNARF was used in single cells to measure pHi. Alteration of pHo caused corresponding changes in pHi that were large (70-80% of pHo) and rapid in coronary myocytes compared to cardiac myocytes. In contrast, changes of pHi produced by weak acids or bases produced similar pHi responses in both types of cells. It is suggested that the differential effects of pHo on coronary and cardiac cells may be functionally significant, as it will allow rapid alteration of coronary perfusion to meet tissue needs, while maintaining cardiac output.

Monensin/roxarsone contaminated dog food associated with myodegeneration and renal medullary necrosis in dogs

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The FPbase microcomputer system for managing community health screening and intervention data bases

Health promotion and intervention projects at State and community levels need computerized data bases to assist in making policy decisions and in operating the projects. Computer data base systems are used in entering, storing, retrieving, and analyzing information about health project activities and their participants in a timely and cost-effective manner. Computer support is essential for such labor-intensive tasks as post-screening followup of participants, identifying subpopulations, and evaluating recruitment efforts and behavior change programs. The Pawtucket Heart Health Program developed a microcomputer software package, FPbase, for community health project data base management. FPbase is described and is available for use by other organizations. FPbase incorporates formative and process interactive data base activities and is suitable for use in operating intervention and screening programs at State and local levels. The system accommodates management of data for social marketing, evaluation, followup, and promotional activities.

Orbital neoplasia with enophthalmos in a cat

A 9-year-old cat was evaluated for left-sided enophthalmos and protrusion of the third eyelid. A primary orbital fibrosarcoma was diagnosed. During the orbital exploration, normal periorbital fascia could not be identified in the lateral and ventral region, thus accounting for the enophthalmos.

An introduction to the practice, prevalence and chemical toxicology of volatile substance abuse

1. Volatile substance abuse is largely a teenage practice; it is estimated that in the UK 3.5-10% of young people have at least experimented and that 0.5-1% are current users. 2. The products abused are many and varied but only about 20 chemical compounds, notably toluene, chlorinated solvents such as 1,1,1-trichloroethane, fuel gases such as butane and aerosol propellants, are commonly encountered. 3. The acute hazard varies with the compound, product and mode of abuse. Mortality in the UK is now about 100 per year, from all social classes, 90% of whom are male. 4. Chronic toxicity is difficult to assess, partly because of the diversity of products abused. However it is clear that some long-term abusers suffer permanent damage to the central nervous system, heart, liver and kidney. 5. Toxicological analysis may be relied upon for confirmation of diagnosis, providing attention is paid to the kinetics of excretion and stability in the sample. 6. Responses include codes of practice for the sale of products and educational strategies; legislation has also been enacted. There is little evidence that any of these measures have made a significant impact on the problem.

Neuropsychological consequences of volatile substance abuse: a population based study of secondary school pupils

OBJECTIVE

To examine the effects of volatile substance abuse on neuropsychological functioning.

DESIGN

A sample of index children and matched controls were identified by a two stage procedure. Firstly, over 5000 secondary school pupils completed a screening questionnaire, and, secondly, a sample of those who acknowledged volatile substance abuse and a matched sample of those who denied the practice were assessed in detail by means of (a) individually conducted interviews and (b) toxicological examination of breath samples (to exclude those intoxicated at the time of testing).

SETTING

16 Local education authority secondary schools in London.

SUBJECTS

160 Pupils aged 13-16: 80 index children who had abused volatile substances to the point of intoxication at least once (confirmed by interview) and 80 controls (confirmed by interview) matched for school year, sex, and ethnic background.

MEASUREMENTS AND MAIN RESULTS

Neuropsychological functioning tests provided 35 main outcome measures and were administered blind. Data on educational test performance before substance abuse began were obtained retrospectively. Information on potentially confounding social factors, such as number of siblings, tenure of housing, and parents' socioeconomic and employment state was also obtained. The index children performed significantly less well than the controls in tests of vocabulary, verbal intelligence quotient, full scale intelligence quotient, and a measure of impulsivity. When background social disadvantage was taken into account these differences were no longer significant. There were no significant associations between performance on psychological testing and frequency of abuse, and relations with other aspects of the children's history of abuse were generally weak or unsystematic. Comparisons between the results of these tests and of educational tests taken before substance abuse produced equivocal findings.

CONCLUSION

Volatile substance abuse, as commonly practised by secondary school pupils, is unlikely to result in neuropsychological impairment.

Neuropathy in a petrol sniffer

A 4 year old boy developed a profound motor neuropathy after repeated deliberate inhalation of petroleum vapour. The condition was characterised by extreme slowing of the nerve conduction velocity. He made a gradual recovery over six months. The neuropathy was attributed to the N-hexane component of petroleum.

Surface modulation of classical pathway activation: C2 and C3 convertase formation and regulation on sheep, guinea pig, and human erythrocytes

We examined the formation of the early classical complement (C) pathway enzymes on sheep (Es), guinea pig (Egp), and human (Eh) erythrocytes (E). Each species' E were sensitized with sufficient IgM or IgG anti-E Ab to establish equal numbers of C1-fixing sites on all E. After sensitization with 100 C1-fixing sites of Ab and excess C1, uptake of C4 was equivalent on all three cell types, judged by anti-C4 binding (for guinea pig C4) or by direct uptake of radiolabeled protein (for human C4). With equal numbers of cell-bound C1 and C4, however, there were marked differences in C2 convertase activity on Es, Egp, and Eh. Sheep EAC14 utilized C2 at least 20 times faster than Egp and Eh bearing the same number of C1 and C4 molecules. C3 cleavage was even further depressed on Egp and Eh, and was not changed by the substitution of oxyC2 for normal human C2. In whole guinea pig serum (GPS), 300 times more C1-fixing sites were required on Egp than on Es to achieve similar amounts of lysis; however, equivalent C3 uptake on Egp and Es was associated with equal extents of lysis, demonstrating that GPS lysis of these cells was regulated by early steps in classical pathway (CP) activation. Incubation of E bearing radiolabeled C4b with Factor I demonstrated that C4b on Egp was highly resistant to cleavage compared to the same protein bound to Es or Eh. Studies with partially purified C3 convertase decay-accelerating factors from Eh stroma demonstrated that these membrane proteins could not account for the observed surface regulation of CP activity because these proteins do not affect the rate of C2 cleavage by EAC14. We conclude that E surface molecules have an important role in modulation of CP activation. This surface-associated CP regulation occurs at the level of cell-bound C4b.

Surface modulation of classical pathway activation: C2 and C3 convertase formation and regulation on sheep, guinea pig, and human erythrocytes

We examined the formation of the early classical complement (C) pathway enzymes on sheep (Es), guinea pig (Egp), and human (Eh) erythrocytes (E). Each species' E were sensitized with sufficient IgM or IgG anti-E Ab to establish equal numbers of C1-fixing sites on all E. After sensitization with 100 C1-fixing sites of Ab and excess C1, uptake of C4 was equivalent on all three cell types, judged by anti-C4 binding (for guinea pig C4) or by direct uptake of radiolabeled protein (for human C4). With equal numbers of cell-bound C1 and C4, however, there were marked differences in C2 convertase activity on Es, Egp, and Eh. Sheep EAC14 utilized C2 at least 20 times faster than Egp and Eh bearing the same number of C1 and C4 molecules. C3 cleavage was even further depressed on Egp and Eh, and was not changed by the substitution of oxyC2 for normal human C2. In whole guinea pig serum (GPS), 300 times more C1-fixing sites were required on Egp than on Es to achieve similar amounts of lysis; however, equivalent C3 uptake on Egp and Es was associated with equal extents of lysis, demonstrating that GPS lysis of these cells was regulated by early steps in classical pathway (CP) activation. Incubation of E bearing radiolabeled C4b with Factor I demonstrated that C4b on Egp was highly resistant to cleavage compared to the same protein bound to Es or Eh. Studies with partially purified C3 convertase decay-accelerating factors from Eh stroma demonstrated that these membrane proteins could not account for the observed surface regulation of CP activity because these proteins do not affect the rate of C2 cleavage by EAC14. We conclude that E surface molecules have an important role in modulation of CP activation. This surface-associated CP regulation occurs at the level of cell-bound C4b.

Circadian cortisol secretory rhythms in Cushing's disease

Plasma cortisol was measured at 20-min intervals for 24 h in eight patients with Cushing's disease and ACTH-secreting pituitary tumors. The 24-h mean (+/- SD) cortisol level was 25.6 +/- 11.3 microgram/dl (range, 15.5--40.6), which was significantly higher than the level of normal control subjects (P less than 0.01). The 24-h mean ACTH level varied between 22--107 pg/ml, with a mean +/- SD of 63.4 +/- 27.2. The mean ACTH level was higher than that of the control subjects but the difference was not statistically significant. The 24-h cortisol secretory pattern was characterized by an absence of the normal circadian variation and a failure of the plasma cortisol level to fall to less than 2 microgram/dl between 2300--0300 h. The coefficient of variation, an expression of the amplitude of cortisol secretory episodes, was significantly decreased in patients with Cushing's disease compared to normal control subjects; there was no significant difference in the number of cortisol secretory episodes in the patients vs. control subjects. Three of the patients were restudied after successful resection of their ACTH-secreting pituitary tumors. Two showed normalization of their 24-h circadian cortisol patterns and normal metyrapone responses. In the third, the 24-h mean cortisol level was normal, but the circadian cortisol rhythm remained abnormal. This patient had diminished ACTH reserve, demonstrated by a subnormal response to metyrapone. Additional studies will be required to determine if normalization of the circadian cortisol rhythm occurs in all patients with Cushing's disease who are cured after transsphenoidal microsurgery and who also show normal ACTH reserve.