Collecting patients' views and perceptions of continence services: the development of research instruments

This paper describes one part of a feasibility study carried out in England which examined the costs, quality and effectiveness of continence services in areas with different approaches to provision. It involved the design of instruments to collect the views and perceptions of patients and an investigation of ways to develop a methodology to implement comparative studies. It is the design and piloting of the questionnaires and the way patients responded that forms the focus of this paper. The main sample group recruited for the study were women who had recently sought formal help with urinary incontinence and were likely to receive conservative treatment or management in the community. They were interviewed and asked to complete four questionnaires at two points in time. A smaller sub-group of disabled women, interviewed only once, were included to compare cost profiles for different client groups. The questionnaires which were developed address the impact of urinary incontinence (using a standard scale), the effectiveness of service provision in terms of patients' clinical history, expectations and hoped-for outcomes, service receipt and its cost, and patients' satisfaction with several aspects of service provision. In total 118 women were interviewed, including 28 disabled women. The study generated a set of survey instruments which might be used for a variety of purposes including audit and future research and which could inform purchaser and provider decisions by using patients' perspectives of quality of life outcomes to enhance service development.

Patients' action during their cardiac event: qualitative study exploring differences and modifiable factors

OBJECTIVES

To explore the circumstances and factors that explain variations in response to a cardiac event and to identify potentially modifiable factors.

DESIGN

Qualitative analysis of semistructured, face to face interviews with patients admitted to two district hospitals for a cardiac event and with other people present at the time of the event. Patients were divided into three groups according to the length of delay between onset of symptoms and calling for medical help.

SUBJECTS

43 patients and 21 other people present at the time of the cardiac event. Patients were divided into three groups according to the length of time between onset of symptoms and seeking medical help: non-delayers (< 4 h; n = 21), delayers (4-12 h; n = 12), and extended delayers (> 12 h; n = 10).

MAIN OUTCOME MEASURES

Decision making process, strategies for dealing with symptoms, and perception of risk and of heart attacks before the event according to delay in seeking help.

RESULTS

The illness and help seeking behaviour of informants had several components, including warning, interpretation, preliminary action, re-evaluation, and final action stages. The length of each stage was variable and depended on the extent to which informants mobilised and integrated resources into a strategy to bring their symptoms under control. There were obvious differences in informants' knowledge of the symptoms that they associated with a heart attack before the event. Non-delayers described a wider range of symptoms before their heart attack and twice as many (13) considered themselves to be potentially at risk of a heart attack compared with the other two groups. For most informants the heart attack differed considerably from their concept of a heart attack.

CONCLUSION

The most critical factor influencing the time between onset of symptoms and calling for professional medical help is that patients and others recognise their symptoms as cardiac in origin. This study suggests that various points of intervention in the decision making process could assist symptom recognition and therefore faster access to effective treatment.

Survey of resistance of herpes simplex virus to acyclovir in northwest England

Acyclovir (ACV) has been used for more than 15 years in the management of herpes simplex virus (HSV) and varicella-zoster virus (VZV) disease. The present survey was undertaken to assess the level of ACV resistance in the population. More than 2,000 HSV isolates from both immunocompetent and immunocompromised patients in northwest England were collected over a 2-year period and tested for sensitivity to ACV. These studies suggested a prevalence of resistance of approximately 0.1 to 0.6% in immunocompetent individuals, with no apparent difference in prevalence between treated and untreated groups. In line with previous studies, the prevalence of resistance in treated immunocompromised individuals was approximately 6%.

Pressure damage prevention: basing practice on evidence

As part of an initiative to develop evidence-based practice at the Northern General Hospital, Sheffield, a three-part project was undertaken. The aims were to identify barriers to using research in nursing, establish a baseline of nurses' knowledge and its influence on their practice in one essential area of nursing care--pressure damage prevention--and develop a strategy for change which took account of the findings from the first two parts of the project. In this article, the authors describe the second part of the project which examined nursing knowledge and practice with reference to the management of pressure damage prevention. The findings are discussed and the authors recommend that nurses integrate into their practice evidence from sources such as systematic reviews.

Improving clinical effectiveness through an evidence-based approach: meeting the challenge for nursing in the United Kingdom

Improving clinical effectiveness is a major challenge facing nurses working in the United Kingdom and requires a coordinated approach in order to ensure that the information about which interventions work is made available to those in a position to use it. This means that policy makers, administrators, and nurses need to base decision making on the best available evidence. In this article we explore the background to the drive for evidence-based practice and discuss how a group of nurse researchers have begun working with nurse administrators and practitioners in a large acute hospital to help change the rhetoric of evidence-based practice in nursing into reality.

Fuzzy logic in computer-aided breast cancer diagnosis: analysis of lobulation

This paper illustrates how a fuzzy logic approach can be used to formalize terms in the American College of Radiology (ACR) Breast Imaging Lexicon. In current practice, radiologists make a relatively subjective determination for many terms from the lexicon related to breast cancer diagnosis. Lobulation and microlobulation of nodules are two important features in the ACR lexicon. We offer an approach for formalizing the distinction of these features and also formalize the description of intermediate cases between lobulated and microlobulated masses. In this paper it is shown that fuzzy logic can be an effective tool in dealing with this kind of problem. The proposed formalization creates a basis for the next three steps (i) extended verification with blinded comparison studies. (ii) the automatic extraction of the related primitives from the image, and (iii) the detection of lobulated and microlobulated masses based on these primitives.

New highly polymorphic microsatellite marker in linkage disequilibrium with HLA-B

The difficulty of molecular typing of the HLA class I genes and the relevance of the genes of this region to disease susceptibility and transplantation have provided an impetus to develop useful typing markers. We have characterized by polymerase chain reaction analysis a new highly informative CA repeat localized approximately 25-kb centromeric to the gene HLA-B and 10-kb telomeric to the gene MICA. Twelve alleles defined by length were found in a sample of French Basques, with the PIC being 0.82. A detailed haplotype analysis was performed to investigate the association between this microsatellite and two others markers of the region (HLA-B gene and TNF region microsatellite). The 10 haplotypes with the highest estimated frequencies show evidence of a gametic association or linkage disequilibrium. A very strong association between the expressed HLA-B polymorphism and microsatellite alleles was also revealed in this sample and confirmed in the workshop cells lines of the Fourth Asia-Oceania Histocompatibility Workshop. This marker can be used in the fine mapping of this region and the association with some alleles of HLA-B may allow the replacement of HLA-B typing at least in a preliminary study. Moreover, these studies support the hypothesis of a high mutability for large alleles in microsatellite loci.

A preliminary study of prostaglandin release by bradykinin (BK) on isolated human myometrium

The aim of this study was to investigate whether the response to BK on isolated human myometrium from non-pregnant (NP) and pregnant (P) donors involves the release of prostaglandin I2 (PGI2) and/or of PGE2. BK was injected as a bolus dose into the flow of the superfusate. The perfusate was collected during a response to BK and PG concentration measured by enzymoimmunoassay for PGE2 or PGI2. The BK response was biphasic, consisting of contraction followed by inhibition of myogenic activity. In tissues from both NP and P donors BK was found to cause a dose related release of PGE2 and PGI2. BK evoked PGE2 release which was greater during the contractile response than in the inhibitory response. Following the same dose of BK, PGI2 release was found to be greater in the inhibitory response than in the contractile phase. The findings indicate that in isolated human myometrium the response to BK does involve the release of PGE2 and PGI2 and in both NP and P tissue PGE2 release is greater in the contractile response phase whilst PGI2 predominates the inhibitory phase.

Investigation into the role of cyclooxygenase products in the bradykinin response on isolated human myometrium and umbilical artery

The aim of this study was to investigate the response to bradykinin (BK) on human myometrium and umbilical artery with respect to cyclo-oxygenase (CO) products. Dose/concentration response curves to BK were performed +/-2.79 microM indomethacin. On human myometrium the response to BK (0.001-50 nmol) was biphasic and consisted of a dose-related increase in myometrial tension which was followed by a period of inhibition of myogenic activity. In tissues from P donors the presence of indomethacin had no significant effect on the excitatory response, but the inhibitory component of the response was reduced. In tissues from NP donors indomethacin significantly enhanced the BK effect at higher doses and the inhibitory component of the response was reduced. On the HUA cumulative addition of BK (1-1000 nM) resulted in dose dependent constriction with desensitisation at the highest dose (EC50 = 38 nM). The presence of indomethacin had no significant effect on BK response on HUA. These findings suggest that CO products contribute significantly to response to BK on the human myometrium but not on HUA and that different CO products are produced by P and NP tissue.

Comparison of the effects of bradykinin and related compounds on isolated mouse and human uterus

The purpose of this study was to investigate and compare the response of the isolated human myometrium (non-pregnant donors) and mouse uterus to bradykinin (BK), Lys-BK and des-Arg9-BK (+/-2.79 microM indomethacin). The uterine strips were set up for superfusion using Kerbs' solution. On the human myometrium the responses to BK and Lys-BK were biphasic and consisted of an increase in myometrial tension which was followed by a period of inhibition of myogenic activity. Des-Arg9-BK evoked a monophasic contractile response. On the mouse uterus the responses to BK, Lys-BK and des-Arg9-BK were monophasic and contractile only. On both of the tissues the contractile responses to BK and Lys-BK were bell shaped and indomethacin abolished the bell-shaped part of the dose response curves. The response to des-Arg9-BK and the inhibitory response to BK and Lys-BK, on the human tissue, was also significantly reduced in the presence of indomethacin. The results of this study suggest that the human and mouse uterus do posses kinin receptors of the B2 type but on human myometrium these are biphasic responses.

Strong association between microsatellites and an HLA-B, DR haplotype (B18-DR3): implication for microsatellite evolution

The HLA haplotype B18-DR3 has a widespread geographical distribution, but has its greatest frequencies in Southern Europe, probably vestigial of the earliest populations of this region, particularly in the Pays Basque and Sardinia. This haplotype is of medical significance, being that most implicated as a factor of risk in insulin-dependent diabetes mellitus. In this study, the closely linked microsatellite markers (TNFa,b,c) in the region of the tumor necrosis factor (TNF) genes have been used in an attempt to subtype this haplotype in the two populations and/or in healthy and diabetic populations. A total of 79 HLA-B18-DR3 haplotypes were analyzed: 54 in Basques (12 from healthy individuals and 42 from diabetics or their first-degree relatives) and 25 in Sardinians (13 from healthy and 12 from diabetic individuals). The TNF haplotype a1-b5-c2 is completely associated with B18-DR3 in both populations. The homogeneity of the B18-DR3 haplotype in two ethnically pure populations implies stability in evolution, which suggests that the mutation rate of these microsatellite markers must be less than is usually assumed (i. e., approximately 5 x 10(-4) per site per generation). Such markers should be powerful tools for studying genetic drift and admixture of populations, but it remains to be established whether this stability is a rule for all microsatellites in HLA haplotypes or whether it is restricted to some microsatellites and/or some HLA haplotypes. The population genetics of those microsatellites associated with HLA B18-DR3 was also studied in a random sample of the Basque population.

HLA -A, -B, -DR haplotype frequencies in France--implications for recruitment of potential bone marrow donors

We have undertaken a study of the haplotypes among French potential bone marrow donors in order to define the geographical regions of France with the maximum of polymorphism and also to develop a strategy for optimal donor recruitment. A maximum likelihood estimator was used to calculate haplotype frequencies and their support limits for each region and for the whole of France. The observed differences between the regions were statistically significant. For each region, the minimum number of haplotypes necessary to explain 50% of the total frequency was calculated and compared with the equivalent values, and confidence intervals, obtained by repeated random samplings from the overall file. This approach shows that some regions (e.g., Provence) appear to be richer in terms of the numbers of haplotypes observed, and others (e.g., Bretagne) poorer. In the latter case, however, the frequencies of the most common haplotypes are greater. The haplotype frequencies of the whole sample were used to calculate the probability of finding a match for the next potential recipient for given sizes of the donor file, assuming random selection of donors. They were also used to calculate expected numbers of the major phenotypes, assuming Hardy-Weinberg equilibrium, and these were compared with those observed in the real data file. In this way, a large number of under-represented and nonrepresented phenotypes were identified. For each of these phenotypes, the most probable haplotypes and the regions in which these have the greatest frequencies have been identified. A search for donors with such particular phenotypes would be much more fruitful if directed towards these regions.

Enlarged follicles in women using oral contraceptives

Ultrasound examination of the ovaries was performed in the first and/or second half of three consecutive cycles in 3 groups of women; Group T who had been using a levonorgestrel triphasic oral contraceptive for at least 6 months, Group P who had been using a progestogen-only pill for at least 6 months, and Group C, a control group. Any follicles greater than 10 mm in diameter and any cysts were measured. Fifty-three scans were performed in Group T, 45 in Group P and 31 in Group C. Only 4 follicles were detected in 17 women in Group T compared to 10 follicles in 15 women in Group P and 7 follicles in the women in Group C; all follicles were 25 mm or less in diameter except for 3 follicles in 2 women. The differences between the groups were not statistically significant. Four enlarged follicles were detected in 3 women during 53 scans in Group T, 15 in 8 women (45 scans) in Group P, and only 1 in 31 scans in Group C. Based upon the proportions of scans with enlarged follicles, the difference between Groups T and P was statistically significant, indicating that the incidence of enlarged follicles was lower in women using a combined oral contraceptive than in those using a progestogen-only pill. Furthermore, the study shows that any enlarged follicles which occurred were transient.

Haplotypes without children: PCR applied to close loci on individual human sperm

Indirect evidence of interindividual variation of the recombination fraction is considerable, but as yet direct evidence is lacking. Such interindividual variation could explain the widely observed gametic association in the major histocompatibility complex (MHC) region. A possible approach to this is the application of the polymerase chain reaction to closely linked markers on individual sperm. The feasibility of this approach is investigated here. Three loci in the human MHC (chromosome 6) were used in this study. Two are polymorphisms identifiable by oligonucleotide dot blotting, and one is a microsatellite polymorphism. The genetic distances between these loci are 0.5 and 1 centi-Morgan. We were able to double-type most cases for the two markers HLA-DPB and HLA-DRB in single haploid cells. The rate of double typings is comparable with that expected from the hypothesis of independent failures at two loci. However, this rate of failure remains too great to allow an analysis of segregation because allele specific failure cannot be ruled out. All double and triple typings (implicating the microsatellite) were perfectly correlated with each other; thus no recombinations were identified. With such close markers recombination would have been surprising and may indicate an inherent accuracy of positive haplotyping.

Molecular genetics of chimpanzee Rh-related genes: their relationship with the R-C-E-F blood group system, the chimpanzee counterpart of the human rhesus system

As the chimpanzee R-C-E-F blood group system appears to be the chimpanzee counterpart of the human Rhesus (RH) system, we have tried to determine whether chimpanzee Rh-like genes encode R-C-E-F-related proteins. Chimpanzee genomic DNA, digested by any of eight endonucleases and hybridized with three Rh exon-specific probes, exhibits a high degree of polymorphism. Analysis of DNA from unrelated individuals of different R-C-E-F types revealed that the presence of some restriction fragments is correlated with particular R-C-E-F types. The cosegregation of these fragments with R-C-E-F haplotypes was confirmed by family studies. Oligonucleotides complementary to regions flanking human exons were used as PCR primers on chimpanzee DNA; the resulting amplified fragments were identical in size to their human counterparts. Moreover, the nucleotide sequences of the fragments present a high degree of similarity to the corresponding human regions.

Localization of the OTF3 gene within the human MHC class I region by physical and meiotic mapping

OTF3 (octamer transcription factor 3) is a transcription factor containing a POU-specific domain and a homeodomain that could play a role in early development. In situ hybridization and pairwise linkage analysis showed that OTF3 gene maps close to the human MHC (major histocompatibility complex). In this paper, we define its localization within the MHC, around 100 kb telomeric to HLA-C, using a combination of physical and genetic analyses.

Tumor necrosis factor polymorphism in multiple sclerosis: no additional association independent of HLA

In order to investigate whether genes coding for tumor necrosis factors (TNF) contribute to the pathogenesis of multiple sclerosis (MS) and also whether they have a non-random association with the MS associated HLA-DRB1*1501-DQA1*0102-DQB1*0602 haplotype, 40 MS patients and their parents were characterized at four polymorphic loci in the region of the TNF genes: a NcoI RFLP and three microsatellites. We were able to determine the parental haplotypes and used those which were not transmitted to the proband as controls. Fifty percent of the HLA-DRB1*1501-DQA1*0102-DQB1*0602 haplotypes carried the TNFc1-n2-a11-b4 allelic combination in both the patient and the control groups. However, there was no association of any of these TNF polymorphisms with MS, independent of that already described for the class II region. This, with the lack of association of DP alleles with MS, effectively marks the boundaries of the MS associated haplotype.