Speech and language therapists as trainers: enabling care staff working with older people

A recently completed evaluation of a one day training package on communication has found evidence of a perceived need for training in both communication and communication impairment among care workers employed by health and social care agencies. This paper is a discussion of the factors that contribute to the delivery of successful workshops to front line care workers.

Longitudinal effects of integrated treatment on alcohol use for persons with serious mental illness and substance use disorders

A randomized experimental design was used to assign participants to an integrated mental health and substance use treatment program or to standard hospital treatment. A multilevel, nonlinear model was used to estimate hospital treatment effects on days of alcohol use for persons with serious mental illness and substance use disorders over 18 months. The integrated treatment program had a significant effect on the rate of alcohol use at 2 months postdischarge, reducing the rate of use by 54%. Motivation for sobriety at hospital discharge, posttreatment self-help attendance, and social support for sobriety were also found to reduce the rate of use during the follow-up period. Implications for mental health treatment and aftercare support are discussed.

Changing attitudes about persons with disabilities: effects of a simulation

The question of whether the use of a teaching strategy employing simulation influences attitudes toward disabled persons over time was addressed in this quasi-experimental intervention study. The experimental group participated in "Sensitivity Day" which incorporated a simulation activity. A total of 77 undergraduate baccalaureate nursing students completed the Attitudes Toward Disabled Persons scale four times: presimulation, immediate postsimulation, six week delayed postsimulation and six month delayed postsimulation. In general, the nursing students had relatively positive scores on the Attitudes Toward Disabled Persons scale in each testing period. The best indicator of postsimulation attitude scores was the presimulation attitude score. Personal and prior nursing experience had no statistical effects on attitude. Improvement that was significant at p = .07 level was noted in the experimental group at the six weeks delayed postsimulation when compared with the presimulation attitude scores. This study supplies data that is useful in constructing learning activities and contributes to the body of knowledge about simulation and attitudes toward persons with disabilities.

T wave alternans associated with HIV cardiomyopathy, erythromycin therapy, and electrolyte disturbances

We report a case of T wave alternans in a patient with HIV cardiomyopathy. T wave alternans is an unusual electrocardiographic finding in acquired long QT syndromes that can precede the development of torsades de pointes. Our patient had multiple risk factors for the development of the acquired long QT syndrome, including HIV cardiomyopathy, electrolyte disturbances, and erythromycin therapy. T wave alternans has not been described previously with HIV cardiomyopathy and only rarely with erythromycin therapy. Patients who have HIV cardiomyopathy and who receive intravenous erythromycin may benefit from monitoring for QT prolongation and electrolyte disturbances to avoid the development of torsades de pointes.

Obstetric outcome in women who present with a reduction in fetal movements in the third trimester of pregnancy

A complaint of decreased fetal movements is a common indication for the assessment of fetal well being. The aim of this study was to review the outcome of a group of women whose primary indication for referral was decreased fetal movements. Over a 20 month period, 435 patients were seen in the fetal assessment unit of an inner London teaching hospital, following a primary complaint of reduced fetal movements. Investigations included: the fetal abdominal circumference (AC), amniotic fluid volume (AFV), the umbilical artery pulsatility index (UAPI) derived from Doppler ultrasound waveforms and a computerised analysis of fetal heart rate (FHR) recordings or cardiotocograph (CTG). Outcome measures were: gestational age at delivery, Apgar score < 7 at 5 minutes, admission to the Special Care Baby Unit (SCBU), the need for delivery by an emergency cesarean section for fetal compromise (CSFC), and any perinatal deaths. A comparison of actual versus expected outcome for women with decreased fetal movement revealed the following relative risks, with the 95% confidence intervals (CI) in brackets; low 5 minute Apgar score 0.03 vs. 0.05 expected (CI = 0.01, 0.05), SCBU admission, 0.06 vs. 0.07 (0.04, 0.08), and preterm delivery, 0.08 vs. 0.11 (0.05, 0.10). Cesarean sections for fetal compromise, 0.07 vs. 0.053 (0.050-0.096). The addition of FHR monitoring to standard ultrasound assessment of well being did not appear to confer any added benefit. There were no fetal deaths. The outcome for pregnancies where the mother presents with decreased fetal movements in the third trimester is comparable with the outcome for the general population.

Generation, characterization and utilization of anti-human growth hormone 1-43, (hGH1-43), monoclonal antibodies in an ELISA

The major isoform of hGH is a polypeptide of 191 amino acids. Human GH1-43 is an amino terminal segment of hGH1-191 which comprises the first 43 amino acids. This peptide is a potent regulator of glucose homeostasis. To facilitate our understanding of the physiological regulation of hGH1-43 an assay to measure its levels in biological fluids and extracts is needed. This communication describes the development of anti-hGH1-43 monoclonal antibodies and their use in the development of an indirect competitive ELISA for the quantification of hGH1-43. Hybridomas were produced by the fusion of FOX-NY myeloma cells with spleen cells taken from a mouse immunized with hGH1-43. The hybridomas were screened for production of antibodies to hGH1-43 by antibody capture ELISA. Hybridomas which produced antibodies reactive to hGH1-43 were cloned by limiting dilution. Three monoclonal hybridomas, CCL-1, CCL-2, and CCL-3 were subsequently obtained. These hybridomas secreted antibodies that were highly reactive towards hGH1-43 but minimally reactive towards hGH1-191. The isotypes of the mAbs secreted by CCL-1, CCL-2 and CCL-3 were all IgG1 kappa as shown by isotype specific antibody capture analysis. An indirect competitive ELISA with a detection limit that ranged from 1 to 10 ng/ml was developed using mAbs from monoclonal hybridoma CCL-3. Dose-response curves for competing hGH1-191, hPRL, and hPL indicated minimal cross-reactivity of mAbs with these hormones and conversely, a high degree of specificity for hGH1-43. Dose-response curves for dilutions of human serum and pituitary extract were parallel to the standard. The availability of a sensitive assay for the measurement of hGH1-43 will help us answer questions regarding the biosynthesis, regulation of secretion, and role of hGH1-43 in the control of glucose homeostasis.

Communicate: organisational issues and their relevance for clinical evaluation

This paper reports the first findings of a two year project funded by the NHS Executive North Thames to provide an independent evaluation of Communicate, Action for Dysphasic Adults' training programme for carers of older people with communication impairments. The project comprises an organisational evaluation (January-July 1998) to review the use of Communicate by purchasers nationally and in the North Thames health region, and (from September 1998) a clinical evaluation in North Thames region, to investigate outcomes for communicatively impaired people themselves and for training participants. The paper outlines the research design and progress so far before presenting initial findings. It concludes by discussing the relevance of organisational issues and social science research insights to the forthcoming clinical evaluation.

Torsional properties of Ni-Ti and copper Ni-Ti wires: the effect of temperature on physical properties

The stress-strain behaviour of two Ni-Ti and two Copper Ni-Ti orthodontic wires was examined in induced torsion under controlled conditions of moment and temperature. The tests clearly demonstrate the diversity of behaviour of these wires. The loading and unloading curves and plateau regions were found to be closely related to temperature with stiffness varying dramatically over mouth temperature range under identical stress. Diversity of reaction to stress is linked to the crystalline structure of the alloys.

Comparative study of serological methods for the detection of antibodies to porcine reproductive and respiratory syndrome virus

A comparison was made of serological diagnostic methods used for the detection of antibodies against porcine reproductive and respiratory syndrome (PRRS) virus. In the "phase I" PRRS test panel comparison, a panel of sera collected from 135 pigs of various ages, from North American herds with and without PRRS histories, were sent to 4 different laboratories and tested by an indirect immunofluorescent assay (IFA), an immunoperoxidase monolayer assay (IPMA) and an indirect enzyme-linked immunosorbent assay (iELISA). In the "phase II" PRRS test panel comparison, a panel of 382 sera collected from pigs of various ages, PRRS histories, and from various locations in North America and France, were divided into 2 panels (A & B) and sent to 3 Canadian laboratories and tested by the IFA and iELISA. In the phase I comparison, agreement between the IFA of laboratory 4 and the iELISA and IPMA of laboratory 3 was excellent (kappa values of 95% and 98%, respectively). This contrasted with the poor agreement between these laboratories and the IFA results of laboratories 1 and 2 in the phase I trial. In the phase II comparison, the results demonstrated good agreement between various tests both within and between laboratories. The overall performance of the iELISA was superior in the combination of sensitivity (96.1%) and specificity (100%) relative to the reference classification of the serum samples and repeatability (kappa value 98%). The iELISA is technically superior to IFA and IPMA, time efficient, cost effective and suitable for testing of a large number of samples over a short period of time. Thus, the iELISA may be a better alternative to IFA or IPMA for routine detection of PRRS viral antibodies in swine sera.

The efficacy of trypsin for disinfection of in vitro fertilized bovine embryos exposed to bovine herpesvirus 1

Bovine cumulus-oocyte complexes (COC) or in vitro fertilized (IVF) embryos were exposed to bovine herpesvirus 1 (BHV-1) during in vitro maturation or co-culture with uterine tubal cells, respectively. Trypsin, at a concentration of 0.25%, was applied (for approximately 90 s) to disinfect either COC or cumulus-free oocytes (CFO) 18 h after insemination, or on day 7 to embryos resulting from infected oocytes. In total, virus was not detected in 71% of 93 samples containing 233 embryos exposed to BHV-1 and trypsin treatment. BHV-1 was detected in 14% and 54% of samples containing a single embryo and five embryos, respectively. In corresponding groups of embryos exposed to BHV-1, then washed but not treated with trypsin (70 samples), 85% and 96% of samples containing one embryo and pooled embryos, respectively, were positive for the virus. There was no effect of trypsin treatment on the development of IVF-embryos. It is concluded that IVF-generated embryos have a greater tendency to carry BHV-1 after experimental exposure to the virus than IVF uterine stage embryos, and that they are more difficult to disinfect by means of the standard trypsin treatment use.

Immediate outcomes of substance use treatment within a state psychiatric hospital

Outcomes of an integrated inpatient treatment program for persons with serious mental illness and substance use disorders are examined in relationship to five stages of treatment--stabilization, engagement, persuasion/awareness, active treatment, and relapse prevention. The study used a randomized design with participants assigned to an integrated mental health and substance abuse treatment program or standard psychiatric hospital treatment. At discharge, participants in the integrated treatment program indicated more active engagement in treatment and greater awareness of mental health issues, substance use issues, and the 12-step program than those who received standard hospital treatment. Participants in the integrated treatment program also saw their treatment as being more effective and had more motivation to stay healthy and sober. The integrated treatment program was not equally effective at each treatment stage with all participants. The implications of the program's success overall and at each treatment stage are discussed.

Early olfactory experience, novelty, and choice of sexual partner by male rats

After rearing by citral-scented or unscented dams, adult male rats were given simultaneous choices of citral-scented or unscented female partners in approach, contact, and sexual behavior tests. There was no evidence that mate choice had been affected by the early rearing experience. In Experiment 1, both citral and control males approached citral-scented females in a T-apparatus at slightly above chance levels and exhibited no differences in copulatory behavior during successive pairings. In Experiment 2, normally reared males directed their first mount more rapidly to a citral female, but otherwise mated equally with the scented and unscented females. In Experiment 3, citral-reared males approached citral and unscented females equally, whereas controls approached citral females less often. With 2 females in the same arena (Exp. 3), the first mount was more rapid when the odor of the partner matched that of the dam, but no other measure of sexual behavior was affected by the partner's odor. Despite the importance of early olfactory experience for the development of social behavior, a preference for estrous-related odors is evidently not learned before mating experience. Under some circumstances, a novel odor added to familiar conspecific odors may attract naive males to potential partners.

Bioenergetics and control of oxygen consumption in the in situ rat heart

Control of respiration by products of ATP hydrolysis was examined in the in situ rat heart using a purpose-built nuclear magnetic resonance (NMR) coil. The in situ ratio of phosphocreatine to ATP concentrations ([PCr]/[ATP]) was 2.30 +/- 0.05, free Mg2+ concentration ([Mg2+]) was 0.57 mM, and cytosolic pH was 7.35 +/- 0.03 (n = 7). Basal inorganic phosphate concentration ([Pi]) was below NMR detection but was estimated to be 0.83 mM. The [ATP]/[ADP] [Pi] ratio, free ADP concentration ([ADP]), and free energy of ATP hydrolyses (delta GATP) were calculated to be 700,000 +/- 78,000 M-1, 18 +/- 3 microM, and -63.93 +/- 0.33 kJ/mol in situ, respectively (n = 7). In contrast, in the Langendorff perfused rat heart [ATP]/[ADP] [Pi] was only 76,140 +/- 12,830 M-1, [ADP] was 65 +/- 9 microM, and delta GATP was -59.92 +/- 0.48 kJ/mol (n = 7), all indicative of a lower energy state in vitro. Epinephrine infusion in situ (0.9 microgram.min-1.kg-1) increased the rate-pressure product 2.05-fold. During stimulation [ATP] was stable at 97 +/- 3% signal intensity, [PCr] declined by 25%, and [Pi] increased to 1.83 mM. Cytosolic pH was 7.27 +/- 0.01 and [Mg2+] was 0.64 +/- 0.05 mM. [PCr]/[ATP] declined to 1.83 +/- 0.13, and [ATP]/[ADP] [Pi] fell to 108,000 +/- 15,000 M-1. delta GATP only fell marginally to -59.56 +/- 0.49 kJ/mol. Free [ADP] increased threefold to 55 +/- 10 microM. Infusion of 2.8 +/- 0.5 microgram.min-1.kg-1 epinephrine increased the rate-pressure product 2.7-fold, further reduced [ATP]/[ADP] [Pi] (5% of basal), and elevated [ADP] more than fourfold without changing [ATP]. We conclude that the in situ heart is highly energetic compared with isolated perfused hearts and operates at a different metabolic "set-point." Because free [ADP] and [Pi] in situ approximate apparent Michaelis constants for mitochondrial respiration in vitro and increase with increased cardiac work, we conclude that each fulfills the criteria for the kinetic control of O2 consumption in the in situ rat myocardium.

Mobile cardiac catheterization registry: report of the first 1,001 patients

The purpose of this study was to evaluate prospectively the efficacy and safety of mobile cardiac catheterization. Mobile cardiac catheterization was introduced into clinical practice in 1989, but there has been no systematic study of its performance and safety. A registry was established in 1989 to monitor outcomes with mobile cardiac catheterization and is reported here. Patients were screened for eligibility for mobile cardiac catheterization using the joint AHA/ACC criteria for outpatient angiography. Eligible patients underwent mobile catheterization at eight hospitals within 120 miles of the base tertiary center. Helicopter evacuation services were available at each mobile site. The indications, findings, dispositions, and complications of mobile cardiac catheterization were recorded by means of a checklist, telephone follow-up and chart review. A total of 1,001 consecutive patients were entered into the registry in the first 20 months of operation, including 436 females and 565 males aged 22 to 84 years. Angina (Canadian Classes II-IV) was the most frequent primary indication for catheterization (46.4%), followed by atypical chest pain (36.9%), or a positive exercise stress test (25.6%). Infrequent indications for catheterization included a history of myocardial infarction (5.6%), congestive heart failure (7.1%), arrhythmias (4.1%), and valvular heart disease (0.7%). Catheterization was accomplished in 99.9% of patients. Angiographically normal studies were observed in 22.8%, and mild (< or = 50%) coronary artery disease in 13.6% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Comprehensive drug and alcohol treatment programming: a bold new approach

We have witnessed, in the latter half of the 20th century, significant revisions in the manner in which medical, psychiatric, and forensic services are delivered. Specifically, it appears that a wide range of treatment services are moving from modes of intervention that are dominated by primary institutional arrangements towards decentralized, community-based models of care. Missouri's CSTAR program represents a similar shift in alcohol and drug treatment. The CSTAR program provides an array of intensive community services that replaces hospital and residential services. In addition, community-based case management services promote social as well as medically based interventions. Parallels between the CSTAR model and the development of Community Support Services in psychiatric care are offered.

Identification and characterization of a novel Bacillus thuringiensis delta-endotoxin entomocidal to coleopteran and lepidopteran larvae

A new class of Bacillus thuringiensis delta-endotoxins, or insecticidal control proteins (ICPs), is defined by an apparently cryptic protein with a unique primary structure and novel entomocidal specificity for certain coleopteran and lepidopteran species. The discovery of a new group of ICPs will extend the use of this natural insecticide in integrated pest-management systems.

New alternatives in gallstone treatment

Within the past few years, a number of new treatment modalities for gallbladder stones have become available. Laparoscopic cholecystectomy has proved as safe as traditional surgical cholecystectomy, without the discomfort and lengthy recuperation associated with a large abdominal incision. Several other new treatments also have been investigated, including percutaneous cholecystolithotomy, peroral drug chemolysis, extracorporeal shock wave lithotripsy, and methyl-tert-butyl ether lavage. The relative merits and disadvantages of these treatments, compared to each other and to standard cholecystectomy, are described herein.

Periprosthetic knee sepsis. The role of irrigation and debridement

Thirty-three infected total knee arthroplasties were treated by irrigation, debridement, and intravenous antibiotics. These cases were retrospectively reviewed with an average follow-up period of 4.5 years. There were 12 revisions and 21 primary arthroplasties in the series. Thirty-two knees were openly irrigated and debrided, and one was arthroscopically treated. In 20 of 33 knees, infection recurred--a reinfection rate of 61%. The authors attempted to identify factors influencing success and failure of infection eradication. There was a statistically significant improvement in the success rate of knees irrigated and debrided within four weeks of index surgery (p less than .05). No statistically significant correlation was found between success and failure with regard to gender, age, preoperative diagnosis, previous surgery, length of intravenous antibiotics, or time from clinical symptoms to debridement. The authors believe that irrigation and debridement have a role in the immediate postoperative period. Caution should be used in periprosthetic knee infection appearing greater than four weeks from index surgery.

Palliative care in a general teaching hospital. 2. Establishment of a service

OBJECTIVE

To assess the first year of operation of a palliative care service in a general teaching hospital.

DESIGN, SETTING, PATIENTS

A retrospective analysis of 241 terminally ill patients referred to the Austin Hospital Palliative Care Service during its first year of operation.

MAIN OUTCOME MEASURES

The occurrence and relief of pain, the occurrence and management of social and psychological problems, involvement of allied health services and the place of death.

MAIN RESULTS

Unrelieved pain was the most frequent medical problem but, with appropriate medical management as well as input from other members of the multidisciplinary team, all patients achieved satisfactory pain control. The occurrence and severity of social and psychological problems was greater than expected. Most of the patients were discharged home and referred to domiciliary palliative care services; one-quarter of patients were able to die at home, one-third died in an inpatient hospice, and the remainder died in hospital.

CONCLUSIONS

The Service was able to achieve most of its stated aims and has generated a much improved appreciation of the palliative care needs of patients with terminal illness and their families within the Hospital. A multidisciplinary approach to the management of terminally ill patients is crucial, and this Service has been successful despite limited staffing because of the willing involvement of other Units and Services in the Hospital. The difficulties inherent in the evaluation of a palliative care program (quality of life, cost-effectiveness) are discussed.

Caregiver's anticipatory grief in dementia: a pilot study

Twenty-seven wives who care for their spouses suffering from dementia completed the Anticipatory Grief Scale (AGS) and the Hopkins Symptom Checklist--SCL-90-R. The alpha coefficient for the AGS was 0.84, indicating good internal consistency. The AGS was also positively and significantly correlated (p less than 0.001) with the depression, anxiety, and hostility dimensions of the SCL-90-R, demonstrating good validity. The study explores bereavement issues of spouses of patients with dementia and provides preliminary findings on a new instrument to measure anticipatory grief.