Evaluation of specialists' outreach clinics in general practice in England: process and acceptability to patients, specialists, and general practitioners

OBJECTIVES

The wider study aimed to evaluate specialists' outreach clinics in relation to their costs, processes, and effectiveness, including patients' and professionals' attitudes. The data on processes and attitudes are presented here.

DESIGN

Self administered questionnaires were drawn up for patients, their general practitioners (GPs) and specialists, and managers in the practice. Information was sought from hospital trusts. The study formed a pilot phase prior to a wider evaluation.

SETTING

Nine outreach clinics in general practices in England, each with a hospital outpatient department as a control clinic were studied.

SUBJECTS

The specialties included were ear, nose, and throat surgery; rheumatology; and gynaecology. The subjects were the patients who attended either the outreach clinics or hospital outpatients clinics during the study period, the outreach patients' GPs, the outreach patients' and outpatients' specialists, the managers in the practices, and the NHS trusts which employed the specialists.

MAIN OUTCOME MEASURES

Process items included waiting lists, waiting times in clinics, number of follow up visits, investigations and procedures performed, treatment, health status, patients' and specialists' travelling times, and patients' and doctors' attitudes to, and satisfaction with, the clinic.

RESULTS

There was no difference in the health status of patients in relation to the clinic site (ie, outreach and hospital outpatients' clinics) at baseline, and all but one of the specialists said there were no differences in casemix between their outreach and outpatients' clinics. Patients preferred, and were more satisfied with, care in specialists' outreach clinics in general practice, in comparison with outpatients' clinics. The outreach clinics were rated as more convenient than outpatients' clinics in relation to journey times; those outreach patients in work lost less time away from work than outpatients' clinic patients due to the clinic attendance. Length of time on the waiting list was significantly reduced for gynaecology patients; waiting times in clinics were lower for outreach patients than outpatients across all specialties. In addition, outreach patients were more likely to be first rather than follow up attenders; rheumatology outreach patients were more likely than hospital outpatients to receive therapy. GPs' referrals to hospital outpatients' clinics were greatly reduced by the availability of outreach clinics. Both specialists and GPs saw the main advantages of outreach clinics in relation to the greater convenience and better access to care for patients. Few of the specialists and GPs in the outreach practices held formal training and education sessions in the outreach clinic, although over half of the GPs felt that their skills/expertise had broadened as a result of the outreach clinic.

CONCLUSIONS

The processes of care (waiting times, patient satisfaction, convenience to patients, follow up attendances) were better in outreach than in outpatients' clinics. However, waiting lists were only significantly reduced for gynaecology patients, despite both GPs and consultants reporting reduced waiting lists for patients as one of the main advantages of outreach. Whether these improvements merit the increased cost to the specialists (in terms of their increased travelling times and time spent away from their hospital base) and whether the development of what is, in effect, two standards of care between practices with and without outreach can be stemmed and the standard of care raised in all practices (eg, by sharing outreach clinics between GPs in an area) remain the subject of debate. As the data were based on the pilot study, the results should be viewed with some caution, although statistical power was adequate for comparisons of sites if not specialties.

Will enrolled nurses feature in the English National Board's equal opportunities policy research?

The English National Board for Nursing, Midwifery and Health Visiting is planning to evaluate the implementation of its equal opportunities policy with reference to the recruitment into nurse education and training of people from ethnic minority groups. This paper argues the case for including in this initiative a close examination of the processes of conversion from enrolled to registered nurse status and of the experiences of those nurses seeking promotion through this route. Past recruitment of many black and ethnic minority people into this level of nursing and their continuing service there makes this a potentially fruitful area of enquiry.

Activation of purinergic receptors triggers oscillatory contractions in adult rat ventricular myocytes

Extracellular ATP is an important neurotransmitter that modulates cardiac function by activation of purinergic receptors. In this study, the effect of P2 purinergic receptor activation on contractions and on [Ca2+]i was investigated in adult rat ventricular myocytes. Fura 2 was used to measure [Ca2+]i, and video edge detection was used to measure contraction. Superfusion of 2-methylthio-adenosine-5'-triphosphate (2-M-S-ATP) over quiescent myocytes induced oscillations in contraction and in [Ca2+]i. The frequency of the oscillatory contractions increased with increasing concentrations of 2-M-S-ATP, but the amplitude of contractions varied from cell to cell and was independent of the concentration of 2-M-S-ATP. During electrical stimulation, activation of purinergic receptors in myocytes potentiated the amplitude of contraction and induced arrhythmias. In populations of quiescent myocytes, the plateau phase of the [Ca2+]i signal evoked by 2-M-S-ATP could be shown to represent summed oscillations in [Ca2+]i in individual cells. Pretreatment of quiescent myocytes with thapsigargin or caffeine reduced or abolished the oscillations in contractions and in [Ca2+]i triggered by 2-M-S-ATP, indicating a dependence of the oscillations on uptake and release of Ca2+ by the sarcoplasmic reticulum. These data demonstrate the novel phenomenon that activation of purinergic receptors in quiescent myocytes stimulates oscillations in [Ca2+]i and contraction. In electrically stimulated myocytes, activation of purinergic receptors triggers oscillatory contractions and potentiates the amplitude of electrically triggered contractions.

Defense styles, hostility, and psychological risk factors in male patients with personality disorders

The purpose of this study was to compare ratings of defense styles and hostility in male patients with personality disorders, to determine whether either of these is related to a borderline diagnosis, or to specific psychological risk factors. Subjects with personality disorders were divided into borderline personality disorder (BPD) (N = 61) and non-BPD (N = 60) groups were given both the Defense Style Questionnaire (DSQ) and the Buss-Durkee Guilt-Hostility Inventory (BDHI). Risk factors were measured by a developmental interview and the the Parental Bonding Index. The BPD group reported more maladaptive and image distorting defenses on the DSQ, as well as higher ratings on the BDHI. Ratings on both dependent measures were strongly related to diagnosis, and more weakly to measures of psychological risk factors. Thus, in men with personality disorders, immature defense styles and high levels of hostility are strongly associated with a borderline diagnosis.

Making sense of action research through the use of a typology

Commenting on earlier work in the Journal of Advanced Nursing on action research, this paper takes up the theme of definition and approach and presents an original action research typology. Three key criteria of action research--'reeducation', 'problem focus', and 'improvement and involvement'--are related to four broad types of action research: 'experimental', 'organizational', 'professionalizing' and 'empowering'. The typology is of general relevance not only to action researchers but to any project concerned to resolve problems and bring about improvements in practice, including evaluation research. Following discussion of the typology, it is used to analyse three different action research projects, including one conducted by the authors in collaboration with a project team. It is shown that each of these projects, which are all concerned in some way to improve standards of nursing care in hospitals, contains elements of different types which may at times be in conflict. The ability to recognize this and to be explicit about the different types may assist action researchers in selecting an appropriate approach and in anticipating problems which may arise during the course of a project's life.

Decreased inotropic response to beta-adrenergic stimulation and normal sarcoplasmic reticulum calcium stores in the spontaneously hypertensive rat heart

Cardiac hypertrophy in the spontaneously hypertensive rat has been shown to be accompanied by a diminished inotropic response to beta-adrenergic stimulation. This diminished response has been attributed to abnormalities in various components of the beta-adrenergic signaling system. There is also evidence that regulation of intracellular Ca2+ cycling may be altered in the hypertrophied heart of the spontaneously hypertensive rat. We proposed that the diminished response to beta-adrenergic stimulation may reflect abnormalities in Ca2+ cycling, specifically alterations in the ability of the sarcoplasmic reticulum to effectively release and resequester Ca2+. We have used the unique combination of functional measurements on isolated, isometrically contracting papillary muscles from hearts of 26-week-old spontaneously hypertensive rats and their Wistar-Kyoto controls, together with electron probe microanalysis measurements of sarcoplasmic reticulum Ca2+ content in the same muscles after rapid freezing, to determine the availability of Ca2+ for activation of contraction, following beta-adrenergic stimulation. We observed a significant decrease in the inotropic response to beta-adrenergic stimulation in papillary muscles from the spontaneously hypertensive rats, as compared with Wistar-Kyoto controls, however in these same muscles, frozen during relaxation, there was no evidence of an accompanying decrease in the size of the sarcoplasmic reticulum Ca2+ store. In an additional group of muscles which were frozen during contraction, the amount of Ca2+ remaining in the sarcoplasmic reticulum after stimulated release was also not different in the two strains. These results indicate that the decreased inotropic response to beta-adrenergic stimulation in hypertrophied hearts of the spontaneously hypertensive rat is unlikely to be due to decreased availability of Ca2+ for activation of contraction. Additionally, to determine whether there is intracellular Ca2+ overload in the cardiac muscle cells of hearts of spontaneously hypertensive rats, we measured the amount of Ca2+ in mitochondrial and at the level of the myofilaments by electron probe microanalysis. These results indicate that intracellular Ca2+ overload does not accompany cardiac hypertrophy in the spontaneously hypertensive rat. This study therefore shows no correlation between altered intracellular Ca2+ cycling and the decreased inotropic response to isoproterenol in the spontaneously hypertensive rat at 26 weeks of age.

Satisfying solutions? A review of some unresolved issues in the measurement of patient satisfaction

The measurement of patient satisfaction has been encouraged by a growing consumer orientation in health care, especially since it yields information about consumers' views in a form which can be used for comparison and monitoring. However, drawing on literature from a variety of sources, this paper suggests that there remain several unresolved issues relating to the measurement of satisfaction, and some serious questions about the validity of the concept. It is argued that current approaches to measuring satisfaction may not be grounded in the values and experiences of patients; therefore satisfaction surveys could be denying patients the opportunity to have their opinions included in the planning and evaluation of health care services.

Generating ideas for research: an Australian research experience

Recent changes in the educational system and career developments in Australia have provided Australian clinical nurses with an opportunity to conduct research in their practice. In this article, the nursing staff of an Australian gastroenterology unit describe their experience in defining a research project.

Arachidonic acid-dependent phosphorylation of troponin I and myosin light chain 2 in cardiac myocytes

Recent evidence has suggested that arachidonic acid (AA) may be an important signaling molecule in cardiac excitation-contraction coupling. We previously showed that AA and endothelin-1 (ET) inhibit distinct K+ channels via protein kinase C-dependent pathways in rat ventricular myocytes. In addition, we demonstrated that Ca2+ transients in populations of fura 2-loaded myocytes were potentiated by AA and ET via activation of protein kinase C. In this study, we have used suspensions of [32P]orthophosphate (32Pi)-labeled rat ventricular myocytes to study the effects of AA and ET at the level of the myofilaments. After a 10-minute incubation of the labeled cells with phorbol 12-myristate 13-acetate (PMA), AA, or ET in the presence or absence of the protein kinase C inhibitor calphostin C, the myofibrillar proteins were separated by PAGE. Measurement of unloaded cell shortening using video edge detection in single electrically stimulated myocytes was also used to assess the effects of AA and ET on myocyte contractility. Incubation with either PMA, AA, or ET resulted in similar increases in 32Pi incorporation into troponin I (TnI) and myosin light chain 2 (MLC2), which was inhibited by preincubation with the protein kinase C antagonist calphostin C. In addition, the ability of these agonists to stimulate phosphorylation of TnI or MLC2 did not require extracellular Ca2+ or intact intracellular Ca2+ stores. The effects of AA and ET together on phosphorylation of TnI or MLC2 were not additive.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of lovastatin on cholesterol content of cardiac and red blood cell membranes in normal and cardiomyopathic hamsters

Lovastatin, an inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A, is used therapeutically to lower plasma cholesterol levels. However, the effect of this therapy on cell membrane cholesterol in vivo is not known. The goal of this study was to investigate whether lovastatin treatment of hamsters decreases cholesterol in cardiac cell membranes and in red blood cell (RBC) membranes. Because abnormal cellular Ca++ regulation has been associated with altered membrane cholesterol in hearts of cardiomyopathic (CM) hamsters, we also measured the cholesterol content of cardiac and RBC membranes from lovastatin-treated and untreated Bio 14.6 CM hamsters to determine whether any differences existed with respect to normals. Sarcolemma-enriched cardiac membranes and RBC membranes were obtained from 42 to 45-day normal and CM hamsters after 13 days of lovastatin treatment (0.1% of food/day) and from untreated normal and CM hamsters. Plasma cholesterol, membrane cholesterol/phospholipid (C/PL) ratio and cholesterol per milligram of membrane protein (C/prot) were determined. In hearts from untreated CM hamsters, C/prot was significantly lower (P < .05) than in untreated normals. Lovastatin decreased plasma cholesterol by 76% and 81% in normal and CM hamsters, respectively (P < .001), but after lovastatin treatment, there was no significant change in C/PL or C/prot in cardiac membranes from either strain; there was also no significant decrease in C/prot or in C/PL of RBC membranes from normals or C/PL of CM hamster RBC membranes. However, lovastatin feeding resulted in a significant (P < .01) 24% decrease in C/prot of CM RBC membranes.(ABSTRACT TRUNCATED AT 250 WORDS)

Altered subcellular Ca2+ regulation in papillary muscles from cardiomyopathic hamster hearts

To investigate whether cardiac dysfunction in prefailure cardiomyopathic (CM) hamster hearts is due to Ca2+ overload or alternatively to decreased availability of Ca2+ in the sarcoplasmic reticulum (SR), the Ca2+ channel agonist, BAY K 8644, was used to compare the effects of increased Ca2+ influx on function and subcellular Ca2+ distribution in papillary muscles from hearts of 110-day-old CM and normal hamsters. A band, mitochondrial, and junctional SR Ca2+ were measured by electron probe microanalysis in CM and normal papillary muscles, which were either untreated or pretreated with BAY K 8644. Muscles were then rapidly frozen during contraction or relaxation. The results showed decreased tension development and decreased inotropic response to BAY K 8644 in CM muscles versus normals. There was no elevation of mitochondrial or A-band Ca2+ in BAY K 8644-treated or untreated CM muscles frozen during contraction or relaxation compared with similarly treated normals. In muscles frozen during relaxation, junctional SR Ca2+ was lower in both untreated and BAY K 8644-treated CM muscles versus comparably treated normals. These results do not support the hypothesis of an increased sensitivity to Ca2+ in hypertrophied, prefailure CM hearts but do indicate that less Ca2+ is available in the SR for activation of contraction.

Exploring patient satisfaction with out-patient services

Despite the widespread use of satisfaction surveys to obtain patients' views about health services, the validity and relevance of self-completion questionnaire surveys has been questioned. This paper reports on an exploratory, qualitative investigation into patients' perspectives on satisfaction and dissatisfaction with out-patient care. Eighty-one new referrals to two out-patient clinics were interviewed before and after their first consultation. Of this initial sample, 23 were interviewed again at their follow-up appointment and a further 10 were interviewed in depth at a location of their choice. The features of the service that drew appreciative comments when they were thought to be present, and criticism when they were felt to be lacking, were: humanity, efficiency, informativeness and continuity of communication. Examples of these features are discussed using patients' own words to illustrate their perspectives. The study demonstrates that unstructured approaches to service evaluation can be employed to develop services which are genuinely listening to their users' views.

Infection with Pseudomonas cepacia in chronic granulomatous disease: role of nonoxidative killing by neutrophils in host defense

Pseudomonas aeruginosa and Pseudomonas cepacia are catalase-producing bacteria, but only P. cepacia causes infections in patients with chronic granulomatous disease (CGD). The in vitro killing of P. aeruginosa and P. cepacia by polymorphonuclear leukocytes (PMNL) from patients with CGD and from healthy adults was assessed. Of 6 patients with CGD who developed severe infections with P. cepacia, 4 died. PMNL from the 2 survivors and 6 other patients with CGD killed P. aeruginosa strains efficiently and P. cepacia strains poorly. PMNL from 2 patients with autosomal recessive CGD and from 2 carriers for X-linked CGD killed P. cepacia intermediately between normal controls and patients with X-linked CGD. When superoxide anion and hydrogen peroxide were scavenged with superoxide dismutase and catalase, normal PMNL killed P. aeruginosa but not P. cepacia. Thus, P. cepacia, but not P. aeruginosa, is a pathogen in patients with CGD, because it resists neutrophil-mediated nonoxidative bactericidal effects.

Knee-joint proprioception during 30-day 6 degrees head-down bed rest with isotonic and isokinetic exercise training

To determine if daily isotonic exercise or isokinetic exercise training coupled with daily leg proprioceptive training, would influence leg proprioceptive tracking responses during bed rest (BR), 19 men (36 +/- SD 4 years, 178 +/- 7 cm, 76.8 +/- 7.8 kg) were allocated into a no-exercise (NOE) training control group (n = 5), and isotonic exercise (ITE, n = 7) and isokinetic exercise (IKE, n = 7) training groups. Exercise training was conducted during BR for two 30-min periods.d-1, 5 d.week-1. Only the IKE group performed proprioceptive training using a new isokinetic procedure with each lower extremity for 2.5 min before and after the daily exercise training sessions; proprioceptive testing occurred weekly for all groups. There were no significant differences in proprioceptive tracking scores, expressed as a percentage of the perfect score of 100, in the pre-BR ambulatory control period between the three groups. Knee extension and flexion tracking responses were unchanged with NOE during BR, but were significantly greater (*p < 0.05) at the end of BR in both exercise groups when compared with NOE responses (extension: NOE 80.7 +/- 0.7%, ITE 82.9* +/- 0.6%, IKE 86.5* +/- 0.7%; flexion: NOE 77.6 +/- 1.5%, ITE 80.0 +/- 0.8% (NS), IKE 83.6* +/- 0.8%). Although proprioceptive tracking was unchanged during BR with NOE, both isotonic exercise training (without additional proprioceptive training) and especially isokinetic exercise training when combined with daily proprioceptive training, significantly improved knee proprioceptive tracking responses after 30 d of BR.

Developmental supervision in health visiting

Although supervision is supposed to be a helpful and supportive process, it is often seen as negative and critical. Meg Bond and Stevie Holland describe a developmental model of supervision, which can enhance health visitors' personal and professional development.

The violence management team. An approach to aggressive behaviour in a general hospital

OBJECTIVES

To describe the establishment of a violence management team (VMT) to manage patients who exhibit violent behaviour in a general hospital (Flinders Medical Centre), and to review data collected in the first 44 months of operation.

METHODS

The VMT consisted of a doctor, a senior nurse and four orderlies. Calls to the team were recorded and audited. Data were collected from patient case notes and supplemented, where necessary, with information from medical and nursing staff.

RESULTS

There were 282 calls for the VMT during the study period, most often to patients with organic mental disorders (45%), substance abuse disorders (18%) and personality disorders (15%). In 30% of calls, verbal placation alone was sufficient to manage the patient; however, 62% of patients needed physical restraint (i.e., were physically held by team members) and 53% were administered a sedative medication.

CONCLUSIONS

Violent behaviour in patients in a general hospital is an important problem, often caused by organic mental disorders. This, and the need to restrain aggressive patients so that they can receive essential medical care, suggest that such behaviour should be treated as a clinical problem rather than one for security guards or the police. The VMT provides a mechanism for dealing with aggressive patients which ensures good patient management, as well as protecting the health and safety of staff. It is also a monitor for quality assurance purposes, and provides data to determine the causes of patient violence and to implement prevention programs.

Measurement of subcellular Ca2+ redistribution in cardiac muscle in situ: time resolved rapid freezing and electron probe microanalysis

To directly assess the physiological roles of sarcoplasmic reticulum (SR) and mitochondria (MT), we have utilized energy dispersive electron probe microanalysis (EPMA) on ultrathin freeze-dried cryosections from isolated papillary muscles, rapidly frozen at precise time points of the contractile cycle. Using this approach, we can detect redistribution of subcellular Ca2+ during the cardiac contractile cycle. Changes in Ca2+ of less than 1.0 mmol/kg dry wt can be detected. By determining the variability of the Ca2+ measurements in preliminary experiments, we have also demonstrated that it is possible to optimize experimental design, i.e., to predict the number of animals per treatment group and the number of X-ray spectra per animal that are required in order to detect a specified Ca2+ difference. Quantitative EPMA of rapidly frozen contracting papillary muscle has also allowed us to correlate the Ca2+ content of SR and MT with the contractile state of the muscle. Our results show a decrease of 40% in the amount of Ca2+ stored in the junctional SR during a cardiac muscle twitch, thus providing direct evidence for a role of the SR as a primary site of Ca2+ release. In addition, we have demonstrated dissociation between MT Ca2+ uptake and activation of regulatory enzymes, such as pyruvate dehydrogenase, indicating that MT Ca2+ uptake is not required for activation of MT metabolism.

Isokinetic strength and endurance during 30-day 6 degrees head-down bed rest with isotonic and isokinetic exercise training

The purpose of our study was to determine if an intensive, intermittent, isokinetic, lower extremity exercise training program would attenuate or eliminate the decrease of muscular strength and endurance during prolonged bed rest (BR). The 19 male subjects (36 +/- 1 yr, 178 +/- 2 cm, 76.5 +/- 1.7 kg) were allocated into a no exercise (NOE) training group (N = 5), an isotonic (lower extremity cycle ergometer) exercise (ITE) training group (N = 7), and an isokinetic (isokinetic knee flexion-extension) exercise (IKE) training group (N = 7). Peak knee (flexion and extension) and shoulder (abduction-adduction) functions were measured weekly in all groups with one 5-repetition set. After BR, average knee extension total work decreased by 16% with NOE, increased by 27% with IKE, and was unchanged with ITE. Average knee flexion total work and peak torque (strength) responses were unchanged in all groups. Force production increased by 20% with IKE and was unchanged with NOE and ITE. Shoulder total work was unchanged in all groups, while gross average peak torque increased by 27% with ITE and by 22% with IKE, and was unchanged with NOE. Thus, while ITE training can maintain some isokinetic functions during BR, maximal intermittent IKE training can increase other functions above pre-BR control levels.

Arachidonic acid and endothelin potentiate Ca2+ transients in rat cardiac myocytes via inhibition of distinct K+ channels

The release of arachidonic acid by phospholipases in response to cell surface receptor activation may be an important step in the initiation of inotropic events in cardiac muscle. Endothelin has been shown to activate phospholipase A2 and release arachidonic acid in isolated rat hearts. Endothelin also has a positive inotropic effect in cardiac muscle, suggesting that endothelin increases Ca2+ influx or the amount of Ca2+ released from the sarcoplasmic reticulum. We used suspensions of adult rat ventricular myocytes loaded with fura-2/AM to compare the effects of arachidonic acid and endothelin on Ca2+ transients evoked by extracellular ATP. We showed recently (Damron, D.S., and Bond, M. (1993) Circ. Res. 72, 376-386) that pretreatment of cardiac myocytes with arachidonic acid significantly potentiated the amplitude of the ATP-triggered Ca2+ transient. We now report that endothelin also enhances the ATP-triggered Ca2+ transient and that the effect of the combination of maximal doses of endothelin and arachidonic acid is additive. Neither endothelin nor arachidonic acid was found to affect the size of the sarcoplasmic reticulum Ca2+ store. The potentiating effects of both arachidonic acid and endothelin were sensitive to inhibitors of protein kinase C. Endothelin was also found to stimulate phospholipase C but not phospholipase A2. Application of arachidonic acid to individual cardiac muscle cells resulted in inhibition of the transient outward K+ current, whereas application of endothelin inhibited the delayed rectifier current. These effects of arachidonic acid and endothelin were additive, and both effects could be blocked by the protein kinase C inhibitor, staurosporine. Similarly, staurosporine inhibited endothelin-induced increases in isometric contractions in ventricular papillary muscle. We conclude that arachidonic acid and endothelin may be involved in the modulation of inotropic activity in cardiac muscle by means of protein kinase C-dependent inhibition of two distinct K+ channels. This would result in a prolongation of action potential duration and thus an increase in Ca2+ influx across the sarcolemma.

The Defense Style Questionnaire

The Defense Style Questionnaire has proven of interest as the first questionnaire to reliably describe defense styles. The 72-item DSM-III-R-labeled Defense Style Questionnaire was administered to 388 controls and 324 patients. Eight statistical and two a priori criteria were used in choosing two items to represent each of the 20 defenses. A new 40-item Defense Style Questionnaire is published together with normative and reliability data on a normal population, patients with anxiety disorders, and child-abusing parents. The scores are unaffected by the sex of the respondent, but the endorsement of immature defense styles decreases with age.

Modulation of Ca2+ cycling in cardiac myocytes by arachidonic acid

It is believed that inotropic agents exert their effects in cardiac muscle via a modulation of Ca2+ cycling; however, the involvement of phospholipase activation and the biochemical pathways participating in inotropic responsiveness remain unclear. The aim of the current study was to determine whether arachidonic acid and/or eicosanoids participate in inotropic responses by modulating Ca2+ cycling in cardiac myocytes. Experiments were performed with populations of freshly isolated, fura-2-loaded adult rat ventricular myocytes. Arachidonic acid stimulated a transient increase in cytosolic free Ca2+, which was still present after addition of EGTA but was significantly reduced by pretreatment with caffeine. Addition of arachidonic acid to either electrically stimulated or quiescent myocytes enhanced the amplitude of the ATP-induced Ca2+ transient. This effect was still observed in the presence of inhibitors of cyclooxygenase, lipoxygenase, and epoxygenase pathways but was significantly diminished after pretreatment with inhibitors of protein kinase C. In contrast, arachidonic acid attenuated the amplitude of electrically induced Ca2+ transients. This effect was mimicked by eicosatetraynoic acid and by the K+ channel agonist pinacidil. The inhibitory effect of eicosatetraynoic acid and arachidonic acid was reversed by addition of fatty acid-free bovine serum albumin. Together, these results suggest that arachidonic acid may play a physiological role in cardiac muscle excitation-contraction coupling as a modulator of sarcolemmal ion channels and/or Ca2+ release from the sarcoplasmic reticulum.

Development of an instrument to study the sexual relationship of partners during pregnancy

The development of an objective self-report instrument designed to identify the domain of sexual behaviours during pregnancy is described. The Pregnancy and Sexuality Questionnaire (PSQ) is concerned with sexual interest and arousal and with specific sexual behaviours of partners in a stable heterosexual relationship. Data were obtained two weeks apart from 15 couples presenting to an antenatal class and from two additional females whose partners did not participate. The validity and reliability of the PSQ are considered with particular emphasis on test-retest reliability. The results in general support the reliability of the instrument. The questionable reliability of some items is attributed to the natural sequence of change in sexual behaviours during pregnancy and to the relatively small sample size used. The PSQ appears to be sufficiently robust to be confidently applied both in sexual behaviour research and as an adjunct to clinical practice.

Fast axonal transport is modulated by altering trans-axolemmal calcium flux

Factors involved in fast axonal transport (motor proteins, microtubules, organelles, etc.) have been identified but the molecular mechanism controlling transport is unknown. We used video enhanced microscopy to directly evaluate the effect of calcium on fast axonal transport (FAxT). FAxT alterations included rapid speed decreases (within minutes) in Ca2+ free buffer and rapid speed increases (within seconds) when axons were treated with parathyroid hormone, BAY K 8644, or K+ depolarization. The speed increases were blocked by dihydropyridine Ca2+ channel antagonists. Ryanodine (20 microM), known to block calcium release from subcellular stores, caused a decrease in the rate of retrograde FAxT. Calcium ionophore A23187 (at 1 and 20 micrograms/ml) caused increases in FAxT, an effect also noted only in retrograde moving organelle traffic. Hyper- or hypo-tonic solutions produced no alterations making axoplasmic viscosity changes an unlikely explanation for the speed changes. Reproducible alteration of FAxT by manipulation of Ca2+ levels provides evidence that Ca2+ modulates fast axonal transport. Retrograde transport appears more sensitive to changes in Ca2+ and differential effects on antero- and retro-FAxT mechanisms suggest directional specificity for some of these signals which may be based upon the organelle size. Endogenous substances (e.g. PTH) that trigger axonal Ca2+ changes may rapidly modulate the rate of material delivery in axons. The results are discussed within the context of a Ca2+/calmodulin-dependent modification of the cytoskeletal matrix.

Effect of inotropic stimulation on mitochondrial calcium in cardiac muscle

Ca(2+)-dependent activation of citric acid cycle enzymes has been demonstrated in isolated cardiac mitochondria. These observations led to the hypothesis that Ca2+ is the signal coupling myofibrillar energy use to mitochondrial energy production in vivo. To test this hypothesis we have measured mitochondrial Ca2+ content during increased energy demand, using electron probe microanalysis. Mitochondrial Ca2+ was measured in hamster papillary muscles rapidly frozen at the peak rate of tension rise under control conditions and after stimulation with the beta-adrenergic agonist isoproterenol (10(-6) M). A third group of muscles was frozen after incubation in low (46.5 mM) Na+ solution to Ca2+ load the cells. Pyruvate dehydrogenase activity was measured in each of the muscles. Isoproterenol caused a 39% increase in force and a 43% increase in pyruvate dehydrogenase activity but no change in mitochondrial Ca2+ (0.46 +/- 0.19 (S.E.) mmol of Ca2+/kg, dry weight) compared with control (0.54 +/- 0.12). In contrast, low Na+ increased pyruvate dehydrogenase activity by 56% and also elevated mitochondrial Ca2+ to 1.28 +/- 0.31 (p less than 0.02). These results demonstrate that mitochondrial Ca2+ is not elevated after inotropic stimulation of cardiac muscle by beta-adrenergic agonists although pyruvate dehydrogenase activity is increased. We conclude that Ca2+ uptake by mitochondria is not a requirement for activation of mitochondrial respiration after increased energy demand.

Control processes and defense mechanisms

Defense-mechanism theory and control-process theory are related psychodynamic approaches to explaining and classifying how people ward off emotional upsets. Although both theories explain defensive maneuvers in the same motivational terms, each defines categories different1y. Classic categories define defense mechanisms at a relatively macroscopic level, whereas control-process theory aims at relatively microgenetic analysis of how cognitive maneuvers-involving what is thought, how it is thought, and how it is organized-may generate defensive states. The theories are not contradictory, but they are focused on different levels of observation; it is useful to compare how these classifications are applied to specific case material.

Calcium is released from the junctional sarcoplasmic reticulum during cardiac muscle contraction

We have used electron-probe microanalysis (EPMA) to address the question of Ca2+ release by junctional sarcoplasmic reticulum (JSR) as well as Ca2+ regulation by mitochondria (MT) during cardiac muscle contraction. Hamster papillary muscles were rapidly frozen during relaxation or at the peak rate of tension rise (+dT/dt). Total Ca2+ content was measured by EPMA in the JSR, within a MT, over the A band, and in the whole cell, in nine cells per animal (five animals per group). JSR Ca2+ content was found to be significantly lower in muscles frozen at the peak of contraction [7.3 +/- 1.3 (mean +/- SE) mmol Ca2+/kg dry wt] than in those frozen during relaxation (12.5 +/- 1.9 mmol Ca2+/kg dry wt; P less than 0.01), suggesting that Ca2+ is released from this storage site during cardiac muscle contraction. In contrast, MT Ca2+ content did not change significantly during contraction (0.4 +/- 0.1 mmol/kg dry wt) compared with relaxation (0.1 +/- 0.2 mmol/kg dry wt). A third group of muscles was frozen during relaxation after pretreatment with 10(-7) M ryanodine. Ca2+ content of the JSR was significantly decreased (P less than 0.01) in this group of muscles, (6.4 +/- 1.8 mmol/kg dry wt) compared with those frozen during relaxation in the absence of the drug. This suggests that the intracellular storage site with a decreased Ca2+ content in muscles frozen at the peak of contraction is the ryanodine-releasable store. These results provide the first direct measurement of the Ca2+ content of both JSR and MT during a normal cardiac muscle contraction and demonstrate that Ca2+ is released from the JSR during muscle contraction.

Teaching infant resuscitation skills to mothers

This paper describes the evaluation of a program designed to teach basic infant resuscitation skills to mothers during the period of postnatal hospitalization. Data collected from participants before and immediately after the program, and at six months, follow-up indicated that knowledge of resuscitation techniques had moderately improved, however there was a substantial increase in participants' confidence and an associated reduction in anxiety. An additional aspect of the evaluation was to identify any logistical problems; data obtained from postnatal midwifery staff indicated none were evident. It was concluded that the Infant Resuscitation Education Program should be implemented for all mothers of newborn infants.

Inotropic effects of angiotensin II on human cardiac muscle in vitro

The direct effects of angiotensin II (Ang II) on human cardiac muscle were investigated using isolated trabecular muscles from failing and functionally normal hearts. Atrial and ventricular trabeculae were studied. Results demonstrated a positive inotropic effect of Ang II on human cardiac muscle. Comparison of the effects of Ang II among groups indicated that the responsiveness tended to be greater in atrial and normal muscle compared with failing muscle. Results of this study also demonstrated heterogeneity in the responsiveness to Ang II among human muscles, which was not correlated with patient age, sex, diagnosis, prior treatment with angiotensin converting enzyme inhibitor, or heart function. A significant correlation between response to Ang II and response to isoproterenol was demonstrated in failing ventricular trabeculae, which may suggest that defects in beta-adrenergic responsiveness in the failing human ventricle are accompanied by a loss of responsiveness to Ang II. Studies were extended to the Syrian cardiomyopathic hamster and its control. A dose-dependent inotropic response occurred in normal hamster ventricular muscle but was significantly diminished in cardiomyopathic muscle. Ang II did not shorten the timing of contraction, and pretreatment with adrenergic-blocking agents did not shift the dose-response curve, indicating that the response was not cyclic AMP mediated. This study demonstrates for the first time that Ang II can exert an inotropic effect directly on human cardiac muscle and confirms that there is a direct effect of Ang II on hamster cardiac muscle. The study further suggests, however, that the inotropic response to Ang II in cardiac muscle is heterogeneous and may be diminished by heart failure.

The development of defenses in childhood

The authors review empirical studies of defense mechanisms and suggest that this concept can be operationalized to permit an investigation of the chronology of the development of defense in childhood. Studies on the coping and defense patterns of normal children are compared with studies that attempt to explain defense patterns in disturbed children and adults. It is argued that empirical study of the development of defense in the normal child will help to determine the validity of theoretical psychoanalytic speculations derived from the retrospective reconstruction of defenses that might have existed in the childhood of ill adults. An attempt is made to place our knowledge of the development of defense in childhood into the context of our knowledge of cognitive development. The authors review the research that attempts direct empirical assessment of defenses in childhood, and make suggestions for how such research could be furthered. It is argued that it may be possible to construct a schedule for the early maturation of defense, and to identify how this changes with pathology, gender, and family context. Such a schedule would be fundamental to our understanding of normality, and the role of regression and precocity in pathology.

Barriers to bicycle helmet use among children. Results of focus groups with fourth, fifth, and sixth graders

As a preliminary step in the development of a school-based educational intervention to promote bicycle helmet use among children, focus group encounters were conducted with fourth, fifth, and sixth graders at three elementary schools in the Boston, Mass, area. Analysis of transcripts of encounter tape recordings indicated that (1) the prevalence of helmet ownership and use was low, (2) children were concerned that helmet use would invite derision from their peers, and (3) children tended to respect other children who wore helmets. We concluded that focus groups can be useful in conceptualizing health education interventions and suggest that school-based peer-led bicycle helmet programs may be effective in developing normative change toward helmet use among elementary schoolchildren.

Subcellular calcium content in cardiomyopathic hamster hearts in vivo: an electron probe study

In the Syrian cardiomyopathic hamster heart, abnormal cellular calcium regulation, resulting in cellular calcium overload, is believed to play a role in the pathogenesis of cardiac hypertrophy and failure. Alternatively, the primary abnormality may be coronary vasospasm, resulting in reperfusion-induced necrosis. According to the latter hypothesis, only those cells that suffer an ischemic insult would contain elevated calcium levels. To determine whether a generalized elevation in myocytic calcium exists in myopathic hamster hearts, we measured cellular and subcellular calcium concentrations by electron probe microanalysis in cryosections of 50-day and 96-day myopathic and control hearts, rapidly frozen in vivo. Total calcium content of ventricular homogenates from each group was also measured by atomic absorption spectrophotometry. No significant differences in subcellular calcium were found by electron probe microanalysis among 50-day and 96-day myopathics and their age-matched controls. In 50-day myopathic and control hearts, mitochondrial calcium was 0.7 +/- 0.2 and 0.9 +/- 0.2, respectively, and A-band calcium was 3.0 +/- 0.4 and 2.6 +/- 0.4 mmol calcium/kg dry wt(+/- SEM). Results from 96-day animals were similar. Localized regions of elevated calcium were found only at sites of necrotic foci: in Na+-loaded cells (mitochondria: 4.7 +/- 1.3 (SEM) mmol/kg dry wt), in dying cells (mitochondria: 72 +/- 22 (SEM) mmol/kg dry wt) or as extracellular deposits (7-10 mol/kg dry wt). Total calcium content of hearts from myopathic hamsters, as determined by atomic absorption spectrophotometry, was also 13 times (50-day) and 50 times (96-day) higher than controls. These results demonstrate that there is a marked heterogeneity in cellular calcium content in myopathic hamster hearts, but the data do not support the hypothesis of a generalized cellular calcium overload.

Chronic sodium depletion increases myocardial calcium content in normotensive rats

Increased myocardial contractility was found in the perfused heart isolated from sodium depleted Sprague-Dawley rats. Previously, it was reported that in vitro exposure of different cardiac preparations to low Na+ buffers was associated with both an increased contractility and an increased Ca2+ content in the cells. Therefore, this study was designed to examine increases in ventricular Ca2+ content in the hearts of chronically sodium depleted rats. Two groups of 12-week-old Sprague-Dawley rats were studied. One group (n = 5) received furosemide (5 mg/kg/day IP for 4 days), a low Na+ diet and distilled drinking water for 6 weeks (low sodium plus diuretics group = LSD). The other group (n = 5) received the same low Na+ diet, but 0.5% NaCl was supplemented in drinking water (regular sodium group = RS). Body weight and blood pressure were measured weekly during the dietary period in all rats. At the end of the 6 weeks, heart weight as well as water and electrolyte contents of the heart were measured in all animals. Results showed that both body weight and heart weight were significantly lower in LSD than in RS. Moreover, ventricular Na+ content was reduced while ventricular Ca2+ content was doubled in LSD compared to RS (8.2 +/- 0.2 units vs. 9.2 +/- 0.3 units, p less than .05 and 0.45 +/- 0.13 units vs. 0.23 +/- 0.01 units, p less than .01, respectively). We conclude that in vivo sodium depletion induces an increase in ventricular calcium content; this increased myocardial calcium may be related to the increased in vitro cardiac contractility observed after chronic in vivo sodium depletion, but its distribution between intracellular and extracellular compartments needs to be determined.

Endothelin is a positive inotropic agent in human and rat heart in vitro

We have investigated the response to endothelin of isolated atrial and ventricular trabeculae from failing human hearts obtained at transplant. Results indicate that endothelin exerts a significant positive inotropic effect on human atrial and ventricular tissue, with increases in developed tension of 74.6 +/- 14.1% (+/- SEM) and 9.9 +/- 4.0%, respectively. Further studies on rat cardiac muscle demonstrate that the greater inotropic effect on atrial than ventricular muscle is also exhibited by the rat heart in vitro, with 39.9 +/- 10.7% and 17.1 +/- 5.9% increases in developed tension for atria and papillary muscle, respectively. Studies in rat atria also provide no evidence for an effect of endothelin on the frequency of spontaneous contractions. These results suggest that the potential exists for regulation of cardiac function in humans and rats by endothelial-derived factors such as endothelin, possibly via augmentation of atrial systole.