Genetic relationship between Escherichia coli strains isolated from the intestinal flora and those responsible for infectious diseases among patients hospitalized in intensive care units

The exact origin of strains of Escherichia coli responsible for infectious diseases in intensive care units (ICUs) remains partly unknown. Our aim was to determine the nature of the link between strains from the intestinal flora of hospital staff, strains from the intestinal flora of patients hospitalized in ICUs and strains isolated from ICU patients with invasive diseases. For this purpose, 77 strains of E. coli were genetically characterized by exploring their entire genomes by random amplified polymorphism of DNA (RAPD), and by determining their phylogenetic position in ECOR (E. coli reference) groups, the virulence factors harboured (pap, sfa, afa, hly, aer and cnf) and their ability to mutate. The strains isolated from the intestinal flora of hospital staff were found to constitute a genetically heterogeneous population compared with the strains isolated from ICU carriers, which were highly clustered. The latter strains harboured numerous virulence factors, and 80% belonged to the group ECOR B2. The strains isolated from infected patients harboured fewer virulence factors than those from the ICU carriers, and only half belonged to ECOR B2. Moreover, these strains were more genetically related to strains from hospital staff than to strains from ICU carriers. Thus, the exogenous origin of the E. coli strains is probably almost as important as translocation from intestinal flora in ICUs. Moreover, a strong mutator phenotype had a minor, or no, role in the rapid adaptation to modifications in the ecological environment.

A cross-sectional study of early identification of postpartum depression: implications for primary care providers from The Ontario Mother & Infant Survey

BACKGROUND

This survey's objective was to provide planning information by examining utilization patterns, health outcomes and costs associated with existing practices in the management of postpartum women and their infants. In particular, this paper looks at a subgroup of women who score >or= 12 on the Edinburgh Postnatal Depression Survey (EPDS).

METHODS

The design is cross-sectional with follow-up at four weeks after postpartum hospital discharge. Five Ontario hospitals, chosen for their varied size, practice characteristics, and geographic location, provided the setting for the study. The subjects were 875 women who had uncomplicated vaginal deliveries of live singleton infants. The main outcome measures were the EPDS, the Duke UNC Functional Social Support Questionnaire and the Health and Social Services Utilization Questionnaire.

RESULTS

EPDS scores of >or= 12 were found in 4.3 to 15.2% of otherwise healthy women. None of these women were being treated for postpartum depression. Best predictors of an EPDS score of >or= 12 were lack: of confident support, lack of affective support, household income of <20,000 dollars, wanting to stay in hospital longer, identification of learning needs while in hospital, self-identified care needs for an emotional/mental health problem that have not been met and mother's rating of own and baby's health as fair or poor.

CONCLUSIONS

Primary care physicians, midwives, and public health nurses need to screen for depression at every opportunity early in the postpartum period. A mother's expression of undue concern about her own or her baby's health may be predictive of postpartum depression. Flexible, mother-focused support from community providers may decrease the prevalence of postpartum depression.

An intracranial neoplasm complicating labour

We present a case in which a 27-year-old primigravida was found to have an intracranial tumour during the first stage of labour. We review previous reports of similar cases and discuss the management options.

Nocardia farcinica infection of a cochlear implant in an immunocompetent boy

The first case of an infection caused by Nocardia farcinica on a cochlear implant and its progression is described. As it is difficult to diagnose Nocardia spp., the identification was confirmed by phylogenetic analysis using 16S rDNA sequencing.

The Ontario Mother and Infant Survey: breastfeeding outcomes

A cross-sectional survey of postpartum women following discharge from five hospitals in Ontario, Canada, examined breatfeeding patterns and risk factors for early discontinuation. Consenting mothers completed self-administered questionnaires prior to discharge (n = 1250) and telephone interviews at 4 weeks postdischarge (n = 875). Breastfeeding initiation rates for women completing the interview varied from 82% to 96% across the sites. Continuation rates rapidly declined, with 13% to 24% of women who had initiated breastfeeding switching to formula by 4 weeks postpartum. Perceived inadequate milk supply, difficulty with breastfeeding techniques, and sore nipples were the main reasons reported. Risk factors for breastfeeding cessation included not completing high school; intention to breastfeed less than 4 months; not anticipating the use of a "mom's group" or "drop-in center"; one or more maternal visits to a family physician; length of postpartum stay greater than 48 hours; unmet need for care or help with breastfeeding; and received advice, information, or support about formula feeding.

Costs of postpartum care: examining associations from the Ontario mother and infant survey

A cross-sectional survey of 1,250 mothers of "normal" newborn infants was conducted to assess mother and infant characteristics as well as the costs of health and social services used in the first 4 weeks after discharge from hospital in the province of Ontario, Canada. Each mother was asked to recall use of services for herself and her infant. This utilization was multiplied by the unit cost of each service and summed to arrive at the total cost of services used. Although re-admission rates were low (1% for mothers, 4% for infants), costs associated with hospital and emergency room care ($194 on average per mother/infant dyad) accounted for the greatest proportion of total health-care costs. Physician or midwife visits, which were received by almost all mothers, were the next most costly service ($128 on average per dyad). Mothers with incomes under $20,000 had more medical costs than those with higher incomes. Costs of community nursing care ($86 on average per dyad) were higher for mothers with more than 5 self-identified learning needs (e.g., infant feeding, infant care and behaviour, emotional changes in self, signs of illness in infant); perception of their own health as poor; perception of inadequate help and support at home; many signs and symptoms of depression; and postpartum hospital stay of 48 hours or less. Costs for social work visits were higher for mothers with depression and mothers with low incomes. Total health and social service costs were double for mothers with family incomes under $20,000 ($788 vs. $399 on average per dyad) and for mothers with clinical depression ($845 vs. $413). Specifically, nursing care costs were greater for mothers with high depression scores ($135 vs. $81).

Understanding newborn infant readmission: findings of the Ontario Mother and Infant Survey

The Ontario Mother and Infant Survey examined health and social service utilization of postpartum women and newborn infants from five hospital sites. A cross-sectional multilanguage survey design with longitudinal follow-up was used: 1,250 eligible, consenting women completed a self-report questionnaire in hospital and 875 women participated in a structured telephone interview at four weeks post-discharge. Rates of newborn infant readmission ranged from 2.4% to 6.7%. The best predictors of readmission were: main source of household income was other than employment; maternal self-rating of health was poor; mother anticipated inadequate help and support at home following discharge; mother received help from friends/neighbours following discharge; and mother had concern about infant care and behaviour. Readmission was not associated with length of postpartum hospital stay. The study findings suggest that there is a complex relationship between infant health care needs, family resources and provider practices that produces clinically important, site-specific readmission patterns.

Production of cloned pigs from in vitro systems

Here we describe a procedure for cloning pigs by the use of in vitro culture systems. Four healthy male piglets from two litters were born following nuclear transfer of cultured somatic cells and subsequent embryo transfer. The initiation of five additional pregnancies demonstrates the reproducibility of this procedure. Its important features include extended in vitro culture of fetal cells preceding nuclear transfer, as well as in vitro maturation and activation of oocytes and in vitro embryo culture. The cell culture and nuclear transfer techniques described here should allow the use of genetic modification procedures to produce tissues and organs from cloned pigs with reduced immunogenicity for use in xenotransplantation.

Clinical decision-making in the context of chronic illness

This paper develops a framework to compare clinical decision making in relation to chronic and acute medical conditions. Much of the literature on patient-physician decision making has focused on acute and often life-threatening medical situations in which the patient is highly dependent upon the expertise of the physician in providing the therapeutic options. Decision making is often constrained and driven by the overwhelming impact of the acute medical problem on all aspects of the individual's life. With chronic conditions, patients are increasingly knowledgeable, not only about their medical conditions, but also about traditional, complementary, and alternative therapeutic options. They must make multiple and repetitive decisions, with variable outcomes, about how they will live with their chronic condition. Consequently, they often know more than attending treatment personnel about their own situations, including symptoms, responses to previous treatment, and lifestyle preferences. This paper compares the nature of the illness, the characteristics of the decisions themselves, the role of the patient, the decision-making relationship, and the decision-making environment in acute and chronic illnesses. The author argues for a different understanding of the decision-making relationships and processes characteristic in chronic conditions that take into account the role of trade-offs between medical regimens and lifestyle choices in shaping both the process and outcomes of clinical decision-making. The paper addresses the concerns of a range of professional providers and consumers.

Well-adjusted children: an alternate view of children with inflammatory bowel disease and functional gastrointestinal complaints

Previous studies have suggested impaired psychosocial adjustment in children and adolescents with inflammatory bowel disease (IBD). We examined 62 subjects referred to a regional Pediatric Gastroenterology Clinic with IBD or functional gastrointestinal (FGI) complaints. Characteristics of the clinic include a unified team approach, regularly scheduled appointments at 3-month intervals, proactive medical care emphasizing maintenance of full functioning, and close medical-surgical interaction (joint clinics). A research assistant administered a questionnaire regarding children's perceptions of their illness, as well as the Child Depression Inventory (CDI), the Piers-Harris (PH) test of self-concept, and the Child Behaviour Checklist (CBCL). The 36 children with IBD (25 Crohn's disease, 11 ulcerative colitis, mean age 13.3 +/- 3.0 years) were compared with 26 patients with FGI complaints (16 recurrent abdominal pain, 10 functional megacolon, mean age 11.4 +/- 2.8 years). The scores on the standardized tests were not clinically significant for either group. In comparison, however, children with IBD were less depressed and had fewer behaviour problems than the FGI group. Surprisingly, only 19% (7 of 36) of children with IBD described their illness as a problem to them, compared with 65% (17 of 26) of children with FGI symptoms. The latter children also considered themselves significantly sicker than did those with IBD. We conclude that normal psychosocial adjustment is possible in pediatric patients with IBD. We speculate that this group benefitted from the professional supports that our clinic specifically provides to patients with IBD. The FGI group may have suffered from a lack of such professional supports, as well as from the absence of a specific diagnosis.

Economic evaluations of community-based care: lessons from twelve studies in Ontario

A series of 12 studies (five historic cohort and seven randomized trials) examined clients in community settings in Southern Ontario suffering from a variety of chronic physical and mental health conditions. These studies are appraised using a framework for evaluating possible outcomes of economic evaluation. In the 12 studies, sample composition and size varied. Each study was designed to quantify the well-being outcomes and expenditures associated with different community-based approaches to care provided in the context of a system of national health insurance. As a collective, these studies represent increasing methodological rigour. Multiple-perspective client well-being outcome measures were used. In two studies, caregiver burden also was analysed. A common approach to quantification and evaluation of expenditures for service consumption was used in all 12 studies. The nature of community-based health services (health vs. disease care orientation) was found to have direct and measurable impact on total expenditures for health service utilization and client well-being outcomes. In most cases, a recurring pattern of equal or better client outcomes, yet lower expenditures for use of community based health services, was associated with well-integrated health oriented services. Integrated services aimed at factors which determine health are superior when compared to individual, fragmented, disease oriented, and focused approaches to care. The main lessons from the 12 studies are that it is as or more effective and as or less expensive to offer complete, proactive, community health services to persons living with chronic circumstance than to provide focused, on-demand, piecemeal services. Complete services would have a psychosocial and mental health focus included with the physical care approach. Furthermore, people with coexisting risk factors (age, living arrangements, mental distress and problem-solving ability) are the ones who most benefit at lower expense from health oriented, proactive interventions.

Effects of reducing attentional resources on implicit and explicit memory after severe traumatic brain injury

Implicit and explicit memory were examined in individuals with severe traumatic brain injury (TBI) under conditions of full and divided attention. Participants included 12 individuals with severe TBI and 12 matched controls. In Experiment 1, participants carried out an implicit test of word-stem completion and an explicit test of cued recall. Results demonstrated that TBI participants exhibited impaired explicit memory but preserved implicit memory. In Experiment 2, a significant reduction in the explicit memory performance of both TBI and control participants, as well as a significant decrease in the implicit memory performance of TBI participants, was achieved by reducing attentional resources at encoding. These results indicated that performance on an implicit task of word-stem completion may require the availability of additional attentional resources that are not preserved after severe TBI.

SHP-1 regulates Lck-induced phosphatidylinositol 3-kinase phosphorylation and activity

Ligation of the T cell antigen receptor (TCR) activates the Src family tyrosine kinase p56 Lck, which, in turn, phosphorylates a variety of intracellular substrates. The phosphatidylinositol 3-kinase (PI3K) and the tyrosine phosphatase SHP-1 are two Lck substrates that have been implicated in TCR signaling. In this study, we demonstrate that SHP-1 co-immunoprecipitates with the p85 regulatory subunit of PI3K in Jurkat T cells, and that this association is increased by ligation of the TCR complex. Co-expression of SHP-1 and PI3K with a constitutively activated form of Lck in COS7 cells demonstrated the carboxyl-terminal SH2 domain of PI3K to inducibly associate with the full-length SHP-1 protein. By contrast, a truncated SHP-1 mutant lacking the Lck phosphorylation site (Tyr(564)) failed to bind p85. Wild-type but not catalytically inactive SHP-1 induced dephosphorylation of p85. Furthermore, expression of SHP-1 decreased PI3K enzyme activity in anti-phosphotyrosine immunoprecipitates and phosphorylation of serine 473 in Akt, a process dependent on PI3K activity. These results indicate the presence of a functional interaction between PI3K and SHP-1 and suggest that PI3K signaling, which has been implicated in cell proliferation, apoptosis, cytoskeletal reorganization, and many other biological activities, can be regulated by SHP-1 in T lymphocytes.

Community care for people with chronic conditions: an analysis of nine studies of health and social service utilization in Ontario

A series of studies conducted in the same region found that programmatic, community-based health and social service interventions have a positive impact on client well-being. These proactive interventions, designed to address the full range of health and social needs, were usually provided at the same--or even lower--costs as uncoordinated, illness-focused care. The results of this series suggest that across-the-board health care reduction, at least in a system of national health insurance, will produce poorer results, at higher cost, for people with chronic conditions living in the community. Policy planners need more research that concentrates on comparisons of outcomes between and within different models of health and social service delivery. The studies should be designed to help them determine who benefits from different service configurations carried out within a range of policy environments at various costs.

Effects of reducing attentional resources on implicit and explicit memory after severe traumatic brain injury

Implicit and explicit memory were examined in individuals with severe traumatic brain injury (TBI) under conditions of full and divided attention. Participants included 12 individuals with severe TBI and 12 matched controls. In Experiment 1, participants carried out an implicit test of word-stem completion and an explicit test of cued recall. Results demonstrated that TBI participants exhibited impaired explicit memory but preserved implicit memory. In Experiment 2, a significant reduction in the explicit memory performance of both TBI and control participants, as well as a significant decrease in the implicit memory performance of TBI participants, was achieved by reducing attentional resources at encoding. These results indicated that performance on an implicit task of word-stem completion may require the availability of additional attentional resources that are not preserved after severe TBI.

The Src-homology domain 2-bearing protein tyrosine phosphatase-1 inhibits antigen receptor-induced apoptosis of activated peripheral T cells

Restimulation of Ag receptors on peripheral T lymphocytes induces tyrosine phosphorylation-based signaling cascades that evoke Fas ligand expression and induction of Fas-mediated programmed cell death. In view of the role for the Src homology domain 2-bearing protein tyrosine phosphatase-1 (SHP-1) in modulating TCR signaling, we investigated the influence of SHP-1 on TCR-mediated apoptosis by assaying the sensitivity of peripheral T cells from SHP-1-deficient viable motheaten (mev) mice to cell death following TCR restimulation. The results of these studies revealed mev peripheral T cells to be markedly more sensitive than wild-type cells to induction of cell death following TCR stimulation. By contrast, PMA/ionophore and anti-Fas Ab-induced apoptotic responses were no different in mev compared with wild-type activated cells. Enhanced apoptosis of TCR-restimulated mev lymphocytes was associated with marked increases in Fas ligand expression as compared with wild-type cells, but was almost abrogated in both mev and wild-type cells by Fas-Fc treatment. Thus, the increased sensitivity of mev T cells to apoptosis following TCR restimulation appears to reflect a TCR-driven phenomenon mediated through up-regulation of Fas-Fas ligand interaction and induction of the Fas signaling cascade. These findings, together with the hyperproliferative responses of mev peripheral T cells to initial TCR stimulation, indicate that SHP-1 modulation of TCR signaling translates to the inhibition of both T cell proliferation and activation and, as such, is likely to play a pivotal role in regulating the expansion of Ag-stimulated T cells during an immune response.

Pilot study of a visitor volunteer programme for community elderly people receiving home health care

There is a need to evaluate community support programmes for elderly people. In this randomized control trial (RCT), we determined the effectiveness of 'friendly visitors' in a volunteer programme of a visiting nurses organization in Southern Ontario, Canada. The Volunteer Friendly Visitor Programme was developed to support elderly people receiving homemaking and nursing care in the community. Volunteers are screened, trained, interviewed and matched to homebound elderly clients for general interest, visit expectations and personality. Volunteers spend three to four hours on average per week with clients socializing in mutually agreed-upon ways. The nursing staff identified clients who were lonely for this additional support. These newly-referred clients were randomly allocated to receive a friendly visitor or not for six weeks. Those receiving the volunteer visitor improved in life satisfaction and two social support measures: worth and social integration. Thus, the addition of volunteer visitors to planned homemaking and nursing care made a difference for elderly in the community.

Problem-solving counseling for caregivers of the cognitively impaired: effective for whom?

BACKGROUND

Individualized problem-solving counseling for caregivers of cognitively impaired relatives is thought to help caregivers cope with the stress and burden of caregiving. Few studies have shown the effectiveness of counseling for these caregivers.

OBJECTIVES

To determine the effectiveness of individualized problem-solving counseling by nurses for caregivers and the expenditures of health care utilization.

METHOD

Caregivers (n = 77) of the cognitively impaired living at home were randomized to receive nurse counseling or not. Psychosocial adjustment to their relative's illness, psychological distress, burden, coping skills, and expenditures were measured after 6 months and 1 year.

RESULTS

Although on average, all caregivers receiving nurse counseling indicated no improvement in psychosocial adjustment to their relative's illness, psychological distress, or caregiver burden, they found counseling very helpful and it was effective for a subgroup of caregivers. Those with poor logical analysis coping skills at baseline had decreased psychological distress (F(1,53) = 9.7, p = .003) and improved psychosocial adjustment (F(1,53) = 4.7, p = .035) after 1 year. Caregivers in control and counseling groups whose relatives entered a nursing home improved their psychosocial adjustment 23% on average whereas those continuing to live in the community decreased by 8%. Almost half as many relatives entered nursing homes in the counseling group (n = 9 vs. n = 5) but these compared to control group relatives had greater annualized per person expenditures for health and social services (Cdn$23,437 vs. Cdn$15,151).

CONCLUSIONS

Caregivers found nurse counseling most helpful. Those indicating infrequent use of logical analysis coping skills showed benefits.

Unusually severe heterozygous beta-thalassemia: evidence for an interacting gene affecting globin translation

A common beta-thalassemia mutation in Asian populations is the C --> T substitution at position 654 of intron 2, which leads to the activation of two cryptic splicing sites and the incorporation of 73 extra nucleotides into the mutant mRNA. Like most beta-thalassemia mutations, it normally exhibits recessive inheritance. We investigated the unusually severe phenotype in two heterozygotes for this mutation, father and son, who had thalassemia intermedia and an apparent dominant mode of inheritance. An increased level of aberrantly spliced transcript in the reticulocytes of the probands compared with asymptomatic beta654 heterozygotes led us to investigate the production and processing of beta654 RNA. We showed that large amounts of the aberrant beta654 transcript were detectable in erythroblasts from one of the asymptomatic cases. The translation product of this mRNA was not detectable in vivo, and we were unable to demonstrate the translation of the mutant mRNA in a cell-free translation system. Although the reticulocyte alpha:beta mRNA ratios in the two probands were within the range observed in the asymptomatic heterozygotes, globin chain biosynthesis studies showed that the probands had considerably greater alpha:beta chain imbalance. These results imply that the more severe phenotype may be due to a second defect, possibly unlinked to the beta-globin cluster, that acts at the translational or posttranslational level.

Electives in Europe

Student nurses at Napier University in Edinburgh have the opportunity to study extracurricular French or German and to gain experience of working in Europe. The authors of this article suggest that this gives students the skill and confidence to practise abroad, and to influence nursing policy and development in the European Union.

Surviving social assistance: 12-month prevalence of depression in sole-support parents receiving social assistance

BACKGROUND

Although it is generally recognized that poverty and depression can coexist among single parents receiving social assistance, there is insufficient research on this topic. The goals of this study therefore were to investigate the prevalence, correlates and health care expenditures associated with depression among sole-support parents receiving social assistance.

METHODS

Sole-support parents who had applied for social assistance in 2 regions of southwestern Ontario were included in the study. Depression was diagnosed with the 1994 University of Michigan Composite International Diagnostic Interview short forms.

RESULTS

The 12-month prevalence rate of depressive disorder among the parents interviewed was 45.4% (345/760). A total of 247 (32.5%) had major depressive disorder alone, 19 (2.5%) had dysthymia, and 79 (10.4%) had both major depressive disorder and dysthymia ("double depression"). Those with major depressive disorder, particularly double depression, had significantly higher rates of coexisting psychiatric disorder than those without depressive disorders. Parents with depression reported higher rates of developmental delay and behaviour problems in their children than parents without depression. Expenditures for health care services were higher for parents with depression and for their children than for parents without depressive disorder and their children.

INTERPRETATION

Single parents receiving social assistance have high rates of depression. Such parents with depression also have higher rates of other psychiatric disorders and higher expenditures for health care services, and their children have higher rates of developmental delay and behaviour problems.

Impaired visual search in patients with unilateral neglect: an oculographic analysis

The attentional deficit underlying hemispatial neglect was examined through a detailed analysis of the eye movement performance of a group of neglect patients. Relative to normal subjects and to patients with hemianopia without neglect, patients with left neglect make fewer fixations and have shorter inspection time on the contralesional left side. They also start their search to the right of the midline and make significantly more fixations and longer fixations on the ipsilesional right side. A positive linear relationship between horizontal location and frequency of fixations was noted for the neglect group as a whole, as well as for most of the individual patients. These findings strongly endorse the view that the attentional deficit in neglect follows a left right gradient. The peak of the maximum fixations, however, is not on the extreme right, as might be predicted by a strict gradient account, and is more consistent with recent views that the midsagittal plane of the viewer is redirected rightwards. These findings provide a detailed analysis of the eye movement patterns in neglect patients and demonstrate the robustness of oculographic analysis for examining their altered spatial representation.