Liquid sterilization versus high level disinfection in the urologic office

OBJECTIVES

Systems are available for liquid sterilization (LS) and high level disinfection (HLD) of flexible cystoscopes. Guidelines from the Association of Operating Room Nurses and the Association for Professionals in Infection Control and Epidemiology recommend HLD for urologic endoscopic equipment. We examine these methods emphasizing costs, performance of procedure, and maintenance.

METHODS

The process of LS using the Steris System 1 Processor (SSP1) was studied from June 1993 to June 1994. The Voluntary Hospital Association (VHA) Plus Glutaraldehyde HLD system was evaluated from July 1994 to July 1995. Costs are those incurred by the Ochsner Department of Urology over these same periods.

RESULTS

Purchase of the SSP1 system proved costly: $16,200 for purchase; $8645 for accessories, service contract, and training seminars; and $5800 for unit installation. Two gallons of glutaraldehyde including the disinfection container cost $15.60. Since government regulation requires less than 0.2 ppm airborne glutaraldehyde concentration, some facilities may need to install ventilation systems. There were no clinical differences between the two systems. Yearly operating expenses in our department for SSP1 was $6037 compared to $445 for HLD. Mean length of time to process was 35 minutes per use for SSP1 and 20 minutes for HLD. Repair of seven cystoscopes during the SSP1 period cost $11,500. No repairs were required for the cystoscopes used during the HLD period.

CONCLUSIONS

Outpatient flexible cystoscopy was performed an average of 988 times per year during the study period. Major cost savings were incurred with institution of the HLD system and no endoscope repairs were necessary. There were no clinical differences between the two systems.

The molecular epidemiology of HIV-1 among male sex workers in northern Thailand

Male commercial sex workers (CSWs) in northern Thailand are at high risk for HIV-1 infection and may be exposed to multiple subtypes of HIV-1 through sexual contact with men and women from Thailand, other Asian nations, and the West. We studied 103 male Thai nationals working in gay bars and clubs in Chiang Mai city who participated in the 1994 sentinel surveillance of the Thai Ministry of Public Health using HIV serologic testing, DNA polymerase chain reaction methods, molecular cloning, differential colony hybridization, nucleotide sequencing, and a third hypervariable region (V3) peptide enzyme-linked immunoabsorbent assay to differentiate subjects infected with HIV-1 subtypes B, E, both, or neither. The majority (58%) reported heterosexual orientation, and 35 (34%) were married. Seventeen (16.5%) were HIV infected: 16 (94%) of 17 had HIV-1 subtype E; 1 had HIV-1 subtype B. Two subjects had dually reactive results by molecular techniques but colony hybridization sequencing revealed only HIV-1 subtype E. HIV-1 subtype E appears to be the predominant clade among male CSWs in northern Thailand. This may have important implications for the global kinetics of the HIV epidemic.

Case-control study of neuroleptic malignant syndrome

OBJECTIVE

The authors performed a case-control study of neuroleptic malignant syndrome to identify potential risk factors.

METHOD

Twenty-five patients with neuroleptic malignant syndrome were matched with 50 comparison subjects on age, sex, primary psychiatric diagnosis, and time of admission to the hospital. The records of all subjects were reviewed independently by two researchers for information on postulated risk factors. Exploratory direct comparisons of the two groups were followed by a conditional logistic regression analysis.

RESULTS

Patients with neuroleptic malignant syndrome were more likely to be agitated or dehydrated before the development of neuroleptic malignant syndrome, often needed restraint or seclusion, and received larger doses of neuroleptics soon after hospitalization. Previous treatment with ECT increased vulnerability.

CONCLUSIONS

The prevalence of neuroleptic malignant syndrome may be reduced by avoiding large doses of neuroleptics over short periods in the management of acute psychosis and by paying adequate attention to the patient's hydration and electrolyte status.

Early management of dental pain in children and adolescents

OBJECTIVES

There is little information regarding the initial management of dental pain in children and adolescents. The present study investigated the early management of 155 children and adolescents with dental pain prior to definitive treatment in the Eastman Dental Institute and Hospital for Oral Health Care Sciences, London, UK.

METHOD

Prior to the child being examined by a qualified dentist in the casualty department, the accompanying parents or guardians were requested to complete a self-administered questionnaire regarding the duration and severity of pain, presence of swelling, professional advice sought and medication taken.

RESULTS

Of the attending children, 83% were in pain, 20% having been in pain for over 1 month. Most parents sought professional health care advice, particularly from a dentist; however, 15% initially obtained advice from a medical practitioner and 5% from a pharmacist. Simple analgesics were taken by 74% of patients; however, these rarely produced complete pain relief. Of concern, 10 children were inappropriately given aspirin, three of whom had taken the aspirin on the advice of a pharmacist. Sixty-seven children received systemic antibiotic therapy; however, 31% of these patients did not have any local swelling.

CONCLUSION

It is evident that children and adolescents often receive inappropriate initial treatment for dental pain and may thus suffer unnecessary symptoms for several weeks. There is thus a need to educate healthcare workers more appropriately on aspects of the management of oral pain and to promote oral health care and hence reduce the incidence of caries in children.

Defining the personality disorders: description of an Australian database

OBJECTIVE

We seek to improve the definition and classification of the personality disorders (PDs) and derive a large database for addressing this objective.

METHOD

The paper describes the rationale for the development of a large set of descriptors of the PDs (including all DSM-IV and ICD-10 descriptors, but enriched by an additional 109 items), the design of parallel self-report (SR) and corroborative witness (CW) measures, sample recruitment (of 863 patients with a priori evidence of personality disorder or disturbance) and preliminary descriptive data.

RESULTS

Analyses (particularly those comparing ratings on molar PD descriptions with putative PD dimensions) argue for acceptable reliability of the data set, while both the size of the sample and the representation of all PD dimensions of interest argue for the adequacy of the database.

CONCLUSIONS

We consider in some detail current limitations to the definition and classification of the PDs, and foreshadow the analytic techniques that will be used to address the key objectives of allowing the PDs to be modelled more clearly and, ideally, measured with greater precision and validity.

Ethical considerations in the management of asylum seekers on hunger strike

Hunger strikes have confronted physicians with complex ethical dilemmas throughout history. Asylum seekers under threat of forced repatriation have emerged as a new category of hunger strikers, posing novel challenges for management. The management of 3 Cambodian asylum seekers on hunger strike admitted to a hospital in Sydney, New South Wales, Australia, posted important ethical dilemmas for the physicians and mental health experts involved in their care. Several factors confounded the task of assessment and decision making, including language and cultural barriers, the patients' past exposure to persecution by authorities, and the complexities of the legal procedures being pursued. Different rules appeared to govern the actions of the hunger strikers, the medical team, and the immigration authorities, creating a ¿malignant triangle¿ of mounting confrontation. Recent recommendations for the management of asylum-seeking hunger strikers include the appointment of an external physician of confidence and the writing of a confidential advance directive specifying the hunger striker's wishes about resuscitation in the event of collapse. In addition, we consider the value of constituting an ad hoc ethics committee to advise the responsible physician on points of conflict in managing the hunger strike. The advantages and limitations of these proposals in relation to the particular cultural, historical, and contextual issues relevant to asylum seekers are examined herein.

Prediction of ECT response: validation of a refined sign-based (CORE) system for defining melancholia

BACKGROUND

The clinical validity of melancholia has been argued on the basis of its capacity to predict response to electroconvulsive therapy (ECT). We have argued that a sign-based (CORE) rating system of psychomotor disturbance can identify patients with melancholia. Therefore, the clinical validity of the CORE system was tested here in terms of its capacity to predict response to ECT.

METHOD

The response of 81 patients with primary affective disorders to an individualised course of ECT was investigated. CORE scores and other clinical predictors were evaluated in terms of their capacity to predict effect size changes in symptoms and disability.

RESULTS

CORE scores predicted ECT response, as did the presence of psychotic features. The combination of marked psychomotor change (high CORE scores) and psychotic features predicted the best response to ECT.

CONCLUSION

This study supports the clinical validity of the CORE system for diagnosing melancholia.

Comparative validity of two measures of psychomotor function in patients with severe depression

Psychomotor function is a key construct in depressed patients and two measures have been developed for systematic rating. Parker and colleagues utilise an observer-rated scale (CORE) while the scale (DRRS) developed by Widlöcher assesses motor and ideational aspects. Association between the scales and their relative capacity to predict ECT response were investigated in a sample of 81 depressed patients. Both predicted ECT response. While the CORE scale rates a wider variety of phenomena (including non-interactiveness and agitation) and does not rely on the subject's capacity to report aspects of their cognitive function, the study supports the predictive and comparitive validity of both scales.

A novel MAP kinase phosphatase is localised in the branchial arch region and tail tip of Xenopus embryos and is inducible by retinoic acid

Using a differential display strategy, we have isolated a cDNA corresponding to a mRNA which is induced by retinoic acid treatment of late gastrula Xenopus embryos, and much more strongly induced by retinoic acid and cycloheximide. The cDNA, designated X17C, encodes a novel mitogen-activated protein (MAP) kinase phosphatase of 378 amino acid residues which is only distantly related to other known MAP kinase phosphatases. In normal embryogenesis, the X17C mRNA is expressed after the midblastula transition and accumulates during gastrulation. In neurula and tailbud stage embryos the mRNA is localised in two domains, one in the anterior region of the embryo, and one at the tail tip. When expressed from synthetic mRNA injected into oocytes, the X17C protein is found within the cytosolic fraction and not in the nucleus. The X17C protein dephosphorylates and inactivates Xenopus MAP kinase in oocytes stimulated to undergo maturation by progesterone. We indicate the application of X17C as a tool for interfering with MAP kinase signaling in somatic cells of embryos, using FGF receptor-mediated MAP kinase activation in animal cap explants.

Multiple supernumeraries: the importance of clinical and radiographic follow-up

The occurrence of multiple supernumerary teeth is a rare phenomenon. Three cases of multiple supernumeraries are presented which illustrate problems which may arise during long-term follow-up: resorption of adjacent teeth, enlargement of the follicles, movement of the unerupted teeth and development of further supernumeraries. These cases highlight the importance of adequate initial surveillance, anticipation of potential problems, assessing the risk-benefits of surgery and long-term monitoring, in some cases following the surgical removal of supernumeraries.

Temporal integration of events within and between the cerebral hemispheres

The effect of interhemispheric transmission time (IHTT) on temporal perception was investigated by comparing simultaneity thresholds under unimanual and bimanual stimulation conditions. In the unimanual conditions the tactile stimuli were delivered to the same hand and were received by the same hemisphere, but in bimanual conditions, where stimuli were delivered to different hands, interhemispheric communication was necessary in order to compare the timing of the two stimuli. Randomised order of stimulating the fingers of the hands was compared with consistent stimulation of each hand. Previous studies have used only consistent stimulation. Thirty-two undergraduate university students (16 males and 16 females) were tested. Bimanual simultaneity thresholds were significantly higher than unimanual. Previous research showing an absence of laterality effects for simultaneity judgements was confirmed, supporting a hemispheric equivalence model of temporal processing. Simultaneity thresholds were not affected by randomisation of stimulus location, indicating that expectancy effects were not responsible for the difference between bimanual and unimanual thresholds. The implication of these findings is that temporal perceptions are affected by the process of interhemispheric transmission.

An overview of depression-prone personality traits and the role of interpersonal sensitivity

A number of personality styles have been proposed as vulnerability traits to depression. In this paper methodological problems associated with identifying such traits are discussed. These include state effects contaminating personality scales and the issue of depressive heterogeneity. Potential depression-prone personality traits are then discussed, including obsessionality, neuroticism, dependency and cognitive dysfunction. High interpersonal sensitivity as a risk factor to depression is then discussed.

The prevalence of clinically significant anaemia and haemoglobinopathy in children requiring dental treatment under general anaesthesia: a retrospective study of 1000 patients

There is little information on the possible value of screening children who are liable to haemoglobinopathies as part of pre-operative assessment for dental treatment under general anaesthesia. The present retrospective investigation examined, first, the number of patients having low haemoglobin levels among 1000 patients who had undergone haematological investigation prior to general anaesthesia in a dental outpatient unit, and, secondly, the subsequent clinical management of these patients. Haemoglobin levels of 10.0 g/dl or less were found in 31 children: 13 Asian, 7 Afro-Caribbean, 5 Mediterranean, 3 Arabic, 1 white Caucasian and 2 Oriental children. In addition, 17 patients had sickle-cell trait and 2 had beta-thalassaemia trait, but there was no relationship between the presence of haemoglobinopathy and low levels of haemoglobin. The planned general anaesthesia was undertaken for 22 of the 31 children who had low levels of haemoglobin and for the 19 children with haemoglobinopathy. Only 6 children ultimately did not undergo general anaesthesia, all failing to return. It is concluded that pre-anaesthetic haematological assessment of children needing minor dental surgery is rarely of any significant clinical value.

The changing pattern of day-care treatment for children in a London dental teaching hospital

Day-stay general anaesthesia facilities may be employed to provide comprehensive dental care for children who are unable to accept treatment using alternative methods of patient management. This approach to delivery of care has been shown to be cost-effective, acceptable and efficaceous. This study was set up to investigate changes in the pattern of care provided in day-care facilities at a London dental teaching hospital over a 20-year period--1972 to 1992. The results show that the use of the facilities at this centre has increased with time, with a greater increase amongst older children in recent years. Although the main use is still for the treatment of caries, oral surgery procedures, especially those related to orthodontic treatment, have increased by 200% between 1982 and 1992. This correlates with the increase in older age groups being treated. Details of mean numbers of teeth restored and extracted for each age group are presented for 1992. They indicate, for the younger age groups, not only the high treatment needs of patients referred to the hospital, but also suggest a trend for more radical treatment planning in order to avoid further general anaesthesia. Readers are reminded that, despite its advantages, general anaesthesia should be avoided if possible.

Unusual distribution of enamel hypoplasia in an 11-year-old child with Proteus syndrome

An 11-year-old girl with Proteus syndrome attended our dental department because her teeth were sensitive to cold stimuli and because of the poor appearance of her anterior teeth. Extraoral examination revealed several of the previously reported craniofacial features of Proteus syndrome: facial and skull asymmetry, exostoses of the nasal bridge, and mandibular prognathism. Intraoral examination revealed enamel hypoplasia of primary and permanent teeth. The distribution of hypoplasia was unusual in that only teeth on the right side of the mouth were affected, and also in that only the distal half of the crown of the maxillary right permanent central incisor was affected. Behavioural problems necessitated treatment under general anaesthesia; the affected primary teeth were extracted and the hypoplastic permanent teeth were restored, relieving the patient's symptoms and greatly improving aesthetics.

Rapid induction of mRNA for nitric oxide synthase II in rat alveolar macrophages by intratracheal administration of Mycobacterium tuberculosis and Mycobacterium avium

Mycobacterium avium complex (MAC) organisms are among the most common bacterial cause of disseminated infection in patients with acquired immune deficiency syndrome (AIDS). An increase in the incidence of virulent Mycobacterium tuberculosis (MTB) is also occurring throughout the world. In vitro data suggest that nitric oxide (NO) may be important in restricting the growth of MAC. However, the ability of MTB to stimulate NO production and the susceptibility of MTB to the bactericidal activity of NO produced by murine alveolar macrophages (AM) is controversial. This study tested the hypothesis that in vivo administration of heat-killed MAC (strain 100 and 101) and human virulent MTB (strain F1) to rats stimulated NO production by rat AM, ex vivo. We show that heat-killed MTB instilled into rat lungs rapidly induced mRNA for NO synthase (iNOS) II in AM obtained by bronchoalveolar lavage (BAL). In contrast, expression of AM iNOS mRNA was only found in 40% of the rats given MAC. Moreover, the change in iNOS mRNA in the AM obtained from rats given MTB and MAC correlated with the production of the reactive nitrogen intermediates (RNI) NO2- and NO3- in BAL fluid, lung homogenate, and the spontaneous generation of RNI by isolated AM ex vivo and occurred without measurable increases in BAL fluid tumor necrosis factor-alpha (TNF-alpha). L-NG-monomethylarginine (50 mg/kg, ip) given 30 min before MAC or MTB attenuated the increase in RNI in lung homogenates and BAL fluid. This is the first demonstration that in vivo exposure to MTB results in rapid upregulation of gene expression for iNOS which is associated with functional RNI production by rat AM. These results show that MTB human virulent strain 1 has the ability to rapidly upregulate iNOS mRNA in AM. If human AM generate NO from L-arginine by either iNOS or other NADPH oxidases then NO may play a role in the overall host-defense response of the lung to MAC and MTB.

In vitro activity of D0870 compared with those of other azoles against fluconazole-resistant Candida spp

We compared the in vitro activity of a new triazole, D0870, with those of fluconazole, itraconazole, and ketoconazole against 41 clinical isolates of fluconazole-resistant Candida belonging to nine different species. The 50% inhibitory concentrations (IC50s) were determined by a microdilution method with morpholinopropanesulfonic acid (MOPS)-buffered RPMI medium and an inoculum of approximately 10(4) yeasts per ml. After incubation for 48 h at 37 degrees C the optical density at 550 nm was measured. The IC50 was the lowest drug concentration which reduced the optical density at 550 nm by > or = 50% compared with that for a drug-free control. D0870 had significant activity against many of the isolates. Its activity was comparable to that of ketoconazole, slightly superior to that of itraconazole, and markedly superior to that of fluconazole against Candida albicans. Against Candida glabrata, Candida krusei, and Candida inconspicua, it had activity similar to those of itraconazole and ketoconazole but had activity superior to that of fluconazole. D0870 IC50s for some isolates were increased. This may be due to cross-resistance mechanisms because the IC50s of both itraconazole and ketoconazole for these isolates were often high. When IC50s and IC80s were compared there was a marked organism and drug variation. With C. glabrata much higher endpoints for itraconazole were observed when an IC80 endpoint was used. For C. albicans there was also a significant shift upward in endpoints for itraconazole and ketoconazole. Values were changed little when IC50 and IC80 endpoints of D0870 were compared. For 35 of 41 isolates tested the D0870 IC50 was less than the 2.5-mg/liter breakpoint threshold proposed previously. Therefore, D0870 may be a useful agent for the therapy of infections caused by fluconazole-resistant Candida spp.

Ethanol suppresses Mycobacteria tuberculosis-induced mRNA for nitric oxide synthase in alveolar macrophages, in vivo

Acute ingestion of alcohol [ethanol (ETOH)] adversely affects the immunocompetence of both naive individuals as well as chronic alcohol abusers. An increased incidence and severity of tuberculosis is found in chronic alcohol abusers. Nitric oxide (NO) produced by alveolar macrophages (AMs) may play a role in the in vitro killing of Mycobacterium avium and Mycobacterium tuberculosis (MTB). Moreover, tumor necrosis factor-alpha (TNF-alpha) is believed to be a primary cytokine mediator of NO production by AMs. Recent studies from our laboratory demonstrated that ETOH suppressed endotoxin-induced increases in both TNF-alpha and NO in AMs, in vivo. We tested the postulate that acute ingestion of ETOH can interfere with mycobacteria-induced upregulation of the NO system in AMs, in vivo. We show that heat-killed M. avium complex (MAC) and human virulent MTB instilled into rat lungs rapidly increased mRNA for inducible NO synthase II (iNOS) of AMs in fluid obtained by bronchoalveolar lavage (BAL fluid). This was associated with production of reactive nitrogen intermediates [(RNIs); NO2- and NO3-] in BAL fluid, lung homogenate, and AMs in the absence of a significant increase in BAL fluid TNF-alpha. A single dose of ETOH (5.5 g/kg, ip) administered 30 min before intratracheal administration of MAC or MTB attenuated both MAC and MTB-induced increases in RNI in BAL fluid, lung, and AMs, and the increase in mRNA for iNOS. Thus, mycobacteria upregulate iNOS mRNA and enhance RNI production by AMs without any increase in the production of TNF-alpha. Moreover, ETOH attenuates mycobacteria-induced upregulation of mRNA for iNOS and RNI production in the absence of ETOH-mediated suppression of TNF. Speculatively, ETOH-mediated inhibition of the AM NO system may offer an explanation for the increased severity of mycobacterial infections in alcoholics.

Is there a physiological basis for the couvade and onset of paternal care?

Couvade is the male experience of pregnancy and couvade syndrome incorporates a range of symptoms suffered by "pregnant" men. The aetiology of the couvade syndrome is unknown. Anthropologists, psychiatrists, nurses and sociologists have provided explanations for behaviour changes in "pregnant" men in terms of cultural pressure, intrapsychic processes and psychosocial adaptation to a new situation. The adoption of a biological perspective allows us to ask a new question: is there a physiological basis for the couvade syndrome? A fresh research agenda would include measurement of physiological change and a search for causation. Implications for nursing are outlined.

Alcohol, tumor necrosis factor, and tuberculosis

Alcohol exerts potent suppressive effects on the immune system that significantly increase host susceptibility to a variety of infections, particularly pneumonia. Historically, tuberculosis has been strongly associated with alcohol abuse. Although the relationship between alcohol abuse and tuberculosis is widely appreciated, the basic mechanisms by which alcohol immunosuppresses the host remain to be clarified. A major obstacle in furthering our understanding of this association has been the difficulty in distinguishing between the effects of alcohol per se and the other frequent sequelae of alcoholism such as nutritional deficiencies, liver disease, cigarette smoking, hygienic factors, and lifestyle. This article focuses on the role of tumor necrosis factor-alpha (TNF) in host defense and how alcohol modulates the activity of this important cytokine. While TNF's role in mediating the lethal consequences of infection has been the subject of much conjecture, this review focuses on the emerging evidence that TNF is an essential factor in the normal immune response to numerous infections, including tuberculosis.

Enroute toward a computer based patient record: the ACIS project

The clinical arm of the University of Utah operates a 400 bed general hospital and 30 specialty and subspecialty clinics and with the advent of managed care will soon be linked to a much wider network of health care facilities throughout the state. Each of these patient care facilities maintains its own patient record. To provide common access to data on any patient needed to provide continuity to the care process where ever it occurs, the institution has embarked on the development of a completely electronic patient record. In this paper we will describe the route we have taken to achieve this goal in hopes of providing some sign posts along the way for others seeking the same destination.

Severe tracheal stenosis and operative delivery

We report the management of anaesthesia for Caesarean section in a woman with severe extensive tracheal stenosis. Management was initially with spinal anaesthesia, but general anaesthesia became necessary as a result of profuse intra-operative bleeding. We describe the use of the Hayek oscillator cuirass ventilator to allow instrumentation of the larynx whilst maintaining respiratory support, and for weaning from mechanical ventilation.

Midline supernumeraries: a family affair

Supernumerary teeth are relatively common in the general population and appear to be more likely to occur in patients with a family history of such teeth. It is important that these teeth are identified and in some cases removed before undertaking orthodontic treatment. This article describes two patients who presented with supernumeraries, and their treatment.

Dental complications associated with repeated orotracheal intubation in infancy: a case report

Various oral and dental problems have been attributed to orotracheal intubation in the neonatal period. A case is described of a child whose dental anomalies are ascribed to multiple orotracheal intubations for the management of a complex cardiac abnormality. Six intubations were required between the ages of 9 days and 4 years for investigation and surgery. His maxillary right primary central incisor did not erupt until 3 years of age and the maxillary left was still unerupted at 6 years and 10 months and was rotated in its crypt. At this time, the mandibular primary incisors were physiologically mobile but the maxillary right primary central incisor remained firm. Both maxillary primary central incisors were extracted and examined histologically and showed abnormal morphology, enamel hypoplasia, and disordered dentine formation and root resorption. Subsequent eruption of the left permanent central incisor revealed hypoplasia of its incisal edge. It is suggested that the delayed eruption and abnormal morphology of the primary incisors were due to pressure effects on the overlying mucosa, follicular displacement and localized trauma caused by intubation. This case highlights the importance of monitoring the developing dentition of patients with a history of orotracheal intubation, so that interceptive treatment may be instituted when appropriate.

An evaluation of the adequacy of health visitor education for neonatal hip screening

Congenital dislocation of the hip (CDH) affects two children per 1000, with potentially serious consequences. Student health visitors in Northern Ireland learn screening techniques for CDH at a half-day workshop at a regional hospital. In order to evaluate the adequacy of this preparation, 71 qualified health visitors were surveyed to assess their knowledge relating to CDH, their views on the adequacy of the training, and their opinions about referral of positive cases. Knowledge in some areas was poor and preparation was considered too short. Direct referrals of positive cases to orthopaedic clinics, without a general practitioner acting as an intermediary, was a frequently cited desire. Recommendations include extending the training for those involved in CDH screening while ensuring that experienced health visitors, from whom novices learn, are themselves using correct procedures.

NDUs: can they fit in a market-led service?

This article discusses how NDUs fit into the concepts that are currently governing the management of the NHS such as marketability, accountability and cost-effectiveness of care. The author argues that while there are potential difficulties, the NDU values of equality, democracy, esteem-building and personal growth are relevant in the business world of health care.

Trigeminal neurapraxia following a blow to the face: a case report

Examination of the cranial nerves is a simple and valuable procedure following trauma to the head and neck. By understanding their courses, branches and distributions, the site of any damage may be localized. Once the site and nature of injury has been determined, correct management may be instigated. A case is presented in which there was some degree of trigeminal nerve damage following trauma. The site of damage was determined to be extracranial and therefore a conservative regimen adopted. The mechanism of injury is postulated.

Cimetidine does not impair pulmonary clearance of Pseudomonas aeruginosa in normal rats

Histamine (H2)-receptor blockers are commonly used in critically ill patients to prevent gastric bleeding and have been implicated in the pathogenesis of gram-negative bacterial (GNB) nosocomial pneumonia. These experiments were undertaken to determine if cimetidine affects pulmonary GNB clearance. Groups of normal Sprague-Dawley rats were given cimetidine (75 mg/kg) or an equal volume of sterile buffer intraperitoneally every 6 hr for 24 hr prior to intratracheal challenge with 1.0 x 10(8) Pseudomonas aeruginosa. At 6 and 24 hr after challenge, animals were sacrificed and gastric pH, quantitative lung cultures, and total and differential [alveolar macrophages (AM) and polymorphonuclear leukocytes (PMN)] cell counts in bronchoalveolar lavage fluid were performed. Results showed that cimetidine therapy resulting in gastric pH greater than 4.0 has no effect on the pulmonary clearance of P. aeruginosa.

The use of CO2 laser in the treatment of gingival fibromatosis: a case report

A case is described of gingival fibromatosis in a 10-year-old boy, in which gingival tissue was removed using a CO2 laser. The advantages of this method over conventional surgery were minimal bleeding and pain, allowing treatment of all quadrants in one visit. The disadvantages were the potential risks to the teeth and to the endotracheal tube. In this case laser treatment achieved a good result with minimal post-operative discomfort, which is an important consideration for children.

A cardiovascular health education program for rural schools

Public understanding of cardiovascular disease (CVD) risk factors and primary prevention has increased, due in part to community prevention efforts. However, many segments of society are difficult to reach. Such groups still need public education to acquire the knowledge that can lead to behavior change. Community intervention programs in rural areas face the challenge of disseminating health information to widely scattered populations isolated by difficult terrain and weather, and restricted by the sparsity of channels for mass communication. School health promotion programs, because of the special role schools play in rural communities, can help reach rural populations. During a five-year period, the Otsego-Schoharie Healthy Heart Program, a state-funded community intervention program, provided presentations to 18% of the combined total population of two rural counties through its school-based component. It also helped promote other program initiatives by establishing linkages in the community. Schools provide an effective channel for health promotion efforts to reach rural populations.

Carbon monoxide exposure in blast furnace workers

This study investigated the occupational exposure to carbon monoxide (CO) of a group of blast furnace workers from an integrated steelworks, compared to a control group having no significant occupational CO exposure from other areas in the same works. The study was undertaken in 1984 at Port Kembla, New South Wales. Carboxyhaemoglobin (COHb) levels before and after an eight-hour work shift were measured in 98 male steelworkers: 52 from two CO-exposed iron blast furnaces and 46 controls from production areas in the same steelworks. The sample was stratified by smoking habits. Environmental air CO levels had been found to be consistently higher on one furnace than on the other. Absorption of CO from the working environment occurred in workers on the blast furnace with higher CO levels, regardless of smoking habits. On this blast furnace, some readings of COHb levels after a workshift in nonsmokers approached the proposed Australian occupational limit of 5 per cent COHb saturation. Overall, workers with the highest occupational exposure who smoked most heavily had the highest absorption of CO over a work shift. Biological monitoring gives an accurate measure of individual worker 'dose' of CO from all sources. Both environmental monitoring and biological monitoring need to be included as part of a program for controlling occupational CO exposure.

Naturally acquired CD8+ cytotoxic T lymphocytes against the Plasmodium falciparum circumsporozoite protein

In rodent malaria model systems, protective immunity induced by immunization with irradiated sporozoites is eliminated by in vivo depletion of CD8+ T cells, and adoptive transfer of CTL clones against the circumsporozoite protein protects against malaria. We recently demonstrated that volunteers immunized with irradiated Plasmodium falciparum sporozoites produce CTL against peptide 368-390 of the P. falciparum circumsporozoite protein. To determine whether natural exposure to malaria induced similar CTL, we studied 11 adult, male, life-long residents of a highly malarious area of Kenya, who were selected because their lymphocytes had been shown to proliferate after stimulation with peptides 361-380, 371-390, or 368-390 and because nine had been resistant to malaria in previous studies. In four of the 11 individuals there was peptide-specific, genetically restricted, CTL activity. In all four individuals, this activity was unaffected by depletion of CD4+ T cells. In three volunteers the activity was eliminated or reduced by depletion of CD8+ T cells; in the fourth volunteer the CD8+ T cell depletion was uninterpretable. This first demonstration of CD8+ T cell, genetically restricted, Ag-specific CTL against a malaria protein among individuals exposed to endemic malaria provides a foundation for studying the relationship between circulating CTL and resistance to malaria infection.

Naturally acquired CD8+ cytotoxic T lymphocytes against the Plasmodium falciparum circumsporozoite protein

In rodent malaria model systems, protective immunity induced by immunization with irradiated sporozoites is eliminated by in vivo depletion of CD8+ T cells, and adoptive transfer of CTL clones against the circumsporozoite protein protects against malaria. We recently demonstrated that volunteers immunized with irradiated Plasmodium falciparum sporozoites produce CTL against peptide 368-390 of the P. falciparum circumsporozoite protein. To determine whether natural exposure to malaria induced similar CTL, we studied 11 adult, male, life-long residents of a highly malarious area of Kenya, who were selected because their lymphocytes had been shown to proliferate after stimulation with peptides 361-380, 371-390, or 368-390 and because nine had been resistant to malaria in previous studies. In four of the 11 individuals there was peptide-specific, genetically restricted, CTL activity. In all four individuals, this activity was unaffected by depletion of CD4+ T cells. In three volunteers the activity was eliminated or reduced by depletion of CD8+ T cells; in the fourth volunteer the CD8+ T cell depletion was uninterpretable. This first demonstration of CD8+ T cell, genetically restricted, Ag-specific CTL against a malaria protein among individuals exposed to endemic malaria provides a foundation for studying the relationship between circulating CTL and resistance to malaria infection.

Non-attendance at out-patient clinics: a case study

Non-attendance at out-patient clinics is a persistent, worldwide problem. In contrast with previous research, a qualitative approach was used in this study to examine reasons for non-attendance at out-patient clinics in one Belfast hospital, by exploring perspectives of general practitioners (GPs), hospital staff and defaulters. Findings revealed conflicts of opinion between GPs and hospital staff on appropriate management of certain medical and postnatal patients. Patients' reasons for defaulting were wide-ranging; however, 32% of those interviewed did not attend, or were recorded as non-attenders, for reasons relating to inefficient hospital administration. It is concluded that the causes of non-attendance were multifactorial, and non-attenders could not be stereotyped as irresponsible. Suggested measures to alleviate the problem include discussion between groups of professionals on responsibility for care of medical and postnatal patients, increased negotiation between patients and physicians in order to develop agreed programmes of care, and, where possible, a shifting of the onus of responsibility for making and cancelling appointments onto patients.

Research in practice: rhetoric or reality?

'Research' has become a fashionable word in nursing circles, but doubts remain about whether nursing is justified in calling itself a research-based profession. The author examines the rhetoric surrounding the word, before citing examples of how research is affecting nursing practice. More work is needed to ensure the gap is closed between talking about research and using it, but nurses should not lose sight of the ultimate aim of research--to enhance the primary vocation of caring.

Thienotriazolodiazepines as platelet-activating factor antagonists. Steric limitations for the substituent in position 2

The preparations of thienotriazolodiazepines bearing a substituted ethynyl group at the 2-position, and the corresponding cis-olefins and fully saturated analogues are described. The compounds were evaluated as potential antagonists of platelet-activating factor (PAF) in in vitro and in vitro test models. The new thienotriazolodiazepines are compared with known related compounds such as WEB 2086 (compound 6) and the phenylethyl derivatives 27 and 28.