Role of the community nurse in caring for people with depression

Depression is often seen as a defect of character, rather than a disorder which can be treated. Elizabeth Armstrong outlines how nurses working in primary care can effectively recognise and refer patients or clients with depression.

Euglycaemic hyperinsulinaemia does not affect gastric emptying in type I and type II diabetes mellitus

Hyperglycaemia slows gastric emptying in both normal subjects and patients with diabetes mellitus. The mechanisms mediating this effect, particularly the potential role of insulin, are uncertain. Hyperinsulinaemia has been reported to slow gastric emptying in normal subjects during euglycaemia. The purpose of this study was to evaluate the effect of euglycaemic hyperinsulinaemia on gastric emptying in Type I (insulin-dependent) and Type II (noninsulin-dependent) diabetes mellitus. In six patients with uncomplicated Type I and eight patients with uncomplicated Type II diabetes mellitus, measurements of gastric emptying were done on 2 separate days. No patients had gastrointestinal symptoms or cardiovascular autonomic neuropathy. The insulin infusion rate was 40 mU x m(-2) x min(-1) on one day and 80 mU x m(-2) x min(-1) on the other. Gastric emptying and intragastric meal distribution were measured using a scintigraphic technique for 3 h after ingestion of a mixed solid/liquid meal and results compared with a range established in normal volunteers. In both Type I and Type II patients the serum insulin concentration had no effect on gastric emptying or intragastric meal distribution of solids or liquids. When gastric emptying during insulin infusion rates of 40 mU x m(-2) x min(-1) and 80 mU x m(-2) x min(-1) were compared the solid T50 was 137.8+/-24.6 min vs. 128.7+/-24.3 min and liquid T50 was 36.7+/-19.4 min vs. 40.4+/-15.7 min in the Type I patients; the solid T50 was 94.9+/-19.1 vs. 86.1+/-10.7 min and liquid T50 was 21.8+/-6.9 min vs. 21.8+/-5.9 min in the Type II patients. We conclude that hyperinsulinaemia during euglycaemia has no notable effect on gastric emptying in patients with uncomplicated Type I and Type II diabetes; any effect of insulin on gastric emptying in patients with diabetes is likely to be minimal.

Statistical algorithm for nonuniformity correction in focal-plane arrays

A statistical algorithm has been developed to compensate for the fixed-pattern noise associated with spatial nonuniformity and temporal drift in the response of focal-plane array infrared imaging systems. The algorithm uses initial scene data to generate initial estimates of the gain, the offset, and the variance of the additive electronic noise of each detector element. The algorithm then updates these parameters by use of subsequent frames and uses the updated parameters to restore the true image by use of a least-mean-square error finite-impulse-response filter. The algorithm is applied to infrared data, and the restored images compare favorably with those restored by use of a multiple-point calibration technique.

Incorporating an environmental/occupational medicine theme into the medical school curriculum

Medical schools have been slow in teaching students how to recognize and intervene in occupationally and environmentally related illnesses. In this article, we report on the efforts at one medical school, in which an occupational medicine physician teamed with medical school educators developed, implemented, and evaluated an environmental/occupational medicine (EOM) curriculum that was introduced in several locations, using a thematic approach. This effort resulted in new EOM content being added to eight core courses in a developmental sequence and the creation of several elective experiences. We describe techniques and strategies that might be useful at other institutions in promoting the EOM theme and improving communication. Occupational/environmental physicians and educators can play leadership roles in raising interest in EOM within the medical school setting and in developing and implementing an EOM curriculum.

Adolescent medicine training in pediatric residency programs: are we doing a good job?

OBJECTIVES

To determine how pediatric residency programs are responding to the new challenges of teaching adolescent medicine (AM) to residents by assessing whether manpower is adequate for training, whether AM curricula and skills are adequately covered by training programs, what types of teaching methodologies are used to train residents in AM, and the needs for new curricular materials to teach AM.

DESIGN

A 3-part 92-item survey mailed to all US pediatric residency training programs.

SETTING

Pediatric residency programs.

PARTICIPANTS

Residency program directors and directors of AM training.

MAIN OUTCOME MEASURES

AM divisional structure, clinical sites of training, presence of a block rotation, and faculty of pediatric training programs; training materials used and desired in AM; perceived adequacy of coverage of various AM topics; competency of residents in performing pelvic examinations in sexually active teens; and manpower needs.

RESULTS

A total of 155/211 (73.5%) of programs completed the program director and the AM parts of the survey. Ninety-six percent of programs (size range, 5-120 residents) had an AM block rotation and 90% required the AM block; those without a block rotation were more likely to be larger programs. Only 39% of programs felt that the number of AM faculty was adequate for teaching residents. Almost half of the programs reported lack of time, faculty, and curricula to teach content in substance abuse. Besides physicians, AM teachers included nurse practitioners (28%), psychologists (25%), and social workers (19%). Topics most often cited as adequately covered included sexually transmitted diseases (81.9%), confidentiality (79.4%), puberty (77.0%), contraception (76.1%), and menstrual problems (73.5%). Topics least often cited as adequately covered included psychological testing (16.1%), violence in relationships (20.0%), violence and weapon-carrying (29.7%), and sports medicine (29.7%). Fifty-eight percent of 137 respondents thought that all or nearly all of their residents were competent in performing pelvic examinations by the end of training; there was no difference between perceived competence and the residents' use of procedure books. Seventy-four percent used a specific curriculum for teaching AM; materials included chapters/articles (85%), lecture outlines (76.1%), slides (41.9%), videos (35.5%), written case studies (24.5%), computerized cases (6.5%), and CD-ROMs (3.2%). Fifty-two percent used Bright Futures, 48% used the Guidelines for Adolescent Preventive Services, and 14% used the Guide to Clinical Preventive Services for teaching clinical preventive services. Programs that used Bright Futures were more likely to feel that preventive services were adequately covered in their programs than those who did not (78% vs 57%). A majority of programs desired more learner-centered materials.

CONCLUSIONS

Although almost all pediatric programs are now providing AM rotations, there is significant variability in adequacy of training across multiple topics important for resident education. Programs desire more learner-centered materials and more faculty to provide comprehensive resident education in AM.

Limbic frontal cortex in hominoids: a comparative study of area 13

The limbic frontal cortex forms part of the neural substrate responsible for emotional reactions to social stimuli. Area 13 is one of the cortical areas long known to be part of the posterior orbitofrontal cortex in several monkey species, such as the macaque. Its presence nevertheless in the human brain has been unclear, and the cortex of the frontal lobe of the great and lesser apes remains largely unknown. In this study area 13 was identified in human, chimpanzee, bonobo, gorilla, orangutan, and gibbon brains, and cortical maps were generated on the basis of its cytoarchitecture. Imaging techniques were used to characterize and quantify the microstructural organization of the area, and stereological tools were applied for estimates of the volume of area 13 in all species. Area 13 is conservative in its structure, and features such as size of cortical layers, density of neurons, and space available for connections are similar across hominoids with only subtle differences present. In contrast to the homogeneity found in its organization, variation is present in the relative size of this cortical area (as a percentage of total brain volume). The human and the bonobo include a complex orbitofrontal cortex and a relatively smaller area 13. On the contrary the orangutan stands out by having a shorter orbitofrontal region and a more expanded area 13. Differences in the organization and size of individual cortical areas involved in emotional reactions and social behavior can be related to behavioral specializations of each hominoid and to the evolution of emotions in hominids.

Nitric oxide and gall-bladder motor function

BACKGROUND

The L-arginine: nitric oxide (NO) pathway has been shown to be important in the regulation of intestinal motility and NO may be the mediator for nonadrenergic noncholinergic (NANC) neurotransmission.

AIM

To determine the role of the L-arginine: NO pathway in gall-bladder motor function.

METHODS

Strips of fresh bovine and human gall-bladders were stimulated with cholecystokinin (CCK). The effects of glyceryl trinitrate (GTN), sodium nitroprusside and Kreb's solution upon CCK-stimulated muscle contraction were examined. The effect of the NO synthase inhibitor, L-NG-monomethyl-arginine (L-NMMA) upon basal muscle tone was also examined. Ten human gall-bladders were immunohistochemically stained for nitric oxide synthase (NOS) and product 9.5 to identify neurones. Postprandial gall-bladder emptying was measured on separate occasions in six healthy volunteers during systemic intravenous infusion of normal saline; glyceryl trinitrate; sodium nitroprusside (SNP), hydralazine and L-NMMA.

RESULTS

In the in vitro study, GTN and SNP significantly reduced the tension of CCK-stimulated muscle contraction whilst Kreb's solution had no effect. L-NMMA increased tonic and phasic muscle contractions. Immunohistochemical staining for NOS was consistently absent in human gall-bladders. In the in vivo study, both GTN and SNP caused significant impairment of gall-bladder emptying; the ejection fraction was only 50% at the end of the study period involving these infusates, this contrasted with ejection fractions in excess of 80% during infusions with hydralazine, saline and L-NMMA.

CONCLUSION

Pharmacological doses of NO donors impair postprandial gall-bladder emptying in vivo and relax gall-bladder smooth muscle in vitro. However, negative immunohistochemical staining suggest NOS is unlikely to be the neurotransmitter for NANC innervation regulating gall-bladder motility.

Effect of euglycaemic hyperinsulinaemia on gastric emptying and gastrointestinal hormone responses in normal subjects

Several studies have shown that hyperglycaemia slows gastric emptying in normal subjects and patients with diabetes mellitus but whether hyperinsulinaemia per se has an effect remains debatable. In the present study we have assessed the effect of hyperinsulinaemia on gastric emptying of a solid and liquid meal in normal subjects. Ten men were studied three times in random order. After an overnight fast, subjects were infused with 0.9% NaCl on two occasions and on the third with insulin, at 40 mU x m(-2) x min(-1) with 20% glucose simultaneously to maintain euglycaemia. Steady-state glucose infusion rate was ensured before the subjects ate a standard meal of a pancake labelled with 99mTc and milkshake labelled with (111)In-DTPA. Gamma-scintigraphic images were then obtained every 20 min for the next 3 h. There were no significant differences between the mean half-emptying times (T50) of the solid and liquid during the two saline infusions (129.6 +/- 28.5 vs 128.4 +/- 23.8 min for the solid and 25.4 +/- 7.0 vs 34.7 +/- 18.0 min for the liquid, mean +/- SD). Hyperinsulinaemia delayed both solid (mean T50 149.6 +/- 30.7, p = 0.031) and liquid emptying (mean T50 39.8 +/- 13.9, p = 0.042). There were no significant differences in the cholecystokinin and glucagon-like peptide 1 responses to the meal during either saline or insulin infusions. There was a tendency towards a greater insulin response to the meal during the hyperinsulinaemic study. Thus, hyperinsulinaemia delayed emptying of both the solid and liquid components of the meal.

Depression: moving on

Care for patients who are (or may be) depressed is delivered in a range of practice settings. All nurses, midwives and health visitors, therefore, need to be alert to the signs of depression, in order that appropriate action can be taken--whether this is initiating self-help, using practical interventions or referring on, where necessary. This Learning Unit focuses particularly on the assessment and prevention of depression and is relevant whatever the setting in which you work.

The linear organization of cell columns in human and nonhuman anthropoid Tpt cortex

Neurons in the cerebral cortex are organized horizontally into laminae and vertically into columns and modules. Little is known about the structural variation of neuronal organization in the vertical (pia to white matter) dimension. We describe here a new computer-assisted methodology that quantifies the linear arrangement of cells and shows how cortical columns in a homologous region differ by species and age. Perikarya in eulaminate temporal cortex, Tpt, were segmented from the background on the basis of their optical densities and sizes in human, rhesus (Macaca mulatta), and chimpanzee (Pantroglodytes) brains. Within each lamina, the two-dimensional arrays of neurons were divided into repetitive, objectively defined vertical clusters. Following this, ratios and indices quantified the displacement of perikaryal centroids from the central axis and from the center point in each cell cluster. The extremely linear and vertical arrangement of cells in the prelaminated fetal cortical plate served as the template to which the other arrays were compared. In all species, the linear arrangements of perikarya in lamina III, and to a lesser extent, in lamina V, closely resemble that of the early fetal template, whereas perikaryal arrangements in layers II and IV diverge from the template formation. Corroborating subjective visualization, each lamina had its own 'fingerprint'. As expected, cell density is less in the species with larger brains, with most of the differences in density coming from increased spacing between cellular columns rather than among the cells within columns. Not all aspects of perik-aryal organization alter when bigger brains are compared with smaller ones. Although chimpanzee brains are about four times bigger than those of rhesus monkeys and human brains are about three times larger than chimpanzee brains, absolute measures of cellular linearity in chimpanzees and rhesus monkeys resemble each other more closely than the same measures do in humans and chimpanzees. After accounting for differences in interval widths, the parameters of linearity sorted on the basis of brain weight in pyramidal cell layers III and V, but not in the stellate cell layers II and IV. Human perikarya have the widest horizontal dispersion and this displacement is most pronounced in layer II, least in layer III.

Expanding access to emergency contraception in developing countries

Emergency contraception has been called the best-kept contraceptive secret. Previous research shows that several regimens of postcoital contraception offer safe and effective ways for women to avoid pregnancy. Yet the methods are typically unavailable to women in developing countries. In this article, the authors review the main methods of emergency contraception and describe experience with them to date. The prevalence and urgency of the need for making these methods available to women in developing countries are assessed. The necessary elements for creating such access are described. In several developing countries, conditions for introducing the methods may be more favorable than in industrialized countries. These advantages are reviewed. Finally, the authors describe the challenges anticipated for broadening the availability of postcoital methods in the developing world. They conclude with a brief series of recommendations for policymakers.