User views of a regional secure unit--findings from a patient satisfaction survey

This paper includes key findings of a patient satisfaction survey, conducted within an English Medium Secure Unit, offering care and treatment for 45 male and female mentally disordered offenders. It aims to identify patients' perceptions of the quality of their care and other aspects of their lives within the secure unit. Following permission from the local Ethics Committee, two interviewers collected data within a two week period, using a semi-structured interview schedule. All but three of the respondents agreed to be interviewed. Talking to nurses was perceived as highly satisfying. However, provision for specific cultural and women's needs, facilities for visitors, opportunities to practise religious beliefs and access to care plans were highlighted as unsatisfactory. The study concludes with recommendations for improvement, some of which have already been considered and implemented.

Psychiatric comorbidity in methadone maintained patients

Diagnosing comorbid psychiatric disorders in methadone maintained patients may help to identify subgroups with different outcomes and needs for treatment. In this study, 75 methadone maintenance clinic patients in treatment longer than 30 days were assessed with the Addiction Severity Index, Global Assessment Scale and Mini-Mental Status Exam, and were interviewed for DSM-III-R psychiatric diagnosis using the computerized Diagnostic Interview Schedule. Psychiatric diagnoses were prevalent in the sample with depression, phobic disorders, antisocial personality and generalized anxiety the most common. Both number of DSM-III-R diagnoses and severity of psychopathology were correlated with outcome measures such as concurrent drug abuse, family-social problems and employment status.

Quality assurance and standards for red cells and platelets

Blood donations vary in composition because of considerable variation in donor cell counts and volume collected. In order to minimize the variation in end products produced, and reduce the likelihood of low quality products, a program called Quality Assurance (QA) is required. Agreement on minimal standards is useful, and a program of quality control (QC) is an important component of QA. However, while QC to ensure compliance with standards is desirable, the objective of manufacturing products of consistently high quality can only be achieved when attention is focused on total process control, self-auditing and the energetic management of errors.

Comparison of results of various methods used to determine the extent of modification of methoxy polyethylene glycol 5000-modified bovine cupri-zinc superoxide dismutase

The protein bovine cupri-zinc superoxide dismutase (SOD) was modified by the reaction of lysine residues with an active ester of methoxy polyethylene glycol 5000 (PEG). The extent of modification was determined by capillary zone electrophoresis, matrix-assisted laser desorption/ionization mass spectrometry, Fourier-transform infrared spectroscopy, and Raman spectroscopy and after removing PEG by alkaline hydrolysis of the linkages to SOD followed by quantification of the released PEG using gel-permeation chromatography. There was generally good agreement among the results obtained by these techniques on a typical sample of the PEG-modified protein. The results, extent of protein modification, determined by the preceding methods were compared to that found from the classical trinitrobenzene sulfonic acid (TNBS) procedure. In addition to providing alternatives to the TNBS procedure, results from the described methodologies strongly suggest that the extent of modification determined from the TNBS procedure is overestimated.

Combined PTCA and aortic valvuloplasty for acute myocardial infarction complicated by severe aortic stenosis and cardiogenic shock

Percutaneous aortic valvuloplasty (PAV) performed in patients with critical aortic stenosis has been shown to increase aortic valve area, decrease aortic valve gradient, and improve left ventricular function. However, the procedure is limited by rapid restenosis. Aortic valvuloplasty in the setting of critical aortic stenosis with cardiogenic shock can be a life-saving procedure, although morbidity and mortality remain high. We describe a patient with critical aortic stenosis who presented with an acute anterior myocardial infarction treated with primary angioplasty. Despite rapidly achieving patency of the culprit vessel, the patient spiraled into cardiogenic shock, which prompted an emergent PAV.

Identification of metallothionein receptors in human astrocytes

Metallothionein (MT) isoforms are low molecular weight (6000-7000 Da) zinc binding proteins containing 60-68 amino acid residues, 25-30% cysteine, no aromatic amino acids, and binding between 5-7 g zinc/mol of protein. Since the synthesis of MT is induced by endotoxin, cytokines, and glucocorticoids, MT is now considered to be an acute phase protein protecting against oxygen radicals and oxidative damages caused by inflammation, tissue injury, and stress to the central nervous system. By postulating that a specific mechanism must exist to foster the induction of MTs I and II by numerous and diversified factors, we searched for and identified for the first time, MT receptors on U373MG cell membrane preparations, by using fluoresceinated MT I isoform probe; and by employing cysteine, glutathione, and four MT isoforms to determine high affinity and specific binding. MT receptors revealed a Kd value of 0.84 nM and a Bmax of 99.82 fmol/mg protein. Moreover, MT receptors were found in greater density on the surface of aggregated astrocytes. We postulate that conditions or agents generating reactive oxygen species may influence the expression of MT receptors.

Creating a new brand of mental health nurse

Mental health nurse training provision has been criticized for failing to develop practitioners with the appropriate skills to care for clients with severe mental illness (Owen and Sweeney, 1995), However, a tide of change is about to wash over the initial and ongoing education of mental health nurses.

Multielectrode nerve cuff stimulation of the median nerve produces selective movements in a raccoon animal model

In this study, an electrode system consisting of twelve small platinum dot electrodes imbedded in a spiral silicone rubber insulating cuff was used to investigate the feasibility of selective (regional) stimulation of the median nerves of the raccoon. Acute experiments in four raccoons consisted of functional responses observations, isometric force recordings from tendon attachments and postmortem fascicular mapping. Functional responses (elbow, wrist and/or digit flexion, pronation and/or thumb abduction) to selective stimulation were noted as dependent upon cuff electrode configuration (longitudinal tripole with and without field steering, as well as a transverse bipolar arrangement) and current level (threshold, 1/2 maximal, maximal). Muscle force recruitment curves (force as a function of stimulus amplitude) were plotted for flexor digitorum superficialis, flexor digitorum profundus, flexor carpi radialis, palmaris longus and pronator teres of three raccoons. Fascicular maps at the level of the nerve cuff were created indicating the approximate position of innervation to each of the aforementioned muscles, as well as other innervation such as paw fascicles, sensory fascicles, and elbow innervation (such as coracobrachialis). The greatest selectivity was observed at or near threshold current levels. In all four raccoons studied, a threshold electrode choice and stimulation strategy could be identified enabling selective production of either digit flexion, wrist flexion and/or digit and wrist flexion. It was possible to elicit a selective pronation response at threshold in three of the four animals. Selective elbow flexion at threshold could be produced in all four experiments. With stronger currents, additional movements were usually induced. The raccoon therefore appears to be a suitable, if challenging, animal model for further development of not only nerve cuff electrode approaches but perhaps other stimulation electrode technologies prior to human neuroprosthetic studies.

Uveitis associated with rifabutin and macrolide therapy for Mycobacterium avium intracellulare infection in AIDS patients

OBJECTIVE

Uveitis has been increasingly recognised as a side effect of rifabutin regimens in the prophylaxis and treatment of Mycobacterium avium intracellulare (MAI) infection. This study describes the clinical features and analyses the factors associated with rifabutin induced uveitis.

DESIGN

Retrospective observational study.

SETTING

Tertiary care institution, The Royal Hospitals NHS Trust, London.

PATIENTS

68 HIV seropositive individuals receiving rifabutin for prophylaxis or treatment of MAI infection.

RESULTS

11 episodes of uveitis occurred in 10 different individuals at a median of 62 days. The disease was bilateral in four and unilateral in the remainder. All subjects experienced ocular pain and photophobia and 9 individuals had a significant reduction in visual acuity. Uveitis was treated with mydriatics and topical steroids and resolved in all cases when rifabutin was stopped. The risk of uveitis was significantly increased with concurrent clarithromycin therapy, Odds Ratio 13.08, 95% Confidence Interval 1.98 to 83.12.

CONCLUSION

Rifabutin can cause a reversible uveitis. This risk is increased with concurrent clarithromycin therapy. Adverse drug interactions can be an important cause of morbidity in patients with advanced HIV disease.

Association between HIV distal symmetric polyneuropathy and Mycobacterium avium complex infection

OBJECTIVES

Pronounced infiltration of activated macrophages occurs in the peripheral nerves of patients with HIV distal symmetric polyneuropathy (DSPN). Mycobacterium avium complex (MAC) is a common facultative intracellular parasite of the macrophage in advanced HIV disease and may induce macrophage activation. Whether MAC disease is associated with DSPN was examined prospectively.

METHODS

One hundred and fifty consecutive patients with HIV infection were assessed for the probability of DSPN. Blood cultures for MAC were performed, independently of neurological assessment, as part of the investigation of unexplained fever, anaemia, weight loss, or, less commonly, diarrhoea.

RESULTS

There were 20 patients with possible, 14 with probable, and 22 with definite HIV DSPN. Blood cultures for MAC were performed on 80 patients, of whom 39 were positive and 41 negative. The test for trend, when corrected for CD4 count, disclosed a significant association (P = 0.01). There was no statistically significant association between DSPN and cytomegalovirus (CMV) disease.

CONCLUSION

Coinfection of the macrophage by MAC may further activate the HIV infected macrophage thereby accelerating the elaboration of neural toxins or MAC infection of the macrophage itself may lead to the production of neural toxins.

Laparoscopic versus open appendectomy: a prospective randomized trial of 81 patients

OBJECTIVE

To compare the efficacy of laparoscopic appendectomy (LA) and open appendectomy (OA) in the treatment of acute appendicitis.

DESIGN

A prospective randomized trial.

SETTING

A university teaching hospital.

PATIENTS

Eighty-one patients with a diagnosis of acute appendicitis were prospectively randomized to undergo either LA or OA. The two groups were matched for age and sex.

INTERVENTIONS

LA or OA.

MAIN OUTCOME MEASURES

Number of days in hospital and time to full recovery.

RESULTS

The mean hospital stay for LA was 3.23 days compared with 3.03 days for OA (p < 0.001). The mean number of narcotic injections required for patients in the LA group was 4.05 compared with 5.58 for patients in the OA group (p < 0.001). The mean time to complete recovery for patients in the LA group was 9.0 days compared with 16.2 days for patients in the OA group (p < 0.001). The mean operative time for LA was 73.8 minutes compared with 45.0 minutes for OA (p < 0.001). Three patients in the LA group had intra-abdominal abscesses (p > 0.25). No significant difference in wound infection rates was demonstrated (p > 0.05). Similarly, pain scores at 7 and 28 days showed no significant difference (p > 0.05).

CONCLUSIONS

With LA significantly fewer narcotic injections are required and there is a more rapid return to normal activities. LA takes longer to perform and was associated with three intra-abdominal abscesses. In cases of simple acute appendicitis the hospital stay for LA is significantly shorter.

Persistent mechanical allodynia following injury of the hand. Treatment through mobilization of the nervous system

Mechanical allodynia (MA) following hand injury is a well-documented clinical problem. The purpose of this pilot study was to examine the relationship between hand MA and the upper limb tension test (ULTT). The ULTT mechanically stresses the neural structures from the C5/6/7 neural foramina to the median nerve distally. This study examined 29 subjects with unilateral hand MA before and after a 2-week neural self-mobilization programme. There was a significant difference between the subjects' affected and unaffected sides when tested using the ULTT, both in reproduction of symptoms and in reduced range of motion of the ULTT. Following the self-mobilization program, there was an improvement in the range of the ULTT, and subjects reported a reduction in their symptoms. Complete recovery was not obtained in all cases. The results of this study suggest that the ULTT is a useful tool both in assessment and treatment of subjects with hand MA.

The raccoon as an animal model for upper limb neural prosthetics

The raccoon was evaluated as an animal model for upper limb neural prosthetics. This animal was selected primarily because the functional use of its forelimb mimics in many ways the usage in humans and because of its optimal size and commercial availability. Eight cadaver and fresh specimen forearms were dissected. Important characteristics of the raccoon forearm were: 1) large muscles in the volar forearm, 2) large digits in the paw that appear more similar to humans than to other species such as cat or dog, 3) persistence of two median nerve cords into the forearm, 4) no separation of individual tendons of flexor digitorum superficialis and flexor digitorum profundus in the carpal tunnel, 5) a small thumb digit with little function and 6) a primary origin of flexor policis longus on the proximal ulna with a secondary origin on the radius. Four animals were anesthetized and responses of the forearm and paw to stimulation of the volar forearm muscles with percutaneous electrodes were evaluated. A pair of stimulating electrodes was placed in each of four muscles or muscle groups. Recording electrodes were placed in two muscles which showed the greatest separation of muscle movements to stimulation. Stimulation currents just above threshold produced discrete motion as well as recordable EMG M-waves. Incremental increases in stimulation current produced an increase in M-wave amplitude up to a maximal stimulating current. Torque recordings for pronation, wrist flexion and finger flexion showed graded and selective responses. These results including anatomical descriptions indicate both the limitations of this animal model and its potential use in the development of upper limb neural prosthetics. We conclude that the raccoon model may be superior to other nonprimate animal models such as the cat because of its extensive forearm and paw movements.

Outreach, consolidation, and networking: Columbia's approach to successful integration of laboratory services in California

At the forefront of integrated laboratory services, Columbia Bay Area Healthcare Network's Lab Link provides a unique approach to operating hospital-based laboratories in today's heavily penetrated managed-care environment. Columbia recognizes that a combined strategy of laboratory consolidation, outreach, and networking is essential to compete successfully with commercial reference laboratories for local and statewide contracts. Implementing this model enables hospital laboratories to produce high quality, cost-effective test results while increasing volume and reducing duplication. When hospital laboratories consolidate and network with local and regional laboratories, inpatient and outpatients information is cross-fertilized through a web of information systems. Patients information can then be accessed easily and monitored throughout the continuum of care. The goal of this article is to provide hospital laboratories with a streamlined approach to structuring and delivering services while maintaining a competitive edge in the tumultuous healthcare market. The future of laboratory services within the hospital setting lies in the aggressive use of three elements--consolidation, outreach, and networking--to ensure quality service as well as economic viability.

Slow-wave sleep and symptomatology in schizophrenia and related psychotic disorders

Deficits in slow-wave sleep (SWS), or delta sleep, are frequently seen in schizophrenia, but their relationship with schizophrenic symptomatology remains unclear. We examined the association between visually scored and automated measures of SWS and positive and negative symptoms in a series of unmedicated patients with schizophrenia and related psychotic disorders. Total and average automated delta wave counts were significantly inversely associated with negative symptoms overall, and the psychomotor poverty syndrome in particular. Total delta counts were also inversely related to the disorganization syndrome. No relation was seen between reality distortion or the Brief Psychiatric Rating Scale (BPRS) positive symptoms and SWS. These findings support the view that SWS deficits may be related to negative symptoms of schizophrenia and may perhaps be mediated by impaired functioning of frontothalamic neural circuits.