Aggression and violence in mental health services: categorizing the experiences of Irish nurses

There is growing evidence that nurses in mental health services are likely to be victims of violence or aggression. One of the key difficulties in comparing international findings, however, has been that there has been an inadequate categorization of the types of incident to which staff are exposed. The current study aimed to identify the types of violent or aggressive incidents that staff in Irish Mental Health Services were exposed to within a 1-month long period. A cross-sectional study was undertaken with all nurses working in one of the Mental Health Services in Ireland, serving both an urban and rural population. Data were collected through a questionnaire (Scale of Aggressive and Violent Experiences) adapted from the Perceptions of Prevalence of Aggression Scale. The questionnaire was designed to collect data relating to both personal and professional demographics of the sample as well as experiences of aggressive or violent incidents respondents may have encountered in their work situation. There was a response rate of 31%. Data were analysed utilizing SPSS-11. Both descriptive and inferential analyses were undertaken. The relevant data were subjected to a series of one-way ANOVAS and chi-squared analysis. The findings suggest that nursing staff in this Mental Health Service experienced high levels of verbal aggression, with distinctions obvious between threatening and non-threatening aggression, suggesting discernment in terms of intentionality. Additionally, respondents encountered greater levels of covert or indirect violence or aggression than forms that were overtly directed towards staff. The implications are discussed in relation to both policy and practice.

Giving and receiving of gifts between pharmaceutical companies and medical specialists in Australia

BACKGROUND

This study investigated the 'gift-relationship' between pharmaceutical companies and doctors.

METHODS

The study was based on a survey questionnaire of 823 medical specialists from across Australia. The aim of this study was to investigate gifts offered to medical specialists in Australia by pharmaceutical companies, financial support actively sought by medical specialists for activities other than research and to consider what is ethically appropriate.

RESULTS

A high percentage of specialists received offers of food (96%), items for the office (94%), personal gifts (51%) and journals or textbooks (50%). Most specialists were invited to product launches, symposia or educational events (75-84%) and 52% received offers of travel to conferences. A high proportion of offers were accepted (66-79%) except invitations to product launches (49%), sponsored symposia (53%) and offers of travel that included partners (27%). Fifteen per cent of specialists requested financial support from pharmaceutical companies for activities and items, including conferences, travel, educational activities, salaries and donations to specific funds. The study outlined guidelines on gifts from pharmaceutical companies and differing standards applying to gifts and grants for travel. We found that, although most gifts and requests for support complied with professional and pharmaceutical industry guidelines, some--including personal gifts, tickets to sporting events, entertainment and travel expenses for specialists' partners--did not.

CONCLUSION

To ensure that physicians' judgements are free from real or perceived influence from industry and to maintain public trust, we support a shift towards more conservative standards on gifts and support for travel evident in recent guidelines.

Cooperative partnerships or conflict-of-interest? A national survey of interaction between the pharmaceutical industry and medical organizations

BACKGROUND

There is extensive and varied interaction between the pharmaceutical industry and the medical profession. Most empirical research concerns contact between individual physicians and industry, and reflects North American experience. We sought to clarify the extent and nature of relationships between the pharmaceutical industry and Australian medical organizations.

METHODS

We administered questionnaires to 63 medical organizations concerned with clinical practice, continuing medical education or professional accreditation, or the political representation of medical professionals.

RESULTS

Survey instruments were received from 29 organizations, giving a response rate of 46%. Seventeen of these organizations (59%) had received support from one or more pharmaceutical company in the past financial year. Support was predominantly for annual conferences, with some support for continuing medical education, research, travel and library purchases. The majority of organizations had an academic journal or newsletter, and 10 (34%) accepted revenue from pharmaceutical advertising. Twenty organizations (72%) had policies or guidelines covering their relationship with industry. Few organizations indicated that they would be unable to continue their activities without pharmaceutical industry support.

CONCLUSION

These data indicate a high level of inter-action between the pharmaceutical industry and medical organizations in Australia. While most organizations have policies for guiding their relationship with industry, it is unclear whether these are effective in preventing conflicts of interest and maintaining public trust.

Apoptosis and the expression of genes of the Bcl-2 family and TGF-beta1 in rat renal allografts transplanted after donor-specific blood transfusion

Factors involved in "operational" tolerance in animal models induced by recipient pre-treatment with donor-specific blood transfusion (DSBT) need elucidation. This study examined apoptosis, expression of genes of the Bcl-2 family and of TGF-beta(1) in isografts, rejecting and tolerant allografts.

METHODS

Adult inbred Dark Agouti (DA) kidneys were transplanted, with immediate nephrectomy of recipient kidneys, to (1) ALLO, inbred Albino Surgery (AS) rats; (2) DSBT ALLO, AS rats who received two DA blood transfusions under cover of cyclosporine prior to transplantation; or (3) ISO, DA rats. Grafts were retrieved on day 1, 3, or 5. Apoptosis was assessed by TUNEL. RNA was extracted and reverse transcribed to cDNA for quantification by real-time PCR, relative to the 18s housekeeping gene.

RESULTS

Apoptosis was negligible in ISO while it increased in allograft groups from day 1. On day 5, apoptosis in ALLO (114.0 +/- 30.6), involved renal tubular cells and leukocytes compared to DSBT ALLO (9.7 +/- 4.0) and ISO (0.9 +/- 0.3) involving leukocytes only. On day 1, DSBT ALLO had higher expression of Bax than ALLO or ISO. On day 3, DSBT ALLO and ALLO had higher TGF-beta(1) mRNA than ISO. On day 5, Bcl-2 expression was significantly decreased (P < .001) in ALLO compared to DSBT ALLO and ISO. Bad and Bid were higher in DSBT ALLO than in ALLO. TGF-beta(1) was higher in DSBT ALLO compared to ISO.

CONCLUSIONS

Decreased expression of anti-apoptotic Bcl-2 gene may be implicated in increased apoptosis in rejecting allograft while expression of pro-apoptotic genes may be involved in the establishment of operational tolerance.

Alternative Pathway to Endothelin-Converting Enzyme for the Synthesis of Endothelin in Human Blood Vessels

We have investigated whether a chymostatin-sensitive enzyme, such as chymase, contributes to the production of vasoconstrictor endothelin peptides from exogenous big endothelin- 1 in endothelium-denuded human umbilical vein. Big endothelin-1 contracted veins with a pD2 = 7.75 +/- 0.08 (n = 23) and was five times less potent than endothelin-1 (pD2 = 8.43 +/- 0.11, n = 10). The selective endothelin-converting enzyme inhibitor, PD159790, (30 microM, n = 17) produced a significant (P < 0.005), threefold rightward shift of the big endothelin-1 concentration-response curve with no reduction in maximum response. A further shift was obtained with 100 microM PD159790 (n = 6), with a significant decrease in the maximum response from 84.0 +/- 5.3%KCl to 34.2 +/- 6.7%KCl (P < 0.005). Chymostatin (30 microM) had no effect on the big endothelin-1 response, however, the inhibitory effect of 100 microM chymostatin was significant (P < 0.005). Unlike PD159790, chymostatin did not significantly modify the maximum response to big endothelin-1. The combination of 30 microM PD159790 and 100 microM chymostatin was more effective than either inhibitor alone. Our data suggest a role for both endothelin-converting enzyme and a chymostatin-sensitive enzyme, such as chymase, in the conversion of big endothelin-1 to constrictor endothelin peptides in human umbilical vein smooth muscle. In cardiovascular diseases in which endothelin-converting enzyme activity is increased, inhibition of both enzymes may be required for effective therapeutic intervention.

Use of the Ilizarov technique to improve limb function following hemipelvectomy

AIMS

Limb salvage surgery combined with tumour resection has become established in the management of pelvic tumours. However, subsequent reconstructive options for maintenance of quality of life lead to varied outcomes. We present a hitherto undescribed use of the Ilizarov technique as a second stage adjunct, for the optimisation of function, after first stage tumour resection and arthrodesis.

METHODS

We describe the surgical technique used to address leg length discrepancy and abductor dysfunction following internal hemipelvectomy with ischifemoral arthrodesis. Distal femoral and distal tibial lengthening using circular frames, with a valgus subtrochanteric femoral osteotomy, enabled a rapid correction of both anomalies. Controlled varus correction at the distal femoral osteotomy site was performed to obtain a horizontal joint line at the knee.

CONCLUSION

The Ilizarov technique is suitable for selected patients with tumour free survival following the initial resection. Our experience indicates that it is a good alternative to a mammoth one stage internal hemipelvectomy with reconstruction. The latter is often attempted even though there is a high risk of local recurrence and distant metastasis.

Intra-cerebral relapse following prolonged remission after autologous stem cell transplantation for multiple myeloma

Central nervous system (CNS) myeloma is a rare phenomenon, especially so after high-dose therapy (HDT) and stem cell transplantation. We describe a case of isolated CNS relapse of myeloma post autologous transplantation that followed a prolonged progression-free interval. Issues regarding the pathophysiology and management of this unusual complication are discussed.

Ability to kneel after total knee replacement

We have investigated the ability to kneel after total knee replacement. We asked 75 patients (100 knees) at least six months after routine uncemented primary total knee replacement, to comment on and to demonstrate their ability to kneel. Differences between the perceived and actual ability to kneel were noted. In 32 knees patients stated that they could kneel without significant discomfort. In 54 knees patients avoided kneeling because of uncertainties or recommendations from third parties (doctors, nursing staff, friends, etc). A total of 64 patients was actually able to kneel without discomfort or with mild discomfort only and 12 of the remainder were unable to kneel because of problems which were not related to the knee. Twenty-four patients therefore were unable to kneel because of discomfort in the knee. There was no difference between the 'kneelers' and 'non-kneelers' with regard to overall knee score, range of movement and the presence of patellar resurfacing.

Ability to kneel after total knee replacement

We have investigated the ability to kneel after total knee replacement. We asked 75 patients (100 knees) at least six months after routine uncemented primary total knee replacement, to comment on and to demonstrate their ability to kneel. Differences between the perceived and actual ability to kneel were noted. In 32 knees patients stated that they could kneel without significant discomfort. In 54 knees patients avoided kneeling because of uncertainties or recommendations from third parties (doctors, nursing staff, friends, etc). A total of 64 patients was actually able to kneel without discomfort or with mild discomfort only and 12 of the remainder were unable to kneel because of problems which were not related to the knee. Twenty-four patients therefore were unable to kneel because of discomfort in the knee.

There was no difference between the ‘kneelers’ and ‘non-kneelers’ with regard to overall knee score, range of movement and the presence of patellar resurfacing.

Traumatically induced lymphangioma of the ulnar nerve. Case report

Lymphangiomas, benign hamartomatous lesions involving lymphatic tissue, result from a failure of lymphatic channels to communicate with the venous system or normal lymphatic channels. The authors describe a case in which a lymphangioma arising within the ulnar nerve developed after trauma to the same area. This is the second reported case of a lymphangioma that originated from a peripheral nerve and the first case in which the lesion was associated with trauma. The authors propose that a lymphangioma involving the peripheral nerve may be the result of trauma.

The impact of elite labour migration on the identification, selection and development of European soccer players

In this study, we examined sociocultural aspects of the identification, selection and development of elite soccer players as part of wider processes of globalization, particularly worker migration. Patterns of migration were identified among the 704 players who comprised the national squads of the 32 nations contesting the finals of the 1998 World Cup in France. An analysis of the migration patterns within and between the six Confederations into which member nations of FIFA are grouped established the European Federation (UEFA) as soccer's core economy. The study is subsequently focused on Europe and, in particular, upon the import strategies of clubs in the four most popular destination countries - England, Germany, Italy and Spain. It is argued that, in light of European Union deregulation of worker migration between member states and, in particular, the Bosman judgement, European soccer is being reshaped. The identification and selection of elite players are producing migrant patterns that are seen increasingly to impact upon indigenous player development and, potentially, the viability and success of national teams. We argue that, although these developments are contoured in part by global economic factors, economic accounts alone do not provide an adequate understanding of them. A series of interrelated economic, political, cultural and social factors is at work. We conclude with a brief outline of the policy implications of the analysis.

Comparison of the vasoconstrictor effects of rizatriptan and sumatriptan in human isolated cranial arteries: immunohistological demonstration of the involvement of 5-HT1B-receptors

AIMS

We compared the vasoconstrictor effects of 5-HT with those of the selective 5-HT1B/1D-receptor agonists sumatriptan and rizatriptan in human isolated cranial (middle meningeal) arteries. In addition selective 5-HT1B- or 5-HT1D-receptor antibodies were used in combination with semiquantitative immunohistochemical techniques to compare the levels of expression of these receptors in human middle meningeal and coronary arteries.

METHODS

Middle meningeal and coronary arteries were obtained (with consent) from either neurosurgical patients or donor hearts, respectively. Segments of middle meningeal artery were mounted in organ baths for isometric recording and cumulative concentration-effect curves to 5-HT, rizatriptan and sumatriptan were obtained. Frozen fresh sections of middle meningeal and coronary arteries were subjected to standard immunohistochemical techniques using specific 5-HT1B- or 5-HT1D-receptor primary antibodies and a radiolabelled secondary antibody. Data were subjected to analysis of variance (ANOVA) and nonlinear regression analysis.

RESULTS

5-HT, rizatriptan and sumatriptan were potent vasoconstrictors in human isolated middle meningeal artery (EC50 values=32, 90 and 71 nM, respectively). A significantly higher level of 5-HT1B-receptor immunoreactivity was detected in middle meningeal artery compared with coronary artery (ANOVA, F=7.95, DF=1,4, P<0.05).

CONCLUSIONS

Rizatriptan and sumatriptan act selectively to cause vasoconstriction in human isolated middle meningeal artery and are 10-fold more potent than in human coronary artery. The higher level of expression of 5-HT1B-receptors in middle meningeal compared with coronary artery provides a pharmacological basis for the craniovascular selectively of both rizatriptan and sumatriptan.

Diagnostic electrocardiography in epidemiological studies of Chagas' disease: multicenter evaluation of a standardized method

An electrocardiographic recording method with an associated reading guide, designed for epidemiological studies on Chagas' disease, was tested to assess its diagnostic reproducibility. Six cardiologists from five countries each read 100 electrocardiographic (ECG) tracings, including 30 from chronic chagasic patients, then reread them after an interval of 6 months. The readings were blind, with the tracings numbered randomly for the first reading and renumbered randomly for the second reading. The physicians, all experienced in interpreting ECGs from chagasic patients, followed printed instructions for reading the tracings. Reproducibility of the readings was evaluated using the kappa (kappa) index for concordance. The results showed a high degree of interobserver concordance with respect to the diagnosis of normal vs. abnormal tracings (kappa = 0.66; SE 0.02). While the interpretations of some categories of ECG abnormalities were highly reproducible, others, especially those having a low prevalence, showed lower levels of concordance. Intraobserver concordance was uniformly higher than interobserver concordance. The findings of this study justify the use by specialists of the recording of readings method proposed for epidemiological studies on Chagas' disease, but warrant caution in the interpretation of some categories of electrocardiographic alterations.