What prevents one to one care?

BACKGROUND

In 2007, West London Mental Health Trust was visited by the Healthcare Commission (now the Care Quality Commission), which identified several issues needing attention. One major concern was the lack of effective interaction between nurses and service users in acute care.

AIM

To determine why mental health nurses on acute admissions wards struggle to spend one to one time with service users, and how to address the problem.

METHOD

Interviews with four senior nurses were conducted to identify initial concerns and problems. This data formed a basis for semi-structured interviews with all 11 acute admissions ward managers at the trust.

RESULTS

Five common themes were identified as the major barriers to one to one care: administrative duties; understanding one to one sessions; control over workload; staff needs; and ward culture.

CONCLUSION

Staff training and education have been improved, and policies implemented. As the study is small, replicating it nationally would give a better overall picture of this issue in mental health services.

Rapid transient induction of phenylalanine ammonia-lyase mRNA in elicitor-treated bean cells

DNAs complementary to a size-selected fraction of poly(A)(+) RNA present in elicitor-treated cells of bean (Phaseolus vulgaris L.) were inserted into pAT153 and used to transform Escherichia coli strain C600. Five clones were identified by hybrid-selected translation and cross-hybridization that contained sequences complementary to mRNA encoding phenylalanine ammonia-lyase (EC 4.3.1.5), which catalyzes the first reaction of phenylpropanoid biosynthesis. The longest insert contained a single open reading frame of 1520 base pairs together with 223 base pairs of 3' untranslated sequence. RNA blot hybridization showed that elicitor caused a rapid, marked but transient increase in phenylalanine ammonia-lyase mRNA that was closely correlated with changes in translatable mRNA activity in vitro and enzyme synthesis in vivo. Blot hybridization of newly synthesized mRNA purified by organomercurial affinity chromatography following in vivo pulse-labeling with 4-thiouridine indicates that elicitor caused a rapid stimulation of phenylalanine ammonia-lyase mRNA synthesis as an early in the defense response leading to accumulation of phenylpropanoid-derived phytoalexins.

HIV/AIDS information and services: The situation experienced by adolescents with disabilities in Rwanda and Uganda

PURPOSE

The study had two aims: (2) To explore whether knowledge about HIV and AIDS was similar among adolescents with disabilities compared with their non-disabled peers; and (2) To determine factors which may increase vulnerability of disabled adolescents to HIV infection and/or inappropriate access to HIV-related services.

METHOD

A qualitative study using focus group discussions and sem-structured interviews was conducted with purposefully selected participants in Rwanda and Uganda. The participants included disabled adolescents, non-disabled adolescents, parents, teachers, members of disabled people's organisations and representatives of HIV/AIDS organisations. Interviews explored issues of HIV/AIDS knowledge, access to HIV/AIDS services and perceptions of personal risk.

RESULTS

Barriers preventing adequate access to information about HIV and AIDS experienced by adolescents with disabilities depended on the nature and severity of the impairment. For example, parents and health workers were unable to communicate with deaf adolescents using sign language, adolescents with physical impairments were often unable to access community meetings about HIV and print material was not adapted for those with visual impairments. Further, assumptions by health workers and community members that people with disabilities were not sexually active led to the marginalisation of disabled people from HIV services. Adolescents with disability described low self-esteem and issues of self-efficacy affecting control of safer sexual relationships. A high level of targeted abuse, rape and exploitation was reported leading to vulnerability among this population.

CONCLUSION

The impact of the HIV epidemic among people with disabilities is a neglected area. This study supports the need to develop strategies in HIV prevention programmes that include people with disabilities.

Accidental acute clidinium toxicity

Clidinium bromide (N-methyl-quinuclidinyl-benzylate) is a rarely used antimuscarinic drug that is marketed in combination with chlordiazepoxide as an antispasmodic for use in irritable bowel syndrome. A case is reported of an accidental staggered overdose of clidinium bromide 50 mg in a patient using illicit chlordiazepoxide. The presenting features were mildly dilated pupils and palpitation secondary to sinus tachycardia that persisted for 11 h after the time of first ingestion. Emergency physicians should be aware of the potential for antimuscarinic toxicity in patients using illicit chlordiazepoxide.

Combined expression of caveolin-1 and an activated AKT/mTOR pathway predicts reduced disease-free survival in clinically confined renal cell carcinoma

We previously reported that tumour-associated caveolin-1 is a potential biomarker in renal cell carcinoma (RCC), whose overexpression predicts metastasis following surgical resection for clinically confined disease. Much attention has recently focused on the AKT/mTOR pathway in a number of malignancies, including RCC. Since caveolin-1 and the AKT/mTOR signalling cascade are independently shown to be important regulators of tumour angiogenesis, we hypothesised that caveolin-1 interacts with the AKT/mTOR pathway to drive disease progression and metastasis in RCC. The aims of this study were to determine (i) the expression status of the activated AKT/mTOR pathway components (phosphorylated forms) in RCC and (ii) their prognostic value when combined with caveolin-1. Immunohistochemistry for caveolin-1, pAKT, pmTOR, pS6 and p4E-BP1 was performed on tissue microarrays from 174 clinically confined RCCs. Significantly decreased mean disease-free survival was observed when caveolin-1 was coexpressed with either pAKT (2.95 vs 6.14 years), pmTOR (3.17 vs 6.28 years), pS6 (1.45 vs 6.62 years) or p4E-BP1 (2.07 vs 6.09 years) than when neither or any one single biomarker was expressed alone. On multivariate analysis, the covariate of ‘caveolin-1/AKT’ (neither alone were influential covariates) was a significant influential indicator of poor disease-free survival with a hazard ratio of 2.13 (95% CI: 1.15–3.92), higher than that for vascular invasion. Tumours that coexpressed caveolin-1 and activated mTOR components were more likely to be larger, higher grade and to show vascular invasion. Our results provide the first clinical evidence that caveolin-1 cooperates with an activated AKT/mTOR pathway in cancer and may play an important role in disease progression. We conclude that evaluation of the ‘caveolin-1/AKT/mTOR axis’ in primary kidney tumours will identify subsets of RCC patients who require greater postoperative surveillance and more intensive treatment.

Cholinesterase inhibitors in dementia with Lewy bodies: a comparative analysis

OBJECTIVE

To compare efficacy of different cholinesterase inhibitors (ChEIs) for treating patients with dementia with Lewy bodies (DLB).

DESIGN

Retrospective comparison of three independent clinical studies of ChEI treatment using donepezil, galantamine or rivastigmine in patients with DLB.

METHOD

Data was obtained from open label trials of donepezil and galantamine and a placebo controlled randomized trial of rivastigmine in DLB. Changes in Mini Mental State Examination (MMSE), Neuropsychiatric Inventory (NPI) and United Parkinson's Disease Rating Scale (UPDRS-III) scores were compared between the three treatments at 12 and 20 weeks.

RESULTS

All ChEIs significantly improved cognitive and neuropsychiatric measures. Reduction in the total NPI score appeared significantly greater after donepezil treatment. There was no significant increase in UPDRS-III scores.

CONCLUSIONS

It is unclear to what extent these findings reflect true differences between ChEIs or are due to methodological artefacts of comparing different studies. There is so far no compelling evidence that any one ChEI is better than the other in treating DLB but head to head comparative studies of different ChEIs are warranted to clarify this.

Characteristics of and risk factors for contact lens-related microbial keratitis in a tertiary referral hospital

AIM

A retrospective case-control study was conducted at a tertiary referral hospital to determine the characteristics of and risk factors for contact lens (CL) related presumed microbial keratitis.

METHODS

Two hundred and ninety-one cases of presumed microbial keratitis were retrospectively identified over a 2-year period. Records were reviewed for a history of CL wear and, where identified, CL, demographic, and clinical data were collected. Lens wearing controls (n=186) were identified by a community telephone survey. Multiple logistic regression estimated risk factors for infection and vision loss.

RESULTS

Ninety-nine (34%) new cases of presumed microbial keratitis were associated with CL wear. Overnight soft CL use was associated with an increased risk of infection compared to daily disposable CL wear (odds ratio (OR): 8.03, 95% confidence interval (CI): 1.82-35.46). Compared with older CL wearers, 15-24 year olds had a 3.5 times greater risk of infection (OR, 95% CI: 1.7-7.4). Of the 84 cases with available data, 24 (29%) lost two or more lines of best-corrected visual acuity. Delaying treatment by 49-72 h had a 4.5 times (OR, 95% CI: 1.4-14.9) greater risk of visual loss compared to seeking treatment early. Of the 99 cases of infection, 88 were scraped and 78% (69/88) of these returned a positive culture. Gram-positive bacteria were the predominant causative organisms.

CONCLUSION

Overnight use of CL and youth carry a greater risk of infection. Practitioners should reinforce the importance of proper CL care at all times, and early presentation following the onset of symptoms.

Efficacy and safety of galantamine in patients with dementia with Lewy bodies: a 24-week open-label study

BACKGROUND

Dementia with Lewy bodies (DLB) is a common dementia of the elderly. A significant cholinergic deficit has been demonstrated that may be responsive to treatment by cholinesterase inhibitors (ChEIs).

METHODS

A 24-week, open-label study was designed to assess the efficacy and safety of a ChEI, galantamine, in 50 patients with DLB.

RESULTS

This study showed beneficial effects with galantamine in 2 of the 3 primary efficacy parameters. The scores on the Neuropsychiatric Inventory (NPI-12) improved by 8.24 points from baseline (p = 0.01) especially in visual hallucinations and nighttime behaviors (p = 0.004). The scores on the Clinician's Global Impression of Change improved by 0.5 points from baseline (p = 0.01). The third primary efficacy parameter, the Cognitive Drug Research Computerized Cognitive Assessment System, was unchanged from baseline. Adverse events were generally mild and transient.

CONCLUSION

Galantamine appears to be an effective and safe therapy for patients with DLB.

Postoperative radiographs after open reduction and internal fixation of the mandible: Are they useful?

Mandibular fractures are common in oral and maxillofacial departments in the UK. The aim of this study was to find out the national practice in preoperative and postoperative radiographic investigations for fractured mandibles and to audit their diagnostic capacity, including specificity and sensitivity to short-term complications. The audit took place over a 4-month period and involved 100 patients across the Northern region. Ninety percent of patients were reviewed up to discharge and five of these patients developed a short-term postoperative complication. The postoperative radiograph was diagnostic in only one of the five cases. Overall, postoperative radiographs had a sensitivity of 20% and a specificity of 5% in their ability to predict short-term postoperative complications.

How well does fetal ultrasound predict the date of birth in Antigua and Barbuda?

This study was done to determine the accuracy of fetal ultrasound (U.S.) predicting the estimated date of delivery (EDD) in a primarily Afro-Caribbean population in Antigua and Barbuda. A total of 206 women had retrospective review offetal ultrasound tests done between July 1994 and January 1996. The EDD based on last menstrual period (LMP) was calculated for 104 women with dates and compared with EDD calculated from ultrasound test. These were then compared with actual date of birth from maternity records. For women with unreliable menstrual data (102 women), ultrasound EDD was compared with actual date of birth. Ultrasound EDD demonstrated a trend toward being more accurate than menstrual history EDD, being 10.0 +/- 9.4 (mean +/- standard deviation) days off versus 13.3 +/- 15 days, p = 0.057, (n=104), CI: -0.1, 6.73 days. Ultrasound EDD was within ten days of delivery 60% of the time versus 57% for menstrual history EDD. The average error in estimating EDD was + 1.7 days for ultrasound and + 3.7 days for menstrual history. In women without menstrual history data (n=102), the ultrasound EDD was just as accurate in both the second trimester, 11.8 +/- 9.5 versus 11.4 +/- 10.7 days off (not statistically significant) and the third trimester, 10.0 +/- 8.0 versus 8.1 +/- 7.0 days off (not statistically significant). Fetal ultrasound is marginally better at predicting the date of birth compared with menstrual history but the difference does notjustify routine use for that purpose. When menstrual history is unknown, ultrasound EDD is just as accurate as when menstrual history is known, making it a very useful test.

The transcript composition of egg cells changes significantly following fertilization in wheat (Triticum aestivum L.)

Here, we report the transcript profile of wheat egg cells and proembryos, just after the first cell division. Microdissected female gametophytes of wheat were used to isolate eggs and two-celled proembryos to construct cell type-specific cDNA libraries. In total, 1197 expressed sequence tags (ESTs) were generated. Analysis of these ESTs revealed numerous novel transcripts. In egg cells, 17.6% of the clustered ESTs represented novel transcripts, while 11.4% novel clusters were identified in the two-celled proembryo. Functional classification of sequences with similarity to previously characterized proteins indicates that the unfertilized egg cell has a higher metabolic activity and protein turnover than previously thought. Transcript composition of two-celled proembryos was significantly distinct from egg cells, reflecting DNA replication as well as high transcriptional and translational activity. Several novel transcripts of the egg cell are specific for this cell. In contrast, some fertilization induced novel mRNAs are abundant also in sporophytic tissues indicating a more general role in plant growth and development. The potential functions of genes based on similarity to known genes involved in developmental processes are discussed. Our analysis has identified numerous genes with potential roles in embryo sac function such as signaling, fertilization or induction of embryogenesis.