Focus Group Interviews: Assessment of Continuing Education Needs for the Advanced Practice Nurse

This article reports the use of focus group interviews to promote the development of continuing education programs that meet the needs of advanced practice nurses (APNs). The three major needs identified were: a) enhancement of clinical practice skills and knowledge in specialty areas, b) education about future changes in the APN role, and c) education in management strategies for the changing health care delivery system. A summary of the investigation and implications for continuing nursing education departments are also presented.

Lack of activity of estradiol in rodent bone marrow micronucleus assays

Estradiol has been evaluated in five independent rodent bone marrow micronucleus assays and has been found to be inactive. The dose-range evaluated extended from three daily doses of 20 micrograms/kg to the rat, a regimen that elicited a potent uterotrophic response from the animals, to single doses of between 10-150 mg/kg to the mouse. The mouse assays simulated and extended the conditions of test employed by earlier investigators who had found estradiol, and three structurally-related synthetic estrogens, to be active in mouse micronucleus assays over the dose range 1-10 mg/kg. It is concluded that estradiol is not genotoxic to the bone marrow of rodents. The top dose-level used in the present micronucleus assays (150 mg/kg) represented approximately 150,000 times the minimum estrogenic dose of this chemical to rodents, and that was considered to be above the dose at which useful genetic toxicity data would be generated for this potent estrogen. The maximum tolerated dose (MTD) of estradiol to rodents remains to be established.

The response of hepatocytes isolated from phenobarbitone treated mice to mitogenic growth factors

The ability was investigated of epidermal growth factor (EGF) and hepatocyte growth factor (HGF) to stimulate DNA synthesis in hepatocytes isolated from C57B1/6J mice following 1, 3, 7, 30 and 90 days pre-treatment with the hepatomegalic drug, phenobarbitone (PB). A 3-fold increase in S-phase labelled hepatocytes was observed in the absence of growth factors after 3 days treatment with PB, which was not seen at other investigated time points. This suggests that the proliferative influence present in vivo at this time interval is maintained in the ex vivo model. Maximum labelling indices of > 5-fold the unstimulated control value were observed in hepatocytes isolated from control and 1 day PB pre-treated mice when cultured in the presence of 5 or 10 ng/ml EGF or HGF. Hepatocytes isolated from 3, 7, 30 or 90 day treated mice showed a considerably reduced responsiveness to growth factors; maximum labelling indices did not exceed by a factor of 2 the value obtained in the absence of growth factors. However, the apparent decrease in responsiveness to growth factors in hepatocytes isolated from 3 day pre-treated mice was due to an increased background level of proliferation and the attainment of a 'ceiling level' of DNA synthesis at approx. 35%. DNA synthesis was not further enhanced by addition of both EGF and HGF. This maximal level of stimulation may indicate that only a specific hepatocyte sub-population is capable of responding to growth factors under the conditions employed. The loss in sensitivity to mitogenic stimuli after 7 days PB pre-treatment correlates with a reported decrease in receptor protein and mRNA levels in rats and coincides with the in vivo shift from hyperplasia to hypertrophy.

The mitogenic response to EGF of rat hepatocytes cultured on laminin-rich gels (EHS) is blocked downstream of receptor tyrosine-phosphorylation

Hepatocytes cultured on type I collagen proliferate in response to mitogenic growth factors yet de-differentiate. By contrast, hepatocytes on laminin-rich gels (EHS) demonstrate stable differentiated functions, while DNA synthesis is negligible. Here we have confirmed that this lack of proliferation was not due to deterioration of the cells because albumin release was maintained for several weeks. Additionally it does not appear to be due to the presence of the growth inhibitor TGF beta within the gel since and anti-TGF beta antibodies did not reverse the growth blockade. The addition of EGF to cells cultured on either type I collagen or EHS gel induced increased tyrosine phosphorylation of a 180kDa protein which ran in a position identical to that of the EGF receptor detected by a specific EGF receptor antibody. We conclude that since functional EGF receptors were present, the mitogenic response of hepatocytes on EHS gels is blocked at some downstream signaling event beyond that of receptor tyrosine autophosphorylation.

Use of restraints in the elderly

Chronologic age older than 65 years is a predictor for restraint use in the acute care setting. The therapeutic effect of restraints has not been established. Geriatric patients in the hospital are more vulnerable to the risks associated with physical and chemical restraints. A framework is presented to guide the clinician in the decision making process on restraint use. Nursing homes have been successful in the implementation of restraint reduction programs, and these models might be reviewed for applicability to the acute care setting.

Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders

A previous study of 22 medical patients with DSM-III-R-defined anxiety disorders showed clinically and statistically significant improvements in subjective and objective symptoms of anxiety and panic following an 8-week outpatient physician-referred group stress reduction intervention based on mindfulness meditation. Twenty subjects demonstrated significant reductions in Hamilton and Beck Anxiety and Depression scores postintervention and at 3-month follow-up. In this study, 3-year follow-up data were obtained and analyzed on 18 of the original 22 subjects to probe long-term effects. Repeated measures analysis showed maintenance of the gains obtained in the original study on the Hamilton [F(2,32) = 13.22; p < 0.001] and Beck [F(2,32) = 9.83; p < 0.001] anxiety scales as well as on their respective depression scales, on the Hamilton panic score, the number and severity of panic attacks, and on the Mobility Index-Accompanied and the Fear Survey. A 3-year follow-up comparison of this cohort with a larger group of subjects from the intervention who had met criteria for screening for the original study suggests generalizability of the results obtained with the smaller, more intensively studied cohort. Ongoing compliance with the meditation practice was also demonstrated in the majority of subjects at 3 years. We conclude that an intensive but time-limited group stress reduction intervention based on mindfulness meditation can have long-term beneficial effects in the treatment of people diagnosed with anxiety disorders.

The histochemical specificity of high iron diamine-alcian blue

The specificity of the High Iron Diamine-Alcian Blue pH 2.5 (HID-AB 2.5) procedure was examined in tissue sites containing sialogycoproteins alone or differing proportions of sialo- and sulphosialoglycoproteins. Studies with HID in differing final concentrations of hydrochloric acid or sodium chloride confirmed that staining is dependent upon both the pH and the ionic strength of the dye bath and demonstrated a marked heterogeneity in the pKa of the anionic groups of sialosulphoglycoproteins. Use of the sequence High Iron Diamine-Alcian Blue pH 1.0 demonstrated that complete or almost complete staining of O-sulphate esters occurred when HID was prepared in water (final pH 1.3). However, under these conditions HID-AB 2.5 was shown to be non-specific because only black HID staining was observed in sites containing large quantities of sialic acids. This non-specificity was due either to the masking of Alcian Blue staining by HID and/or the black HID staining of anionic groups other than sulphate. These results may account for some of the conflicting data obtained by different groups of investigators who have studied 'transitional mucosa' in human colonic diseases. Caution should be used in drawing conclusions from the use of HID-AB 2.5 without confirmatory evidence from other more specific procedures.

Molecular cloning of DNA sequences from cervical intraepithelial neoplasia that hybridize to human cytomegalovirus DNA

We have prepared EMBL3 libraries of DNA extracted from the cervix of a patient with cervical intraepithelial neoplasia (CIN) and isolated seven recombinant clones containing sequences that hybridize to human cytomegalovirus (HCMV) DNA. Restriction analysis of one clone with BamHI and SalI endonucleases revealed that the insert DNA showed a high degree of homology to the HCMV Ad169 genome over the region between the HindIII K/E site and the SalI site located within the BamHI P fragment. The HCMV insert in the CIN clone is integrated and flanked by cellular sequences. The major immediate early gene that encodes a polypeptide of approximately 69 kD was found to be conserved in the CIN clone. Transfection of clones encoding the immediate early region of HCMV resulted in cells that were positive in immunofluorescence studies with two monoclonal antibodies directed against the HCMV 69 kD immediate early polypeptide. Infection of human ectocervical cells with HCMV Ad169 revealed that they could express the 69 kD polypeptide encoded by the immediate early gene but could not replicate the virus, whereas HCMV was able to replicate productively in cultured endocervical cells. HCMV has been shown to activate endogenous retroviruses and also to transcriptionally activate the long terminal repeat of human immunodeficiency virus. Activation of virus and cellular genes by HCMV may be a means by which this virus is involved in the multistage process of oncogenesis and/or the activation of latent infections.

Comparative amnestic effects of benzodiazepine hypnotic agents

The effects of triazolam 0.5 mg and temazepam 30 mg on immediate and delayed recall in normal and insomniac subjects were evaluated in three separate, randomized, placebo-controlled, parallel group studies. Neither drug caused significant impairment of immediate recall. In the tests of delayed recall, triazolam caused a consistent anterograde amnestic effect. No significant impairment of delayed recall was observed in the temazepam study. Anterograde amnesia is thought to be a dose-related effect of benzodiazepines. Compounds with high benzodiazepine receptor affinity such as triazolam are thought to cause this type of amnesia more often than the lower-affinity compounds such as temazepam.

Histological and cytological evidence of viral infection and human papillomavirus type 16 DNA sequences in cervical intraepithelial neoplasia and normal tissue in the west of Scotland: evaluation of treatment policy

Biopsy samples from 27 patients referred to a colposcopy clinic in Glasgow for cervical abnormalities were assessed for the relations among colposcopic appearances, cytological and histological diagnosis, expression of papillomavirus antigen, and the presence of human papillomavirus (HPV) types 6, 11, 16, and 18 deoxyribonucleic acid (DNA) sequences. Specimens were from colposcopically abnormal areas of the transformation zone and from colposcopically apparently normal areas of the zone in the same patients (paired matched internal control tissue). All 27 women referred for abnormal smears had colposcopic abnormalities. HPV-16 or 18 DNA sequences were detected in 20 of the 27 colposcopically abnormal biopsy samples and 13 of the 27 paired normal samples. Twelve samples of colposcopically normal tissue contained histological evidence of viral infection but only four of these contained HPV DNA sequences. The other nine samples of colposcopically normal tissue which contained HPV DNA sequences were, however, histologically apparently normal. HPV-6 and 11 were not detected. Integration of the HPV-16 genome into the host chromosome was indicated in both cervical intraepithelial neoplasia and control tissues. In two thirds of the HPV DNA positive samples the histological grade was classed as normal, viral atypia, or cervical intraepithelial neoplasia grade 1. Papillomavirus antigen was detected in only six of the abnormal and three of the normal biopsy samples, and HPV DNA was detected in all of these. The detection of HPV DNA correlates well with a combination of histological and cytological evidence of viral infection (20 of 22 cases in this series). A poor correlation between the site on the cervix of histologically confirmed colposcopic abnormality and the presence of HPV DNA sequences implies that a cofactor other than HPV is required for preneoplastic disease to develop. A separate study in two further sets of biopsy samples examined the state of HPV DNA alone. The sets were (a) 43 samples from cervical intraepithelial neoplasia and nine external controls and (b) 155 samples from cervical intraepithelial neoplasia, cervical cancer, vulval intraepithelial neoplasia, and vulval cancer and external controls. HPV-11 was found in only two (4.7%) of the 43 specimens from cervical intraepithelial neoplasia, whereas HPV-16 was found in 90 (58%) of the other 155 specimens. These results also suggest that HPV subtype is subject to geographical location rather than being an indicator of severity of the lesion or of prognosis.

Specific and nonspecific immunoregulatory factors and renal transplantation

From a study population of 208 consecutive first cadaver renal transplant recipients a proportional hazard model was used to simultaneously quantify the role in graft failure of matching for specific HLA antigens and constitutional factors (age, sex, duration of dialysis (Dt), and pre- (PTr) and peri-(PerTr) operative transfusions) that influence nonspecific immune response. A comparison was also made of graft survival in patients treated by the two principal methods of dialysis, hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD). The advisability of including nonimmunological failures in studies of graft survival was also considered. The analysis indicated that factors influencing a patient's innate nonspecific immune response (e.g., Dt and PTr) are important determinants of graft survival and should be taken into account when considering matching for specific HLA-B or DR antigens prior to transplantation. While there was no overall effect of dialysis type on graft survival, the influence of other risk factors depended on the method of dialysis. Failure to identify and exclude graft loss for nonimmunological reasons can give rise to misleading conclusions in analysis of immunoregulatory factors in organ transplantation.

Factors influencing haematological measurements in healthy adults

By studying 516 healthy adults normal reference intervals were established for the Coulter "S" haematological indices with the plasma ferritin, B12, folate and red cell folate in a subgroup of 306. Significant sex related differences were found for all measurements other than MCV, MCH and B12. After allowing for these sex related differences, the effects of age, body size, fasting, smoking, alcohol, exercise and contraceptive pill usage on the parameters studied was defined.

Continuous ambulatory peritoneal dialysis after the honeymoon: review of experience in Newcastle 1979-84

Two hundred and twenty nine consecutive patients (129 men, mean age 45) were reviewed 12 to 65 months after starting treatment with continuous ambulatory peritoneal dialysis (CAPD) from January 1979 to December 1983. They received CAPD for a mean of 19.8 (range 0.5-62) months. Actuarial patient survival was 79% at 24 months and 72% at 36 months. Half of the 46 deaths were related to cardiovascular disease, while eight patients died of abdominal complications, including three patients with peritonitis. Peritonitis occurred at a rate of one episode per 35 patient weeks, and 88% of episodes were cleared by one or more courses of antibiotics. This still left peritonitis as the commonest cause of failure of CAPD, leading to a permanent change of treatment in 44 patients and temporary interruption in a further 25. CAPD remains a reasonable medium term treatment in chronic renal failure. Despite the persisting problem of peritonitis the results are comparable with those achieved by haemodialysis, and CAPD has become the treatment of first choice for end stage renal failure in Newcastle. In younger patients judged unsuitable for transplantation and facing long term dialysis, however, haemodialysis is preferred.

Detection of sequences that hybridize to human cytomegalovirus DNA in cervical neoplastic tissue

Punch biopsies were taken from patients with cervical intraepithelial neoplasia and the DNA was extracted and examined for sequences which hybridized to human cytomegalovirus DNA by Southern blotting analysis. Two biopsies out of 43 were found to contain DNA which hybridized to human cytomegalovirus DNA. In one biopsy DNA sequences were detected which contained four restriction sites colinear with those of the prototype strain AD169. Evidence of rearranged viral DNA sequences was also found.

Continuous ambulatory peritoneal dialysis and renal transplantation: a five year experience

Continuous ambulatory peritoneal dialysis is a new and increasingly popular method of routine dialysis, but its effect on renal transplantation is uncertain. A non-randomised comparison was made of the outcome of grafting in patients who had been treated before transplantation with continuous ambulatory peritoneal dialysis with that in patients treated with haemodialysis. During the five years, 1979-84, after continuous ambulatory peritoneal dialysis was introduced to Newcastle upon Tyne 220 patients have received transplants after either continuous ambulatory peritoneal dialysis (61 patients) or haemodialysis (159 patients). During follow up no significant differences occurred in survival of patients or grafts between the two treatment groups. One year after transplantation the percentages of survivors who had received continuous ambulatory peritoneal dialysis and haemodialysis were 88% and 91% respectively, and overall graft survival was 66% and 72%, respectively. A multiple regression model was used to allow for differences among patients--for example, duration of dialysis and number of preoperative transfusions--on the survival of grafts. When only first cadaver grafts were considered (in 152 patients) graft survival (non-immunological failures excluded) was not significantly different between the patients treated with continuous ambulatory peritoneal dialysis and haemodialysis. Continuous ambulatory peritoneal dialysis is not a risk factor in renal transplantation, and its continued use in treatment of potential renal graft recipients is recommended.

Factors influencing normal reference intervals for creatinine, urea, and electrolytes in plasma, as measured with a Beckman Astra 8 Analyzer

In a study of 514 healthy adults, we used a Beckman Astra 8 Analyzer to establish normal reference intervals for plasma creatinine, urea, and electrolytes. For potassium and chloride these were considerably lower and higher, respectively, than previously reported ranges. All of these analytes showed significant sex-related differences; all except chloride showed age-related changes. The relationship of these biochemical indices to fasting, cigarette smoking, alcohol intake, regular exercise, and the contraceptive pill--independent of these age- and sex-related differences--was assessed by multiple linear regression. The effect was significant in each case. Our results underline the importance of regular review of reference values.

Factors influencing normal reference intervals for creatinine, urea, and electrolytes in plasma, as measured with a Beckman Astra 8 Analyzer

In a study of 514 healthy adults, we used a Beckman Astra 8 Analyzer to establish normal reference intervals for plasma creatinine, urea, and electrolytes. For potassium and chloride these were considerably lower and higher, respectively, than previously reported ranges. All of these analytes showed significant sex-related differences; all except chloride showed age-related changes. The relationship of these biochemical indices to fasting, cigarette smoking, alcohol intake, regular exercise, and the contraceptive pill--independent of these age- and sex-related differences--was assessed by multiple linear regression. The effect was significant in each case. Our results underline the importance of regular review of reference values.

Prevalence and pathogenesis of impotence in one hundred uremic men

In a study of dialysis patients 79% of men complained of sexual dysfunction and 61% erectile impotence following uremia and the onset of regular dialysis therapy. Plasma testosterone levels were significantly higher in patients treated by continuous ambulatory peritoneal dialysis (p = 0.001) but the incidence of sexual dysfunction was not different from patients treated by hemodialysis. Although follicle-stimulating hormone levels were higher (p = 0.001) and penile blood pressure index levels lower (p less than 0.05) in patients with impotence, sexual function was not improved by exogenous testosterone, and vasculogenic impotence was identified in only 6% of patients. These findings suggest that a major component of uremic impotence is unrelated to primary testicular failure or penile vascular insufficiency.