Mental health nursing: making it a primary concern

This article suggests that the focus of mental health nursing is narrowing at a time when nurses in other areas are widening their roles and responsibilities. The author calls for more co-operation between mental health nurses and their colleagues in primary health care.

Persecution complex: the enigma of paranoid disorders

Understanding the clinical meaning of paranoid and defining the role of the nurse in stages of treatment.

Community nurses take on the task of selling themselves

Nurses are increasingly called upon to promote and justify their services within a market-driven NHS. If purchasers fail to understand the complexity of nursing, a reductionist approach--involving purchasing of only minimal nursing tasks--may result. This article uses a case study approach to illustrate the considerable scope of community nursing practice. It concludes that nurses need to become bicultural, developing the ability to communicate nurturing and healing values in a way that can be understood in the increasingly commercial NHS context.

Diagnostic indicators in the early recognition of severe cocaine intoxication

Acute cocaine intoxication is an ever increasing problem in the United Kingdom. Aggressive resuscitation linked to early diagnosis is essential in preventing death. Three cases of severe cocaine toxicity are presented to highlight certain diagnostic indicators in recognising the condition in patients presenting in a collapsed state to the accident and emergency department. Acidosis was a striking feature. The acute management of such patients is supportive and should involve methods to minimize continuing absorption.

High-dose therapy and autologous stem cell rescue for poor risk and refractory lymphoma: a single centre experience of 123 patients

Over an 8-year period we autografted 123 patient with poor-risk lymphoma. Sixty-three patients had Hodgkin's disease (HD) and 60 non-Hodgkin's lymphoma (NHL). Of the patients with HD, 45 had responsive and 18 resistant disease prior to high-dose therapy. Fifty-three patients with NHL had responsive and seven had resistant disease at the time of transplantation. Seventy-seven patients received autologous bone marrow (BM) rescue, 39 autologous peripheral blood progenitor cell (PBPC) rescue, and seven combined BM and PBPC rescue. High-dose chemotherapy was BEM in 67, BEAM in 39, TBI and cyclophosphamide or etoposide or BCNU in 10, etoposide/mitozantrone in six and etoposide/melphalan in one. There was eight (6.5%) deaths due to treatment-related toxicity, within the first 100 days post-transplantation. Of the patients with HD 41 (65%) are alive at a median follow-up of 39 months (range 2-94). Thirty-three (52%) patients remain in CR. The median DFS of the 63 patients with HD is 34 months (95% CI 7-61). The median DFS for patients transplanted with responsive disease was significantly better than for those transplanted with refractory disease (61 vs 21 months P < 0001). Thirty-five (58%) of the patients with NHL are alive, and 20 (33%) remain in CR. The median DFS for patients transplanted with responsive and refractory disease was 11 months (95% CI 3-19) and 4 months (95% CI 0-9; P = NS) respectively. The median DFS for patients transplanted with HD was significantly better than for patients transplanted with NHL (34 vs 8 months, P < 0.002). In both groups there was no significant difference in DFS in patients receiving one, two, three or more lines of therapy prior to transplantation. In summary, in patients with poor-risk lymphoma who have responsive disease high-dose therapy may result in durable CRs. Conversely, only a small proportion of patients with HD or NHL with resistant disease achieve CR after autologous stem cell rescue.

Peripheral blood progenitor cell transplantation: a single centre experience comparing two mobilisation regimens in 67 patients

Between June 1991 and January 1995 we performed 67 peripheral blood progenitor cell transplants (PBPCT). Ten patients (group 1) were mobilised with 7 gm/m2 of cyclophosphamide followed by daily G-CSF injections (5 micrograms/kg, subcutaneously). When the white cell count reached 1 x 10(9)/1 they were leukapheresed for 5 days. After stem cell infusion they received G-CSF (10 micrograms/kg/day) until the neutrophil count reached 1.5 x 10(9)/1. Fifty-six patients had PBPCs mobilised with 3 gm/m2 of cyclophosphamide followed by daily subcutaneous G-CSF (5 micrograms/kg) and PBPCs were harvested on 2 consecutive days, when the white cell count rose to 4 x 10(9)/1. After stem cell infusion this group did not receive G-CSF. In 47 of the 56 patients (group 2) adequate MNC (> or = 4 x 10(8)/kg) and/or CFU-GM (> or = 10 x 10(4)/kg) were obtained. Insufficient MNC and/or CFU-GM were obtained in 10 patients. They were therefore transplanted using a combination of bone marrow and peripheral blood progenitor cells (group 3). Overall 64 patients successfully engrafted. Median days to neutrophils > or = 0.5 x 10(9)/1 were 9 (range 8-13), 12 (range 8-25) and 11 (range 9-16) and to platelets > or = 50 x 10(9)/1 were 11 (range 9-23), 13 (range 9-90) and 16 (range 13-99) in groups 1, 2 and 3 respectively. Patients in group 1 had a faster neutrophil recovery than patients in group 2 (P = 0.0002). The three patients who failed to engraft all received a combination of autologous peripheral blood and bone marrow cells.

Early death due to defective neonatal lung liquid clearance in alpha-ENaC-deficient mice

The amiloride-sensitive epithelial sodium channel, ENaC, is a heteromultimeric protein made up of three homologous subunits (alpha, beta and gamma) (1,2). In vitro, assembly and expression of functional active sodium channels in the Xenopus oocyte is strictly dependent on alpha-ENaC--the beta and gamma subunits by themselves are unable to induce an amiloride-sensitive sodium current in this heterologous expression system (2). In vivo, ENaC constitutes the limiting step for sodium absorption in epithelial cells that line the distal renal tubule, distal colon and the duct of several exocrine glands. The adult lung expresses alpha, beta and gamma ENaC (3,4), and an amiloride-sensitive electrogenic sodium reabsorption has been documented in upper and lower airways (3-7), but it is not established whether this sodium transport is mediated by ENaC in vivo. We inactivated the mouse alpha-ENaC gene by gene targeting. Amiloride-sensitive electrogenic Na+ transport was abolished in airway epithelia from alpha-ENaC(-/-) mice. Alpha-ENaC(-/-) neonates developed respiratory distress and died within 40 h of birth from failure to clear their lungs of liquid. This study shows that ENaC plays a critical role in the adaptation of the newborn lung to air breathing.

Working with mental distress

Although there is a need to learn from the experience of the Allitt inquiry the notion of 'health checks' for staff is fraught with complications. Not only might it be impossible to isolate nurses who are 'unhealthy', but the measures might discourage nurses from admitting to psychological problems. Most important, the therapeutic relationship between nurses and those in their care might be threatened.

Short-course intravenous antibiotics with oral quinolone prophylaxis in the treatment of neutropenic fever in autologous bone marrow or peripheral blood progenitor cell transplant recipients

The effectiveness of short-course intravenous antibiotics concurrent with prophylactic oral ciprofloxacin in the treatment of neutropenic fever was studied in 81 patients undergoing autologous bone marrow or peripheral blood progenitor cell transplantation (ABMT or PBPCT). During the neutropenic period following ABMT or PBPCT, 10/81 (12%) patients did not require treatment with intravenous antibiotics. Seventy-one patients required antibiotics. Forty-seven of the 71 (66%) responded to 72 h treatment with gentamicin, azlocillin or ceftazidime, and vancomycin. Thirty-three of the 47 (70%) responders had a complete resolution of their fever with no further recurrence. Fourteen of the 47 responders developed a second fever between 2 and 25 days after stopping first-line antibiotics. Eleven of the 14 patients responded to a second course of intravenous antibiotics. Twenty-four of the 71 patients did not respond to intravenous antibiotics and were treated with intravenous amphotericin and the intravenous antibacterial agents were discontinued. Eighteen of the 24 patients responded to amphotericin. The 6 patients who had persistent fever resolved their temperature when their neutrophil count recovered. There were no deaths due to infection during the study. Short-duration intravenous antibiotics in conjuction with oral ciprofloxacin prophylaxis are a safe and effective treatment for neutropenic fever.

Autografting for multiple myeloma: a 5-year experience at a single institution

Over a 5-year period, we have performed 33 autologous bone marrow or PBPC transplantations for multiple myeloma. Nine patients were in complete remission and 24 in partial remission at time of transplantation. Conditioning regimens were BEM (BCNU, etoposide and melphalan) in 29, busulphan and cyclophosphamide in three and melphalan alone in one. Two patients (6%), died within 3 months of transplant-related mortality, seven (21.3%), died of disease progression at a median follow-up of 11 months (range 4-24). Twenty-four patients (72.7%) are alive at a median follow-up of 15 months (range 4-61). Of nine patients transplanted in CR, four have relapsed and are alive and five remain in CR. Of 24 patients transplanted in PR, nine have died, six remain in PR, eight achieved CR and one has progressive disease. The overall median progression-free survival (PFS) is 31 months (95% CI = 20-42). For patients transplanted in PR the median PFS is 24 months (95% CI = 22-26), the median PFS for patients transplanted in CR has not yet been reached. The median PFS for patients achieving CR pre- or post-transplantation was better than for patients neither achieving CR pre- nor post-transplantation (P = 0.05). The median PFS was also significantly improved for patients requiring only primary therapy, compared to patients needing second-line therapy to achieve CR or stable PR prior to transplantation (31 vs 11 months, P = 0.02).

Resonant degenerate four-wave mixing in I(2): effect of buffer gas pressure

The influence of molecular collisions on the production of the degenerate four-wave mixing signal in I(2) is presented. Measurements were performed on gaseous molecular iodine, I(2), contained in a glass cell in which pressure, temperature, and species concentration are easily and independently varied. Frequencydoubled outputs from a seeded Nd:YAG laser and an excimer-pumped dye laser were used as excitation sources. We have studied the dependence of signal strength versus buffer gas pressure, with pump intensity as a third parameter. It is evident from our results that, for pump intensities of less than 1 MW/cm(2), the pressure dependence of the signal follows that given by a simple two-level model in the homogeneously broadened regime. In this regime collisional deexcitation becomes significant, leading to changes in saturation intensity. This is evidenced by a reduction in the signal with an increase in buffer gas pressure. This behavior is similar to that seen in laser-induced fluorescence. At higher pump intensities, the signal is seen to increase with pressure; this behavior cannot be described by the simple two-level model.

Localization in the nervous system of Drosophila melanogaster of a C-terminus anti-peptide antibody to a cloned Drosophila muscarinic acetylcholine receptor

Localization in the nervous system of Drosophila melanogaster of a cloned Drosophila muscarinic acetylcholine receptor (mAChR) was investigated using a polyclonal antiserum raised against a peptide corresponding to the predicted receptor carboxyl terminal domain. Immunocytochemical studies on fly sections indicated that the product of the Dm1 mAChR gene was localized in the antennal lobes and in other regions of the brain and thoracic nervous system. Intense staining in the glomeruli of the antennal lobes, the region of the nervous system containing terminals of antennal olfactory sensory neurones and mechanosensory neurones, indicates possible roles for this mAChR gene product in the processing of olfactory and mechanosensory signals in the fly. The staining of a discrete group of neurosecretory cells in the pars intercerebralis of the brain indicates a possible new role for this mAChR in the regulation of neurosecretion. Very little staining is detected in the thoracic nervous system.

Comparative genomic analysis of tumors: detection of DNA losses and amplification

We demonstrate the use of representational difference analysis for cloning probes that detect DNA loss and amplification in tumors. Using DNA isolated from human tumor cell lines to drive hybridization against matched normal DNA, we were able to identify six genomic regions that are homozygously deleted in cultured cancer cells. When this method was applied in the reverse way, using normal DNA to drive hybridization against tumor cell DNA, we readily isolated probes detecting amplification. Representational difference analysis was also performed on DNAs derived from tumor biopsies, and we thereby discovered a probe detecting very frequent homozygous loss in colon cancer cell lines and located on chromosome 3p.

Iodine-131 in breast milk following therapy for thyroid carcinoma

This study evaluates breast milk secretion of 131I following therapeutic administration of 4000 MBq of 131I-iodide during lactation.

METHODS

Breast milk 131I activity concentration was measured over a 32-day period. Dosimetry calculations were undertaken to estimate the period for discontinuation of breast feeding and the equivalent dose to the breasts.

RESULTS

To achieve an infant effective dose < 1 mSv and an infant thyroid dose < 10 mSv, breast feeding would need to be discontinued for at least 52 days. The estimated equivalent dose to the breasts was 1.6 Gy.

CONCLUSION

It is suggested that 131I-iodide administration is not undertaken during lactation and that breast feeding is discontinued several days prior to administration.

3D bolus tracking with frequency-shifted BURST MRI

OBJECTIVE

Our goal was to develop and test a 3D bolus-tracking MR technique for perfusion imaging of normal and pathological (infarcted) human brain.

MATERIALS AND METHODS

All experiments were performed on standard 1.5 T GE/Signa clinical scanners. Five normal volunteers and one patient with a subacute brain infarct were studied. Modified [frequency-shifted (FS)] BURST MRI was performed during injection of a bolus of Gd-DTPA (0.13 mmol/kg) in the antecubital vein. The 3D datasets were acquired with a time resolution of 2.2 s and an effective spatial resolution of 4.3 x 4.3 x 6.4 mm. Three-dimensional maps of blood volume and bolus arrival time were determined by fitting a synthetic curve to the intensity time course on a voxel-by-voxel basis.

RESULTS

Both relative cerebral blood volume and arrival time maps demonstrated sensitivity to regional differences in blood supply in both normal brain and in the subacute brain infarction. The transit time maps showed arrival time delays of 5-7 s within and around the infarct and confirmed the diagnosis of left middle cerebral artery occlusion.

CONCLUSION

The results of the measurements on both normal and diseased human brain demonstrated the ability to acquire valuable 3D information about brain perfusion using FS BURST MRI.

A Critique: WATSON'S CARING IDEOLOGY: The Proper Focus of Psychiatric Nursing?

1. Watson's (1989) conceptualization of care possesses limited clinical utility in psychosocial contexts, given that there already exists an extensive lineage of human concepts of helping, within various psychotherapeutic traditions. 2. Watson's (1989) use of language delimits any utility that the "caring" construct might possess, Watson's conceptualization of caring is an inappropriate focus for psychiatric nursing, and historical precedents exist for many of the propositions upon which the science of caring is based. 3. Four decades of psychiatric nursing practice research and education render Watson's notion of a "science of caring" redundant.

Molecular cloning and sequencing of coat protein-encoding cDNA of rice tungro spherical virus--a plant picornavirus

Rice tungro spherical virus (RTSV) was shown to have three coat protein (CP) species by high resolution NaDodSO4-PAGE and Western blot analyses. The sequence of a coat protein-expressing cDNA clone that was identified and selected from a RTSV cDNA library showed that the insert was composed of 2823 bp with only one large open reading frame (ORF) coding for 941 amino acids. The positions of the three coat proteins were located in the putative polyprotein by N-terminal microsequencing and were shown to start at amino acids 287, 495, and 698 for CP-1, CP-2, and CP-3, respectively. The coat proteins are expressed as a polyprotein at the 5' region of the viral RNA genome, and all are cleaved at glutamine carboxy termini, presumably by picornavirus 3C-type of protease(s). Sequence comparisons of coat proteins revealed that there are high amino acid homologies between CP-2 of RTSV and VP3s of encephalomyocarditis virus (EMCV) and Theiler's murine encephalomyelitis virus (TMEV). These results indicate that RTSV is a plant picornavirus.

Purification and properties of the Clostridium thermocellum bglB gene product expressed in Escherichia coli

The Clostridium thermocellum beta-glucosidase B was purified to homogeneity in its recombinant form from Escherichia coli. The purification protocol included ion exchange, hydrophobic interaction and hydroxyapatite chromatography. The polypeptide was found to have a molecular mass of 84,000 daltons and a pI of 4.4. There was a differential effect of temperature on the aryl-beta-glucosidase and cellobiase activities of the purified protein. The cellobiase activity had an optimum of 45 degrees C, and aryl-beta-glucosidase 60 degrees C. Both activities had an optimum pH of 5.6, although the aryl-beta-glucosidase had a secondary peak at 7.0. Both activities were stimulated by divalent cations and DTT, but inhibited by thiol reagents. The enzyme was found to have a broad substrate specificity. Using cellobiose as substrate and a temperature of 45 degrees C, the Km and Vmax values were 1.6 mM and 5.5 U mg-1 respectively. The aryl-beta-glucosidase when assayed against pNP glucopyranoside and a temperature of 60 degrees C had Km and Vmax of 2.9 mM and 1.1 U mg-1 respectively. The enzyme was very stable at 45 degrees C, but rapidly inactivated at 60 degrees C.

Measurement of the sensitivity of upper airway reflexes

We describe a method for measurement of the sensitivity of upper airway reflexes. The technique is based upon delivery of an irritant chemical stimulus (dilute concentrations of ammonia vapour) to the upper airway. The technique is non-invasive and uses equipment which is portable, allowing measurements to be made in the clinical environment.

Effect of oral diazepam on the sensitivity of upper airway reflexes

In a double-blind, cross-over study, we have investigated the effect of oral diazepam 20 mg and placebo on the sensitivity of upper airway reflexes in 10 male volunteers (aged 25-35 yr). Upper airway reflex sensitivity (UARS) was assessed using small concentrations of ammonia vapour as a stimulus to upper airway receptors. A threshold concentration of ammonia, at which reflex glottic closure occurred in response to the ammonia stimulus, was used as a measure of UARS. With diazepam, there was significant depression of UARS from 30 to 150 min after administration.

The determination of the geometric isomers and related impurities of dothiepin in a pharmaceutical preparation by capillary electrophoresis

The application of capillary zone electrophoresis in the assay of the tricyclic antidepressant drug, dothiepin, in tablets is discussed. The method developed for dothiepin which exists as the cis- and trans-isomers and contains two major related impurities, an 11-oxo compound and a propanamine, utilizes inclusion complexation with beta-cyclodextrin. For optimization of the method the structured procedure of factorial design was used; the electrolyte solution was 50 mM disodium hydrogen phosphate with 10 mM beta-cyclodextrin-propan-1-ol(90:10, v/v). Good precision (RSD = 1.06%, n = 6), linearity (y = 26.84x + 2.25), and correlation (r = 0.999, n = 7) was obtained for trans-dothiepin. The reproducibility of tablet extraction was also acceptable (RSD = 0.77%, n = 6); the recovery of the trans-isomer was 98% (w/w) and the level of cis-isomer in tablets of dothiepin (75 mg) was 5.58% (w/w).

Perioperative continuous monitoring of ST-segment changes in patients undergoing elective caesarean section

Using continuous ambulatory electrocardiography, we have investigated the incidence of ST-segment changes occurring in patients undergoing elective Caesarean section under extradural, spinal or general anaesthesia. There was no evidence of significant perioperative ST-segment changes. The findings contrast with the results of other work published recently.

Effect of the laryngeal mask airway on lower oesophageal sphincter pressure in patients during general anaesthesia

We have studied the tone of the lower oesophageal sphincter (LOS) in 40 adults undergoing routine body surface surgery and allocated randomly to receive anaesthesia either by face mask and Guedel airway or by laryngeal mask airway. In the laryngeal mask group there was a mean (SEM) decrease in barrier pressure (LOS minus gastric pressure) of 3.6 (1.4) cm H2O, compared with a mean increase of 2.2 (1.2) cm H2O in the face mask group (P < 0.005).

Regurgitation of gastric contents during general anaesthesia using the laryngeal mask airway

We have investigated the incidence of regurgitation of gastric contents during general anaesthesia administered via a laryngeal mask airway (LMA) or face mask and Guedel airway in 56 patients with no risk factors for regurgitation. Patients swallowed a gelatin capsule containing methylene blue 10 min before induction of anaesthesia. Fibreoptic laryngoscopy in the LMA group or conventional laryngoscopy in the face mask group was performed at the end of surgery. Dye was observed within the laryngeal mask in seven of 28 patients (25%). No patients in the face mask-Guedel airway group regurgitated dye (P = 0.005). There was no evidence of aspiration of dye.

A comparison of gastric emptying rate after cimetidine and ranitidine measured by applied potential tomography

Gastric emptying was measured using applied potential tomography (APT) after crossover administration of 800 mg cimetidine and 300 mg ranitidine orally. Ten volunteers were studied, each on two occasions. Two hours after taking ranitidine or cimetidine, the volunteer was given a liquid and gastric emptying was measured over 60 min. There was a small but statistically significant delay in gastric emptying following ranitidine compared with cimetidine (P less than 0.04). The median (range) time to 50% emptying (t50) was 24 (15-60) min after ranitidine compared with 22 (15-46) min after cimetidine.

A study of the effect of Picolax on body weight, cardiovascular variables and haemoglobin concentration

This study compared the effect of Picolax when administered for large bowel preparation in combination with preoperative fasting on body weight, haemoglobin concentration, haematocrit, and cardiovascular variables with matched subjects who were fasted before surgery. Picolax resulted in significantly greater weight loss, increases in haemoglobin concentration combined with cardiovascular changes suggesting hypovolaemia in the Picolax group. Intravenous fluid replacement is recommended in patients receiving Picolax.

Spatiotemporal increases in epidermal growth factor receptors following peripheral nerve injury

Non-neuronal cells of peripheral nerve respond to axonal injury with a series of cellular changes that facilitate neuronal regeneration. To characterize the potential role of the epidermal growth factor (EGF) family of proteins in this response, we monitored the expression of EGF receptor mRNA and protein in the injured rat sciatic nerve. EGF receptor mRNA is synthesized in both primary cultured fibroblasts and Schwann cells, and Schwann cells express EGF receptor-like immunoreactivity. In situ hybridization and immunocytochemistry revealed that EGF receptor mRNA and protein are expressed in Schwann cells and fibroblasts of the sciatic nerve in vivo, and that receptor levels increase following nerve injury. Thirty-six hours postlesion, EGF receptors were expressed in gradients along the nerve both proximal and distal to the lesion, with the highest levels localized adjacent to the transection site. By 72 hr, receptor levels were maintained in a gradient in the proximal segment, but were uniformly increased throughout the portions of the distal segment that were analyzed. These changes were similar to those observed for low-affinity NGF receptor mRNA and protein, with transection causing increased expression in both Schwann cells and fibroblasts. Northern blots confirmed that primary cultured fibroblasts express low-affinity NGF receptor mRNA. To determine whether spatiotemporal gradients were a general characteristic of the nerve injury response, we monitored expression of the mRNA encoding the major myelin protein P0. Levels of P0 mRNA decreased initially in cells immediately adjacent to the transection site and, by 72 hr, were uniformly decreased throughout the distal segment. These data suggest that members of the EGF family of proteins may play a role in the peripheral nerve response to injury, and demonstrate a generalized gradient of cellular responses that commence at the transection site and progress distally in the nerve in the absence of intact axons.

Movements of the vocal cords on induction of anaesthesia with thiopentone or propofol

Using a fibreoptic laryngoscope, we have recorded on video tape the movements of the vocal cords after induction of anaesthesia with either propofol or thiopentone. The angle formed by the vocal cords decreased after induction of anaesthesia in both groups. This reduction in angle was significantly greater in the thiopentone group. The vocal cords closed completely in four patients in the thiopentone group and one patient in the propofol group. This difference may be explained by greater depression of laryngeal reflexes by propofol and this may account for the lower incidence of laryngospasm after induction of anaesthesia with propofol in comparison with thiopentone.