Early experience and validation work with Procedicus VA--the Prosolvia virtual reality shoulder arthroscopy trainer

Shoulder arthroscopy is a difficult procedure, commonly used for both diagnostic and therapeutic purposes. Until now, the majority of training has been done in theatre, assisting and practising under supervision. Few good simulations exist. Procedicus VA, from Prosolvia Clarus, is a virtual reality simulation of shoulder arthroscopy, with interactive graphics and haptic feedback. The simulator has various modes including anatomy manipulation pathology subacromial decompression. We describe our experience with the simulator, attempting to validate some of the scoring mechanisms, and highlighting some of the pitfalls discovered as the simulator is first trialled by surgeons. This early experience has highlighted both successful aspects of the simulator, and some of the initial pitfalls. Our initial experience confirms the need for close collaboration between virtual programmers and surgical trainers. We are revising the assessment criteria over the coming months.

Molecular typing methods to investigate transmission of Escherichia coli O157:H7 from cattle to humans

The utility of phage typing, pulsed-field gel electrophoresis (PFGE), and plasmid profile analysis was compared, to differentiate between Canadian Escherichia coli O157:H7 strains of human (n = 27) and cattle (n = 24) origin. The diversity indices for phage typing, plasmid analysis and PFGE were 0.85, 0.69 and 0.93, respectively. PFGE and phage typing were also applied to study the role of direct transmission of E. coli O157:H7 from cattle to humans on isolates collected from two separate farm outbreaks. PFGE showed that more than one E. coli O157:H7 strain with varying PFGE DNA subtype profiles, may be responsible for an outbreak, and that more than one E. coli O157:H7 subtype may be circulating on a particular farm at any one time. To our knowledge, this is one of the first reports where PFGE typing was used to verify the direct transmission of E. coli O157:H7 from cattle to humans.

Oral prostaglandin (PGE2) therapy for chronic viral hepatitis B and C

The cytoprotective effects of prostaglandins have been utilized in the prevention of hepatitis B virus reactivation after liver transplantation. This pilot study evaluated the effects of oral prostaglandin E2 (PGE2) in chronic viral hepatitis B and C. Twenty patients with chronic hepatitis B and 20 patients with chronic hepatitis C received 4mg day-1 PGE2 for 6 months. The lymphocyte antiviral enzyme 2',5'-oligoadenylate synthetase (2',5'-OAS) and peripheral blood monocyte procoagulant activity (PCA) were measured before, during and after the treatment. Three of 20 hepatitis B and five of 20 hepatitis C patients withdrew from the study. Eight of 17 hepatitis B patients responded: in seven of these eight patients, serum alanine aminotransferase (ALT) levels normalized; loss of viral replication was sustained in all eight patients; and seroconversion from hepatitis Be antigen (HBeAg) to hepatitis Be antibody (HBeAb) positivity occurred in seven patients over the 48-week duration of this study. In 14 of the 15 hepatitis C patients, hepatitis C virus (HCV) RNA remained detectable and the serum ALT levels remained elevated. 2',5'-OAS levels and PCA values did not correlate with other markers of response to PGE2 therapy in either chronic hepatitis B or C. In summary, PGE2 was associated with sustained loss of viral replication in 47% of chronic hepatitis B patients; no beneficial effects were apparent in chronic hepatitis C.

Inappropriate admissions to hospital: the views of nursing and residential homes

Acute admissions of older people from residential and nursing homes are often seen as inappropriate by both residential and hospital nursing staff. In this survey, nursing staff from the primary care sector were asked their views on these admissions. Their comments indicate that with better staff education, role support and more effective communication between the two sectors, the continuity of care would be improved. This, in turn, would reduce the number of unnecessary hospital admissions, and improve overall quality of care.

Application of multiplex PCR for detection of non-O157 verocytotoxin-producing Escherichia coli in bloody stools: identification of serogroups O26 and O111

Primers were designed to amplify sequences of verocytotoxin genes and eaeA genes of Escherichia coli O26:H11, O111:H8, and O157:H7 in a multiplex PCR assay. This assay successfully detected E. coli O26:H11 in bloody stool specimens in which other enteric pathogens were not detected by culture-based methods. Rapid assays to detect non-O157:H7 verocytotoxin-producing E. coli is important to improve methods for the etiologic diagnosis of hemorrhagic colitis.

CD38+ CD45RB(low) CD4+ T cells: a population of T cells with immune regulatory activities in vitro

An antibody reactive with CD38 revealed both phenotypic and functional heterogeneity amongst CD45RB(low) cells. Functional analysis of the CD38+ and CD38- fractions showed that the latter contained T cells which responded to recall antigens and produced high levels of cytokine in response to polyclonal stimulation. In contrast, the CD38+ population failed to proliferate or to produce detectable levels of cytokines. Despite appearing unresponsive, the CD38+ population significantly inhibited anti-CD3-induced proliferation and cytokine secretion by the reciprocal CD38- population. Immune suppression required stimulation through the TCR and was dependent on a physical interaction between regulatory and responding CD4+ populations. It did not involve killing of the responding T cells or secretion of IL-10 or TGF-beta. Despite some similarities there is no direct correlation between the in vitro suppression characteristic of the CD38+ CD45RB(low) subset and in vivo suppression which has been shown to be mediated by unseparated CD45RB(low) CD4+ T cells. However, these results demonstrate that two functionally distinct subsets of T cells reside within the antigen-exposed or CD45RB(low) CD4+ T cell population and are thus generated in vivo: (1) conventional memory T cells which proliferate and secrete cytokines in response to activation and (2) a population of regulatory T cells which inhibit T cell activation in vitro. Antibodies reactive with CD38 may provide a useful tool with which to study the role of these T cell subsets in the induction and regulation of the immune response.

An automated fluorescent PCR method for detection of shiga toxin-producing Escherichia coli in foods

An automated fluorescence-based PCR system (a model AG-9600 AmpliSensor analyzer) was investigated to determine whether it could detect Shiga toxin-producing Escherichia coli (STEC). The AmpliSensor PCR assay involves amplification-mediated disruption of a fluorogenic DNA signal duplex (AmpliSensor) that is homologous to conserved target sequences in a 323-bp amplified fragment of Shiga toxin genes stx1, stx2, and stxe. Using the Amplisensor assay, we detected 113 strains of STEC belonging to 50 different serotypes, while 18 strains of non-Shiga-toxin-producing E. coli and 68 strains of other bacteria were not detected. The detection limits of the assay were less than 1 to 5 CFU per PCR mixture when pure cultures of five reference strains were used and 3 CFU per 25 g of food when spiked ground beef samples that were preenriched overnight were used. The performance of the assay was also evaluated by using 53 naturally contaminated meat samples and 48 raw milk samples. Thirty-two STEC-positive samples that were confirmed to be positive by the culture assay were found to be positive when the AmpliSensor assay was used. Nine samples that were found to be positive when the PCR assay was used were culture negative. The system described here is an automated PCR-based system that can be used for detection of all serotypes of STEC in food or clinical samples.

Exploring new roles for nurses in the acute sector

Recent changes in the NHS have resulted in numerous developments in nursing roles. A project has been undertaken to identify the wide range and purpose of extended nursing roles, and to discover the differences between them.

Prospective randomized trial of two dose levels of interferon alfa with zidovudine for the treatment of Kaposi's sarcoma associated with human immunodeficiency virus infection: a Canadian HIV Clinical Trials Network study

PURPOSE

Interferon alfa alone has shown antitumor activity against Kaposi's sarcoma (KS), and phase I and II clinical trials showed that interferon and zidovudine could be administered safely to patients with human immunodeficiency virus (HIV)-associated KS. These observations led to our trial of zidovudine with two dose levels of interferon alfa.

METHODS

HIV-positive patients with KS were eligible if they were older than 18 years of age, had a performance status of 0 to 2, and were free of active infection. All patients received zidovudine 500 mg daily and were randomized to receive-interferon alfa 1 million U or 8 million U subcutaneously daily.

RESULTS

The 108 eligible and assessable patients were well balanced for known prognostic factors. Response was reported in 31% of high-dose therapy and 8% of low-dose therapy patients (P=.011). Response at both dose levels was higher for patients with CD4 counts greater than 150 x 10(9)/L. The median time to progression was longer for patients in the 8-million U arm (18 v 13 weeks; P=.002). Both hematologic and nonhematologic toxicities were higher in the high-dose arm; 50 of 54 patients who received 8 million U required dose alterations in the first 4 months compared with only 19 of 53 patients who received 1 million U (P=.0002). No significant differences were reported with respect to improvement in CD4 count, elimination of p24 antigen, or development of opportunistic infections.

CONCLUSION

Zidovudine and moderate-dose-interferon alfa may be combined safely for the treatment of HIV-associated KS, and both response to treatment and toxicity are dose related.

Self-injury and violence in people with severe learning disabilities

BACKGROUND

Psychiatry in severe and profound learning disability is essentially behavioural psychiatry. Some clinical and research observations of disorders of behaviour in this group are summarised in this study.

METHOD

After inspection of the literature, I postulated a clinical syndrome of violence and self-injury in the severely learning disabled. A check-list of behavioural symptoms was developed and used in a community survey.

RESULTS

Behaviour, assessed by the check-list, supported the existence of organic behaviour disorder, as did small-scale psychophysiological testing.

CONCLUSIONS

Self-injury is strongly associated with violence, and with severe and profound learning disability. Pathophysiology of violence and self-injury may include high levels of psychophysiological arousal demonstrated by unstable EEGs. Reduction of arousal by antipsychotic medication is associated with clinical improvement in violent and self-injurious behaviours.

The use of reverse transcriptase-polymerase chain reaction to investigate environmental samples for the presence of enteroviruses

Molecular techniques developed for detection and diagnosis of enteric viruses have been adapted for use with water samples. Although problems of interference and sensitivity remain, reliable and consistent methods should soon be available for the detection in water of enteroviruses, Norwalk-like viruses, and rotavirus.

The development of a specimen exchange system for quality assessment of polymerase chain reaction tests

A programme of external quality assessment of polymerase chain reaction (PCR) assays through regular exchange of appropriate clinical or spiked specimens between Oxford and Cambridge public health laboratories began in February 1997. We report on 60 specimens included in the exchange. These covered most of the molecular diagnostic assays in use at present. In two cases discrepant results were obtained. We conclude that the exchange of specimens under code between laboratories that use molecular techniques as a diagnostic service is an inexpensive way of achieving regular external quality assessment.

Breaking bad news to people with a learning disability

This article identifies the difficulties often associated with breaking bad news, from a nursing perspective. The additional considerations involved in breaking bad news to people with learning disabilities are identified, and a six-step protocol (Buckman, 1991) is introduced and explored in relation to this client group. Effective communication is seen to be crucial when working with people with a learning disability, and a system for accurate listening is offered (Conboy-Hill, 1992). Finally, recommendations for helping professionals to learn how to break bad news sensitively to this client group are suggested. They include multi-agency working, education and training opportunities, standard statements, resources, support and research initiatives.

Detection of the hepatitis C virus by rt-PCR

The hepatitis C virus (HCV) is an orgainsm of the age of molecular biology, for its discovery and much of the research into the infection have relied heavily on molecular techniques. The development of molecular cloning enabled a successful strategy that finally identified HCV (1)as the cause of 90% of posttransfusion (2)and > 50% of sporadic non-A, non-B hepatitis (3) after the failure by immunological techniques to discover the responsible agent. It is an important infection as most infected patients developed chronic hepatitis (> 50%) that can progress to cirrhosis and hepatocellular carcinoma (4-6) . Following the identification of the viral genome, antibody tests were developed which could detect exposure to the virus (7). The presence of antibodies to HCV, however, does not distinguish between those with chronic infection and those who had cleared the virus. Chronic HCV infection can be difficult to diagnose as patients may be asymptomatic and have normal liver biochemistry (8),(9) despite abnormal liver histology. Therefore, demonstration of virus RNA (usually from serum samples) is often necessary to confirm Infection. Detection of HCV RNA requires the sensitivity of nucleic acid amplification (e.g., the polymerase chain reaction) as circulating levels of vnus RNA can be very low (10),(11). Such tests are now widely used to confirm infection, monitor the response to anti-viral therapy, and in epidemiological studies of HCV infection.

Realizing specialist and advanced nursing practice: a typology of innovative nursing roles

This paper outlines the findings of the first phase of a Department of Health funded project: Realizing Specialist and Advanced Nursing Practice establishing the parameters of and identifying competencies for 'Nurse Practitioner' roles and evaluating programmes of preparation. An extensive literature review and interviews with 49 key informants was used to revise a typology of Domains of Innovative Nursing Roles which the authors had constructed. It also emerged from the key informant interviews that a substantial number of respondents considered the role of the Nurse Practitioner (NP) to be a composite of both specialist and advanced practice. Further analysis indicated that although current preparation for a 'specialist' role would meet many of the outcomes perceived necessary to prepare individuals for the NP role, something 'extra' was seen as a prerequisite for the NP. It is suggested, therefore, that there is a strong case for considering the NP role in terms of 'specialist plus', and that the typology can be helpful in considering the major emphasis within NP roles.

Sexual dysfunction in primary medical care: prevalence, characteristics and detection by the general practitioner

BACKGROUND

Despite the recent focus on sexual behaviour and AIDs, there are almost no data on the prevalence of sexual dysfunction within primary care settings.

METHOD

One hundred and seventy patients attending a general practice participated in a questionnaire survey of the prevalence and characteristics of sexual problems. The detection rate of the general practitioners (GPs) and indicators in the patient notes were also investigated.

RESULTS

Thirty five per cent of the men (n = 22) reported some form of specific sexual dysfunction: premature ejaculation was identified in 31 per cent of the men; 17 per cent experienced erectile dysfunction, which was associated with current medication, a high mean annual attendance and increasing age. The prevalence of sexual dysfunction in the women was 42 per cent (n = 41); vaginismus was reported by 30 per cent of the sample; 23 per cent of the women suffered from anorgasmia. General sexual dissatisfaction was more common than specific dysfunction; 68 per cent (n = 66) of the women and 75 per cent (n = 54) of the men reported at least one problem with dissatisfaction, avoidance, infrequency or non-communication. The large majority of the sample (70 per cent) considered sexual matters to be an appropriate topic for the GP to discuss. Despite this, sexual problems were recorded in only 2 per cent of the GP notes.

CONCLUSIONS

This study confirms the high prevalence of sexual disorders in the population. Many of these problems are concealed from GPs. Predictors in patients' notes could help GPs to detect those patients with more serious problems.

An evaluation of a nurse-led ear care service in primary care: benefits and costs

BACKGROUND

Nurses trained in ear care provide a new model for the provision of services in general practice, with the aim of cost-effective treatment of minor ear and hearing problems that affect well-being and quality of life.

AIM

To compare a prospective observational cohort study measuring health outcomes and resource use for patients with ear or hearing problems treated by nurses trained in ear care with similar patients treated by standard practice.

METHOD

A total of 438 Rotherham and 196 Barnsley patients aged 16 years or over received two self-completion questionnaires: questionnaire 1 (Q1) on the day of consultation and questionnaire 2 (Q2) after three weeks. Primary measured outcomes were changes in discomfort and pain; secondary outcomes included the effect on normal life, health status, patient satisfaction, and resources used.

RESULTS

After adjusting for differences at Q1, by Q2 there was no statistical evidence of a difference in discomfort and pain reduction, or differential change in health status between areas. Satisfaction with treatment was significantly higher (P = 0.0001) in Rotherham (91%) than in Barnsley (82%). Average total general practitioner (GP) consultations were lower in Rotherham at 0.4 per patient with an average cost of 6.28 Pounds compared with Barnsley at 1.4 per patient and an average cost of 22.53 Pounds (P = 0.04). Barnsley GPs prescribed more drugs per case (6% of total costs compared with 1.5%) and used more systemic antibiotics (P = 0.001).

CONCLUSIONS

Nurses trained in ear care reduce costs, GP workload, and the use of systemic antibiotics, while increasing patient satisfaction with care. With understanding and support from GPs, such nurses are an example of how expanded nursing roles bring benefits to general practice. Nurses trained in ear care reduce treatment costs, reduce the use of antibiotics, educate patients in ear care, increase patient satisfaction, and raise ear awareness.

Adverse reactions to trimethoprim-sulfamethoxazole among children with human immunodeficiency virus infection

BACKGROUND

The clinical course of HIV infection is frequently different among infants and children from that in adults. In adults among the most common sources of morbidity related to therapy are adverse drug reactions, notably to trimethoprim-sulfamethoxazole. Although there are case reports of serious adverse reactions to trimethoprim-sulfamethoxazole among infants and children with HIV infection, the precise rate and clinical characteristics of these adverse reactions among HIV-infected children are unknown.

METHODS

We reviewed the clinical records of all children referred to a regional HIV clinic in a 6-year period. Therapy and suspected adverse drug reactions to therapy were reviewed by one of the investigators not involved in patient care. Adverse drug reactions were identified and characterized according to previously established criteria.

RESULTS

During this time 78 children were referred for assessment of possible HIV infection, 45 of whom were ultimately determined to have the infection. Twenty-five were treated with trimethoprim-sulfamethoxazole, 15 (60%) of whom tolerated therapy and 10 (40%) of whom had adverse reactions. The most common type of adverse reaction was erythema multiforme (70%), followed by neutropenia (20%) and Stevens-Johnson syndrome (10%). In two patients a serious adverse reaction to trimethoprim-sulfamethoxazole led to the diagnosis of HIV infection.

CONCLUSIONS

The overall incidence and type of serious adverse reactions to trimethoprim-sulfamethoxazole among infants and children with HIV infection appear to be similar to those among adults.

Chronic pain in the setting of Parkinson's disease and depression

A 65-year-old woman with chronic pain was admitted to the hospital for severe recurrent major depression complicating Parkinson's disease (PD). Pain complaints were closely related to the fluctuating motor syndrome of PD. Specifically, pain was experienced in conjunction with hypomobility, and, as a result, she self-medicated with extra carbidopa/levodopa. A regimen of tramadol and cyclobenzaprine, along with sustained-release carbidopa/levodopa for PD and buproprion for her depression resulted in sustained symptomatic and functional improvement. Craving for, and self-medication with, supplemental carbidopa/levodopa ceased. Theoretical support for synergism among dopamine and opioid neurotransmitter systems can be found in recent literature.

Use of the flagellar H7 gene as a target in multiplex PCR assays and improved specificity in identification of enterohemorrhagic Escherichia coli strains

PCR products of 1.8 kb were generated with DNAs from all Escherichia coli H7 strains tested by using oligonucleotide primers which flank the fliC gene. Three RsaI digestion profiles of these PCR products were evident on agarose gels; the first occurred with serotype O55:H7, O157:H7, or nonmotile (NM) strains, the second occurred with serotype O1:H7 and O18:H7 strains, and the third occurred with serotype O?:H7, O19:H7, O121:H7, O88:H7, and O156:H7 strains. Despite these differences, the nucleotide sequences of the E. coli E32511 (O157:NM) and U5-41 (O1:H7) fliC genes were 97% homologous. Two PCR primer pairs synthesized on the basis of the E32511 H7 fliC sequence amplified specific DNA fragments from all E. coli H7 strains, but did not amplify DNA fragments from the other bacterial strains. The H7-specific primers were used in combination with other primers which target the Verotoxin 1(VT1) and VT2 genes and the E. coli O157:H7 eaeA gene in multiplex PCR assays. In these assays, vt and eaeA PCR products were observed with DNAs from the majority of EHEC strains and vt, eaeA, and fliC PCR products were observed with DNAs from E. coli O157:H7 or NM strains. Only eaeA PCR products were present with DNA from enteropathogenic E. coli, and only vt PCR products occurred with VT-producing E. coli which are not EHEC. The multiplex PCR assays described allow for the specific identification of E. coli O157:H7 or NM and other EHEC strains.

Analysis of whole-cell fatty acid profiles of verotoxigenic Escherichia coli and Salmonella enteritidis with the microbial identification system

Differentiation of strains within bacterial species, based on gas chromatographic analysis of whole-cell fatty acid profiles, was assessed with 115 strains of verotoxigenic Escherichia coli and 315 strains of Salmonella enteritidis. Fatty acid-based subgroups within each of the two species were generated. Variability of fatty acid profiles observed in repeat preparations from the same strain approached that observed between subgroups, limiting the usefulness of using fatty acid profiles to subgroup verotoxigenic E. coli and S. enteritidis strains.