Polymerase chain reaction for the laboratory diagnosis of aseptic meningitis and encephalitis

A protocol for testing cerebrospinal fluid specimens using a range of PCR assays for the diagnosis of central nervous system infection was developed and used to test prospectively 383 specimens. PCR assays were used for the detection of adenovirus, Borrelia burgdorferi, enteroviruses, Epstein Barr virus, cytomegalovirus, herpes simplex virus, human herpes virus type 6, JC virus, Leptospira interrogans, Listeria monocytogenes, lymphocytic choriomeningitis virus, measles virus, mumps virus, Mycobacterium sp. , Mycoplasma pneumoniae, Toxoplasma gondii and varicella zoster virus. Of the 383 specimens tested in this study, 46 (12.0%) were found to be positive. The microorganisms detected were CMV, enterovirus, Epstein Barr virus, herpes simplex virus, human herpes virus type 6, JC virus, L. monocytogenes, Mycobacterium genus, Toxoplasma gondii and varicella zoster virus. The introduction of the PCR protocol described has improved the diagnosis of a range of central nervous system infections in our laboratory. We believe however that further evaluation of these assays in immunocompromised patients is necessary to better determine the predictive value of positive PCR results in these patient groups.

Practical considerations in case study research: the relationship between methodology and process

This paper explores the extent to which the design of a research study is influenced by pragmatic as well as theoretical considerations by describing the authors' experience of conducting multiple case studies in the context of a policy-orientated research project. The case studies in question formed part of a collaborative project exploring the development of innovative roles in nursing and the professions allied to medicine. The researchers adopted Yin's approach to the conduct of multiple case studies to explore issues relating to the effectiveness of new roles, their resource implications and educational issues surrounding their development. They address the fact that methodological decisions have practical implications and also explore the effects of practical and ethical issues on research design. Three purposively selected acute National Health Service Trust hospitals in England formed the case study sites for the work recorded in this paper. In each Trust, three nursing roles were selected, making nine cases for study. A variety of data collection strategies were used including semi-structured interviews with post-holders and other stakeholders (n = 51), non-participant observation of meetings, collection of audit, financial and statistical data and review of relevant documentation. This paper describes some of the dilemmas which arose during the course of the study, the rationale for methodological decisions taken to resolve these dilemmas and the steps taken to enhance rigour. In particular, the authors discuss the problems associated with obtaining informed consent in the context of qualitative research and with member validation of transcripts in a context where confidentiality was crucial. The decision to present findings thematically rather than as individual cases is justified both in terms of the nature and purpose of the research and in relation to the particular importance of anonymity and confidentiality in this study. Finally, the degree of reciprocity between researcher and researched is discussed.

Predictive validity of the New Zealand MacArthur Communicative Development Inventory: Words and Sentences

This study assessed the long-term predictive validity of the MacArthur Communicative Development Inventories: Words and Sentences (CDI:WS; Fenson, Dale, Reznick, Thal, Bates, Hartung, Pethick & Reilly, 1993) for children's expressive and receptive vocabulary development. Sixty-one New Zealand children (31 females) were assessed with a New Zealand version of the CDI: WS at 1;7 and 2;1 and with the Expressive Vocabulary Test (Williams, 1997) and the Peabody Picture Vocabulary Test-III (Dunn & Dunn, 1997) at 2;8 and 3;4. Excellent reliability and good predictive validity was obtained for the NZ CDI:WS even over a 21-month delay. Predictive validity of the NZ CDI:WS for the PPVT-III was higher for children of mothers with less education. We discuss the implications of these results for use of the CDI:WS with children from a broad range of cultural and educational backgrounds.

District nurses' needs: palliative care for people with learning disabilities

The aim of this article is to identify national palliative care issues, and current palliative care services provided by district nurses for people with a learning disability in North Staffordshire, UK. The professional and educational needs of district nurses in the role of palliative care providers for people with a learning disability were identified by two small focus groups involving district nurses. This resulted in the formulation of a questionnaire, which was circulated to 165 district nurses. While the initial part of the research is qualitative, the final survey involved a quantitative analysis using a questionnaire and a three-point Likert scale. This compared a number of independent variables such as age range, length of experience and number of contacts with clients who have a learning disability and palliative care needs. The results provide an overview of existing service uptake and a profile of the professional and educational needs of district nurses when caring for people with a learning disability who also have palliative care needs.

Do new roles contribute to job satisfaction and retention of staff in nursing and professions allied to medicine?

BACKGROUND

Studies have suggested that job dissatisfaction is a major factor influencing nurses' and occupational therapists' intention to leave their profession. It has also been related to turnover of qualified nurses. However, literature relating to these factors among nurses and professions allied to medicine in innovative roles is scarce.

AIMS

This paper considers the views of 452 nurses and 162 professionals allied to medicine (PAMs) in innovative roles, on job satisfaction, career development, intention to leave the profession and factors seen as hindering and enhancing effective working.

METHODS

A self-completion questionnaire was developed as part of a larger study exploring new roles in practice (The ENRiP Study).

FINDINGS

Overall there was a high level of job satisfaction in both groups (nurses and PAMs). Job satisfaction was significantly related to feeling integrated within the post-holder's own professional group and with immediate colleagues, feeling that the role had improved their career prospects, feeling adequately prepared and trained for the role, and working to protocol. Sixty-eight percent (n = 415) of respondents felt the role had enhanced their career prospects but over a quarter of respondents (n = 163; 27%) said they would leave their profession if they could. Low job satisfaction was significantly related to intention to leave the profession.

CONCLUSIONS

The vast majority of post-holders in innovative roles felt that the role provided them with a sense of job satisfaction. However, it is essential that the post-holders feel adequately prepared to carry out the role and that the boundaries of their practice are well defined. Career progression and professional integration both being associated with job satisfaction.

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.