Power in the nursing home: the case of a special care unit

This article examines the effects and nature of power in a special care unit of a nursing home devoted to elders with dementia and/or disturbed behaviors. Drawing from two case studies and contemporary theories on power, I illustrate how the hierarchical structure of the clinic, together with the diffuseness and pervasiveness of disciplinary power, serves to shape the lives of--and to constrain the resistance opportunities open to--elders within the clinic. I also discuss the dilemma facing ethnographers of the clinic who may witness the sometimes disastrous effects of power but feel incapable, in their positions as researchers, of challenging the actions of clinical staff. At the same time, I observe how the contradictions of disciplinary power are often experienced by clinical staff who themselves struggle between taking actions they feel they must and those they would prefer. Far from acceding to the impotency that clinical anthropologists too often feel within a research setting, I argue that they can help to incite in their clinical colleagues the urgency of carrying out more productive alternatives to conventional "disciplinary" practices.

Determination of amphetamine in dog plasma by gas chromatography with mass selective detection

This paper describes the validation of an analytical method for the determination of amphetamine in beagle dog plasma by gas chromatography coupled to mass spectrometry (GC-MS). d-Amphetamine-d(6) was used as the internal standard. The method consisted of a rapid single-step liquid-liquid extraction and derivatization of amphetamine with 2,2,2-trichloroethyl chloroformate, followed by sensitive GC-MS detection. This is the first report utilizing the combination of trichloroethyl chloroformate as a derivatization reagent and a deuterated amphetamine analog as an IS for the quantification of amphetamine in plasma. The method was validated in terms of specificity, curve fit, precision, accuracy, recovery and stability, and was acceptable according to FDA draft guidelines for validation of bioanalytical methods. The limit of detection was 0.65 ng/mL. The calibration range was 5-150 ng/mL. The validated method was successfully employed for the quantitation of amphetamine in dog plasma samples for pharmacokinetic profiling.

The influence of food on the bioavailability of a twice-daily controlled release carbamazepine formulation

Carbatrol, a new dosage form of carbamazepine (CBZ), was developed consisting of three different types of pellets (immediate release, controlled release, and enteric release). The objective of this study was to explore the influence of food on absorption of CBZ. This was a randomized, open-label, single-dose crossover study conducted in 12 healthy volunteers. Treatments were 2 x 200 mg Carbatrol with a high-fat meal, fasted, or sprinkled over applesauce (but otherwise fasted). Each subject received one dose of each treatment separated by a washout period of at least 2 weeks. CBZ bioequivalence was established based on the equivalence of AUC (extent of absorption) in all three conditions. Carbatrol may be taken with or without food or the capsule opened and sprinkled on food.

Encouraging prospects for immunisation against primary cytomegalovirus infection

Congenital cytomegalovirus (CMV) infection is the leading infectious cause of mental retardation in children. Using seroprevalence data from two large antenatal populations (in excess of 14000 women) coupled with a mathematical modelling approach, we have shown that CMV has a low force of infection (ca. 0.03 per seronegative per annum) and its basic reproductive number R0 is relatively modest at 2.4. On the basis of these results, the critical vaccination proportion required for eradication of CMV is between 59-62%. In contrast to the predicted and observed effects of rubella vaccination on the incidence of congenital rubella, the increase in the average age of infection following instigation of a CMV vaccine programme will not increase the number of congenital infections. In conclusion, CMV is a prime candidate for eradication from the human population through vaccination.

Interhemispheric comparisons in a man with complete forebrain commissurotomy

J. Sergent (1991) claimed that split-brained people are highly accurate in judging which is the larger of 2 circles in opposite visual hemifields but are relatively poor at judging whether circles in the 2 hemifields are of the same size. The discrepancy could be due, at least in part, to an artifact. A split-brained man, L.B., was markedly worse than normals at judging which was the larger of 2 circles or the longer of 2 horizontal lines in opposite hemifields, and his performance could be largely accounted for without assuming any interhemispheric transfer. L.B. also judged whether a single flashed line extended further into the left or right hemifield and, as in a previous study (M. C. Corballis, 1995), was strongly biased to respond "right longer." This bias was not observed in the judgments about the circles or the separated lines, suggesting that it is not due to a compression of perceived space in the left hemifield.

Quality of life of mothers and families caring for preterm infants requiring home oxygen therapy: a brief report

OBJECTIVE

To investigate the impact on mothers and families of caring for a premature infant receiving home oxygen therapy (HOT).

METHODS

Standard questionnaires were used to compare the functioning of mothers and families of 10 premature infants receiving HOT, 10 premature infants who were discharged from hospital on HOT but who no longer required it and 20 premature infants who had never required treatment with HOT.

RESULTS

After adjustment for gestational age, chronological age, birthweight and place of residence (urban/rural), the care required by premature infants receiving HOT had a significantly greater impact on their families than the care of infants not receiving HOT. Mothers of premature infants receiving HOT reported significantly less vitality and more mental health problems than mothers of infants not receiving HOT.

CONCLUSIONS

The use of HOT for premature infants may have a significant adverse impact on their mothers and families.

Immunopharmacological activity of Echinacea preparations following simulated digestion on murine macrophages and human peripheral blood mononuclear cells

We have investigated the immunostimulatory, anti-inflammatory, and antioxidant activities of various Echinacea raw materials and commercially available products on murine macrophages and human peripheral blood mononuclear cells (PBMCs). To emulate oral dosing, a simulated digestion protocol was employed as a means of sample preparation. Echinacea-induced macrophage activation was used as a measure of immunostimulatory activity determined via quantitative assays for macrophage-derived factors including tumor necrosis factor alpha, interleukin (IL)-1alpha, IL-1beta, IL-6, IL-10, and nitric oxide. Echinacea herb and root powders were found to stimulate murine macrophage cytokine secretion as well as to significantly enhance the viability and/or proliferation of human PBMCs in vitro. In contrast, Echinacea extracts chemically standardized to phenolic acid or echinacoside content and fresh pressed juice preparations were found to be inactive as immunostimulatory agents but did display, to varying degrees, anti-inflammatory and antioxidant properties.

Interhemispheric comparisons in a man with complete forebrain commissurotomy

J. Sergent (1991) claimed that split-brained people are highly accurate in judging which is the larger of 2 circles in opposite visual hemifields but are relatively poor at judging whether circles in the 2 hemifields are of the same size. The discrepancy could be due, at least in part, to an artifact. A split-brained man, L.B., was markedly worse than normals at judging which was the larger of 2 circles or the longer of 2 horizontal lines in opposite hemifields, and his performance could be largely accounted for without assuming any interhemispheric transfer. L.B. also judged whether a single flashed line extended further into the left or right hemifield and, as in a previous study (M. C. Corballis, 1995), was strongly biased to respond "right longer." This bias was not observed in the judgments about the circles or the separated lines, suggesting that it is not due to a compression of perceived space in the left hemifield.

Response of naïve and memory CD8+ T cells to antigen stimulation in vivo

We studied the influence of memory T cell properties on the efficiency of secondary immune responses by comparing the in vivo immune response of the same numbers of T cell receptor (TCR) transgenic (Tg) naïve and memory T cells. Compared to naïve Tg cells, memory cells divided after a shorter lag time; had an increased division rate; a lower loss rate; and showed more rapid and efficient differentiation to effector functions. We found that initial naïve T cell priming resulted in cells expressing mutually exclusive effector functions, whereas memory T cells were multifunctional after reactivation, with each individual cell expressing two to three different effector functions simultaneously. These special properties of memory T cells ensure the immediate control of reinfection.

Comparison of Pulmicort pMDI plus Nebuhaler and Pulmicort Turbuhaler in asthmatic patients with dysphonia

BACKGROUND

Dysphonia is a known local adverse effect of inhaled corticosteroids. This symptom was investigated by laryngoscopy and assessment in a voice laboratory. The effects of changing the treatment of patients with dysphonia, reported whilst using the pMDI, to pMDI plus Nebuhaler or Tubuhaler was also assessed.

METHODS

Seventy-two patients reporting dysphonia and taking inhaled steroids from a pMDI entered a 12-week, open, parallel group study. Fifty-one completed the study per protocol; 26 in the Nebuhaler group [21 female, mean age 57 years (22-77)] and 25 in the Turbuhaler group [18 female, mean age 58 years (21-81)]. A dysphonia diary card was completed weekly. Voice laboratory assessments and laryngoscopy were performed on entry and at 12 weeks.

RESULTS

There were no differences in voice laboratory data, laryngoscopic evidence of disordered glottic closure and diary data between the two groups at 12 weeks. At study entry laryngoscopic appearances were normal in almost half the patients. Vocal cord bowing was rarely seen. Glottic closure changed in nine patients during the study period, but there was no correlation with voice symptoms. The trend of symptomatic improvement of voice status in the Turbuhaler group did not correlate with voice laboratory assessments and laryngoscopic evidence of disordered glottic closure. After 4 weeks, 40% of patients using Turbuhaler and 8% in the Nebuhaler group scored their voice status as better (P < 0.02) but there was no significant difference between the two groups at 12 weeks (Turbuhaler 52%, Nebuhaler 23%, P=0.08).

CONCLUSION

This study does not support the view that dysphonia in asthmatics inhaling corticosteroids is usually caused by myopathic bowing of the vocal cord muscles.

Innovations in neonatal case management: an integrated, data-driven approach

The intent of this article is to provide one company's perspective on the challenging and complex care management of the high-risk neonate. The strategies presented herein should enable and encourage case managers to implement an integrated management process for the frail neonatal population.

Peak inspiratory flow through Turbuhaler in chronic obstructive airways disease

Many patients with chronic obstructive airways disease (COAD) receive therapy by the inhaled route. This study was performed to assess whether patients with severe COAD could generate sufficient peak inspiratory flow (PIF) through Turbuhaler (Astra, Sodertalje) to operate it effectively. One hundred patients (45 men, 55 women, mean age 69.1 years) with COAD (mean (SD) duration 17.7 (16.3) years) and peak expiratory flow (PEF) < or = 200 l min-1 or forced expiratory volume in 1 sec (FEV1) < or = 1 litre were studied. A series of randomly assigned inspiratory and expiratory lung function tests were contiguously performed, using portable spirometers, within 48 h of a screening visit. An empty Turbuhaler was used in the study. The patients' normal medication was not restricted. Sixty-six patients were previous smokers, eight occasional smokers, 19 habitual smokers and seven had never smoked. Mean (SD) FEV1 was 0.7 (0.2) 1 and mean PEF was 182 (68) l min-1. All patients were able to generate PIF through Turbuhaler (PIF-T) of 28 l min-1 (mean 53; range 28-78 l min-1). Eighty-three patients generated PIF-T of > or = 40 l min-1. PIF-T correlated with PIF without Turbuhaler (r = 0.35), PEF (r = 0.3), FEV1 (r = 0.2) and forced vital capacity (FVC) (r = 0.23) although the relationships were too weak to be used to predict PIF-T. The results suggest that patients with severely limited lung function caused by COAD can operate Turbuhaler effectively.

Intravenous therapy for women in labor: implementation of a practice change

BACKGROUND

Intravenous therapy for women in labor has been routinely administered in many North American hospitals since the 1950s. The purpose of this study was to evaluate a change in intravenous therapy practice.

METHODS

The evaluation study, using a posttest, quasi-experimental design, examined the responses of women in labor and nurses to a questionnaire. Proxy prestudy cohort data were used for comparison of some patient outcomes. The convenience sample comprised 219 women admitted to the labor and delivery unit of a community hospital in Toronto, Ontario, between August and October 1997.

RESULTS

Under the new intravenous therapy protocol, 26 percent of the women in labor did not receive intravenous therapy compared with 100 percent under the old protocol. The primary reasons for therapy were to enable administration of prescribed medication and bolus intravenous administration associated with epidural anesthesia. At the first after-delivery void, 61 percent of study women-65 percent of those who received intravenous therapy and 50 percent of those who received no intravenous therapy-tested negative for ketonuria. All 119 comments from nurses indicated comfort with their judgments related to the initiation of intravenous therapy.

CONCLUSIONS

The change in the intravenous therapy protocol was supported by the study findings. Nurses should increase patient education about drinking and eating adequately throughout labor if appropriate, and resuming adequate fluid and food intake as quickly as possible after childbirth.

Predictably restoring endodontically treated teeth

Endodontically treated teeth can be restored with a wide range of techniques of varying complexity. This paper presents a straightforward technique for the restoration of endodontically treated teeth that meet certain standards. Criteria are provided for the utilization of crowns, composite resins, cast gold post cores, amalgam or composite build-ups, and passive, parallel, small diameter stainless steel posts to restore these teeth. Consideration is given to ferrule design and its importance in achieving success.

An audit of patient acceptance of one-stop diagnosis for symptomatic breast disease

AIMS

The impetus for optimizing outpatient provision of breast-care services has come both from the patient and management in order to reduce anxiety and make full use of scarce resources. The one-stop diagnostic clinic for the investigation of symptomatic breast lesions is a relatively recent concept with well-known service benefits. However, acceptance to the patient has not been previously investigated.

RESULTS

The results of this prospective audit demonstrate a high level of patient satisfaction with the multi-disciplinary, one-stop breast clinic.

Criteria for the predictably restorable endodontically treated tooth

This paper outlines criteria which allow the clinician to identify endodontically treated teeth that can be restored with a high level of predictability. The intent of the article is not to preclude the restoration of teeth that do not meet these criteria; it is to provide a science-based approach for identifying those teeth with a high probability of long-term success upon restoration. For an endodontically treated tooth not requiring a post, the requirements are for biologic width + ferrule length, (i.e. 4.5 mm of supra-bony solid tooth--dentin a minimum of 1 mm thick after preparation). A tooth requiring a post needs, in addition, enough root length to allow a 4 mm apical seal and a post length--apical to the crown margin, equal to the length of the crown. It is essential to assess the functional loads to which the restored tooth would be subjected. Teeth that are endodontically treated, or are likely to be in future, should be avoided as abutments supporting precision attachment RPDs, distal extension RPDs or cantilever FPDs.

Prevalence of sensitization to aeroallergens in California patients with respiratory allergy. Allergy Skin Test Project Team

BACKGROUND

The number of allergy skin tests required to evaluate patients with respiratory allergy has recently been challenged by the managed care community.

OBJECTIVES

The purpose of this study was to determine which aeroallergens are prevalent in patients with respiratory allergy (allergic rhinitis and bronchial asthma) in California.

METHODS

Utilizing aeroallergens thought to be relevant from recent aerobiologic and botanic data, 141 allergic and 17 asymptomatic control subjects were tested for the prevalence of 103 allergens. A standardized prick puncture technique and standardized interpretation of wheal/flare responses were utilized using the same lot of allergen for 13 allergy practices distributed throughout California. Frequency curves based on prevalence were established to determine the number of tests required to give up to 90% of positive responses for tree, weed and grass pollen, mold spores, and miscellaneous allergens which included house dust mite, cat, dog, and cockroach allergens.

RESULTS

Positive responses in allergic subjects for grasses ranged from 46% to 54%, for weeds 19% to 37%, and for trees 10% to 42%. For molds the range was from 11% to 22%. The response rate for Dermatophagoides pteronyssinus was 53%, for Dermatophagoides farinae 42%, for cat pelt 39% and cat hair 37%, for cockroach 23% and dog dander 19%. Asymptomatic control subjects responded to only 4% of all allergens tested. Ninety percent of all positive tests required three miscellaneous allergens (house dust mite, cat, and cockroach), 9 molds, 2 grasses, 16 weeds, and 27 trees for a total of 57 allergens (56% of total tested). There was no clear relationship between locale and specific allergen response, probably related to the limited number of subjects tested and variability within the same geographic region. Several seldom tested tree and weed allergens showed a higher prevalence rate than several commonly tested for allergens.

CONCLUSIONS

This preliminary study suggests that approximately 57 aeroalleroens might be adequate to detect 90% of all positive responses in patients with respiratory allergy in California. This study was limited by subject number and variability between study sites. It is hoped a standardized model can be developed from this pilot study to definitively determine which aeroallergens are relevant in the United States.

Hemorrhagic necrotic schwannoma presenting as purulent meningitis

BACKGROUND

Intracranial schwannoma involving the XIIth cranial nerve is rare. We report an unusual clinical presentation and pathological verification of a schwannoma, which had become haemorrhagic and necrotic, simulating acute purulent meningitis.

METHODS

A literature review of intracranial tumors presenting as acute purulent meningitis, with emphasis on schwannomas, was undertaken.

RESULTS

Few cases of hypoglossal schwannoma have been reported; the association with purulent meningitis has not been previously documented.

CONCLUSION

In patients presenting with sterile purulent meningitis, a necrotic tumor should be considered as a possible etiology.

Effect of the nitric oxide donor, glyceryl trinitrate, on human gall bladder motility

BACKGROUND

Nitric oxide is a major neurotransmitter in non-adrenergic, non-cholinergic (NANC) pathways. NANC inhibitory innervation has been shown in human gall bladder muscle in vitro; the role of nitric oxide in human gall bladder emptying however is undefined.

AIMS

To study the effect of glyceryl trinitrate, a nitric oxide donor, on gall bladder emptying in healthy subjects using a randomised, double blind, cross-over, placebo controlled design.

METHODS

Ultrasonographic gall bladder volume was measured in the fasting state in eight healthy volunteers after randomised administration of either glyceryl trinitrate 1200 micrograms buccal spray or placebo spray. On two further occasions, after randomised administration of either glyceryl trinitrate 1200 micrograms buccal spray or placebo spray, gall bladder volumes were also measured after a liquid test meal.

RESULTS

Glyceryl trinitrate significantly increased fasting gall bladder volume to a mean of 114% (SEM 5%) of pretreatment volume (p = 0.039). Glyceryl trinitrate also significantly impaired gall bladder emptying between five and 40 minutes postprandially. Gall bladder ejection fraction was also reduced after glyceryl trinitrate compared with placebo (43 (6.9)% versus 68.4 (6.5)%, p = 0.016).

CONCLUSIONS

This study shows that glyceryl trinitrate produces gall bladder dilatation in the fasting state and reduces postprandial gall bladder emptying, suggesting that nitric oxide mechanisms may be operative in the human gall bladder in vivo.