Molecular weight dependence of reductions in the glass transition temperature of thin, freely standing polymer films

We have used transmission ellipsometry to perform a comprehensive study of the glass transition temperature T(g) of freely standing polystyrene films. Six molecular weights M(w), ranging from 575 x 10(3) to 9100 x 10(3), were used in the study. For each M(w) value, large reductions in T(g) (as much as 80 degrees C below the bulk value) were observed as the film thickness h was decreased. We have studied in detail the dependence of the T(g) reductions on M(w) in a regime dominated by chain confinement effects. The empirical analysis presented is highly suggestive of the existence of a mechanism of mobility in thin freely standing films that is inhibited in the bulk and distinct from the usual cooperative motion associated with the glass transition.

Comparison of an enhanced versus a written feedback model on the management of Medicare inpatients with venous thrombosis

BACKGROUND

A multistate randomized study conducted under the Health Care Financing Administration's (HCFA's) Health Care Quality Improvement Program (HCQIP) offered the opportunity to compare the effect of a written feedback intervention (WFI) with that of an enhanced feedback intervention (EFI) on improving the anticoagulant management of Medicare beneficiaries who present to the hospital with venous thromboembolic disease.

METHODS

Twenty-nine hospitals in five states were randomly assigned to receive written hospital-specific feedback (WFI) of feedback enhanced by the participation of a trained physician, quality improvement tools, and an Anticoagulant Management of Venous Thrombosis (AMVT) project liaison (EFI). Differences in the performance of five quality indicators between baseline and remeasurement were assessed. Quality managers were interviewed to determine perceptions of project implementation.

RESULTS

No significant differences in the change from baseline to remeasurement were found between the two intervention groups. Significant improvement in one indicator and significant decline in two indicators were found for one or both groups. Yet 59% of all quality managers perceived the AMVT project as being successful to very successful, and more EFI quality managers perceived success than did WFI managers (71% versus 40%). In the majority of EFI hospitals, physician liaisons played an important role in project implementation.

CONCLUSION

Study results indicated that the addition of a physician liaison, quality improvement tools, and a project liaison did not provide incremental value to hospital-specific feedback for improving quality of care. Future studies with larger sample sizes, lengthier follow-up periods, and interventions that include more of the elements shown to affect practice behavior change are needed to identify an optimal feedback model for use by external quality management organizations.

Sacral nerve root stimulation for lower urinary tract dysfunction: overcoming the problem of lead migration

OBJECTIVE

To evaluate lead migration for two different test electrodes and the response to trial stimulation of the S3 nerve root during the selection of patients for a sacral neuromodulation implant to manage lower urinary tract dysfunction.

PATIENTS AND METHODS

Twelve women (mean age 49 years, range 23-79; seven with detrusor instability and five with sensory urgency) undergoing peripheral nerve evaluation for refractory lower urinary tract symptoms were recruited. Urodynamics and a urinary diary were completed before and during test stimulation. Two electrodes (the original 041830-002 and new 3057 models, Medtronics Inc, USA) were inserted under local anaesthesia into the S3 nerve roots bilaterally. The location was determined by the functional response to stimulation. Stimulation was applied for one week using the new lead; a positive response was defined as a subjective improvement (> 50%) in urinary symptoms. Lateral sacral X-rays were taken after placement and before removing the lead. The distance from the lead tip to the ventral aspect of the S3 sacral foramen was measured by two assessors.

RESULTS

Ten of the women had a positive response; the mean (range) migration of the new lead (on X-ray) was 4 (2-11) mm, and of the old lead was 12 (10-45) mm (P = 0.02).

CONCLUSION

The response rate to trial stimulation was greater than in previous studies, possibly reflecting reduced migration of the new lead. The new electrode may reduce the number of test failures caused by lead migration rather than no response.

Laparoscopic Donor Nephrectomy: Impact on an Established Renal Transplant Program

The current disparity of viable organs and patients in need of a transplant has been an impetus for innovative measures. Live donor renal transplantation offers significant advantages compared with cadaveric donor transplantation: increased graft and patient survival, diminution in incidence of delayed graft function, acute tubular necrosis (ATN), and reduction in waiting time. Notwithstanding these gains live donors continue to be underutilized and account for only approximately one quarter of all renal transplants performed in the United States. It has been felt that inherent disincentives to live donation have slowed its growth. These include degree and duration of postoperative pain and convalescence, child care concerns, cosmetic concerns, and time until return to full activities and employment. In an attempt to curtail the disincentives to live donation, laparoscopic live donation (laparoscopic donor nephrectomy; LDN) was developed. The purpose of this study was to compare the results of our first 25 laparoscopic nephrectomies (performed over a 10-month period from September 1998 through July 1999) with the previous 25 standard open donor nephrectomies (ODNs) completed over the past 3 years. We conducted a retrospective review of all donor nephrectomies and recipient pairs performed over the past 3 years. End points included sex, operative time, length of stay, immediate and long-term renal function, and willingness to donate. There were no differences in demographics of the ODN versus the LDN group. The average length of stay was 2.48 ± 0.72 days for the LDN versus 4.08 ± 0.28 days for the ODN. ODN and LDN have comparable short- and long-term function with no delayed graft function and no complications. Growth of living donor transplant has increased from 16 per cent of all kidney transplants performed in 1995 to 23 per cent in 1999. We conclude that LDN is a viable alternative to the standard donor operation. LDN has had a positive impact on the donor pool by minimizing disincentives to live donation. With the initiation of our laparoscopic program the number of LDNs has increased. Presently the live donor pool is the most viable alternative to significantly increase the number of kidneys for transplantation.

Laboratory sleep correlates of nightmare complaint in PTSD inpatients

BACKGROUND

Nightmares are rare in the sleep laboratory, even in patients with posttraumatic stress disorder for whom nightmare complaints are diagnostic. Nevertheless, it is possible that laboratory conditions do not preclude the observation of telltales-nightmare-related modifications of tonic sleep-given sufficiently large samples.

METHODS

Sixty-three unmedicated, nonapneic Vietnam combat veterans undergoing inpatient treatment for posttraumatic stress disorder underwent polysomnographic testing and assessment of nightmare complaint.

RESULTS

Trauma-related nightmare complaint, but not non-trauma-related complaint, was associated with increased wake-after-sleep-onset in the sleep laboratory. No relationships between nightmare complaint and rapid eye movement sleep architecture were observed.

CONCLUSIONS

Increased wake-after-sleep-onset was specifically associated with trauma-related nightmare complaint, confirming data from other quarters suggesting they are both phenomenologically and functionally distinct from normal dreaming.

Laparoscopic donor nephrectomy: impact on an established renal transplant program

The current disparity of viable organs and patients in need of a transplant has been an impetus for innovative measures. Live donor renal transplantation offers significant advantages compared with cadaveric donor transplantation: increased graft and patient survival, diminution in incidence of delayed graft function, acute tubular necrosis (ATN), and reduction in waiting time. Notwithstanding these gains live donors continue to be underutilized and account for only approximately one quarter of all renal transplants performed in the United States. It has been felt that inherent disincentives to live donation have slowed its growth. These include degree and duration of postoperative pain and convalescence, child care concerns, cosmetic concerns, and time until return to full activities and employment. In an attempt to curtail the disincentives to live donation, laparoscopic live donation (laparoscopic donor nephrectomy; LDN) was developed. The purpose of this study was to compare the results of our first 25 laparoscopic nephrectomies (performed over a 10-month period from September 1998 through July 1999) with the previous 25 standard open donor nephrectomies (ODNs) completed over the past 3 years. We conducted a retrospective review of all donor nephrectomies and recipient pairs performed over the past 3 years. End points included sex, operative time, length of stay, immediate and long-term renal function, and willingness to donate. There were no differences in demographics of the ODN versus the LDN group. The average length of stay was 2.48+/-0.72 days for the LDN versus 4.08+/-0.28 days for the ODN. ODN and LDN have comparable short- and long-term function with no delayed graft function and no complications. Growth of living donor transplant has increased from 16 per cent of all kidney transplants performed in 1995 to 23 per cent in 1999. We conclude that LDN is a viable alternative to the standard donor operation. LDN has had a positive impact on the donor pool by minimizing disincentives to live donation. With the initiation of our laparoscopic program the number of LDNs has increased. Presently the live donor pool is the most viable alternative to significantly increase the number of kidneys for transplantation.

Effect of delayed placement on the incidence of Campylobacter jejuni in broiler chickens

An experiment was conducted with broiler chickens to evaluate the effect of delayed placement on reused litter and the isolation of Campylobacter jejuni. The experiment also assessed the presence of C. jejuni in the crop following feed withdrawal periods in cages vs floor environments. Trial 1 utilized 320 female broiler chicks obtained from a commercial hatchery. The chicks were randomly placed into the following experimental groups that were replicated four times with 20 chicks per pen: 1) 0-h, 2) 24-h, 3) 48-h, and 4) 72-h delayed placement. Fecal samples were collected via the cloaca at 7, 14, 21, and 28 d of age; enriched in Bolton broth; and plated onto BBL agar. Campylobacter jejuni was isolated at 1 wk of age in the 48- and 72-h experimental groups but did not differ significantly from the others. Sampling results at 14 d of age showed that 63, 68, 73, and 80% of chicks were positive for the 0-, 24-, 48-, and 72-h treatments, respectively. At 28 d of age, 100% of all chicks sampled tested positive. In Trial 2, 60 market age broilers were evaluated for the presence of C. jejuni in the crop by subjecting them to 0-, 4-, 8-, 12-, and 16-h feed withdrawal times on litter or in wire cages. Crops were collected aseptically from the broilers, stomached, enriched in Bolton broth, and then plated on BBL agar. There were no significant (P < 0.05) differences between cage and floor withdrawal times for the presence of C. jejuni in the crop samples of broilers; however, there were significant differences in the length of withdrawal on the presence of C. jejuni. Collectively, these results suggested that the isolation of C. jejuni occurred earlier in broilers that were subjected to delayed placement on reused litter and that extended feed withdrawal times in cages or on litter may increase the possibility that the crop of broilers may contain a higher isolation rate of C. jejuni.

How much interest is the Internet to patients?

OBJECTIVES

To assess the accessibility of the internet, the level of interest from patients attending genitourinary (GU) medicine clinics, and explore potential concerns about confidentiality.

METHODS

Questionnaire based survey of patients attending five GU medicine clinics in England.

RESULTS

41% of GU medicine clinic patients in 1999 had access to the internet (range 31%-52%) with access more common in younger age groups, and less common in women and black Caribbean patients. One in 10 patients (with internet access) had used the internet to find out more about the problem with which they had come to the clinic. 60% of patients replied that information on sexual health on the internet was of interest to them and a high proportion of patients said they would use the internet to access information about GU clinics (64%), book an appointment (64%) or get test results (63%). Almost a quarter of patients who made additional suggestions wanted an interactive website.

CONCLUSIONS

A high proportion of patients attending GU clinics have access to the internet with potential uses for health education and service delivery.

Oocyte and semen donation: a survey of UK licensed centres

In view of the difficulties encountered by licensed clinics in the recruitment of oocyte and semen donors, the present survey was commissioned by the National Gamete Donation Trust (NGDT) to provide systematic information on current practice as a basis for planning future recruitment strategies. Sixty-four clinics agreed to participate in the survey, of which 55 recruited oocyte donors, 30 recruited semen donors, and 24 recruited both oocyte and semen donors. Almost all of the clinics had experienced difficulty in obtaining a sufficient supply of donated oocytes, and many patients requiring treatment with donated oocytes were placed on a waiting list for more than one year. Three-quarters of potential donors changed their mind about donating after receiving information on the procedures involved. The difficulties in recruiting semen donors were generally less acute. In this case, the greatest problem was the high proportion of potential semen donors who were deemed unsuitable after completing the screening process. Clinics also reported a shortage of both oocyte and semen donors from specific ethnic groups.

The transcription factor E2F1 modulates apoptosis of neurons

The transcription factor E2F1 is known to mediate apoptosis in isolated quiescent and postmitotic cardiac myocytes, and its absence decreases the size of brain infarction following cerebral ischemia. To demonstrate directly that E2F1 modulates neuronal apoptosis, we used cultured cortical neurons to show a temporal association of the transcription and expression of E2F1 in neurons with increased neuronal apoptosis. Cortical neurons lacking E2F1 expression (derived from E2F1 -/- mice) were resistant to staurosporine-induced apoptosis as evidenced by the significantly lower caspase 3-like activity and a lesser number of cells with apoptotic morphology in comparison with cortical cultures derived from wild-type mice. Furthermore, overexpressing E2F1 alone using replication-deficient recombinant adenovirus was sufficient to cause neuronal cell death by apoptosis, as evidenced by the appearance of hallmarks of apoptosis, such as the threefold increase in caspase 3-like activity and increased laddered DNA fragmentation, in situ endlabeled DNA fragmentation, and numbers of neuronal cells with punctate nuclei. Taken together, we conclude that E2F1 plays a key role in modulating neuronal apoptosis.

Family dysfunction and bulimic psychopathology: the mediating role of shame

OBJECTIVE

Although disturbed family function has some association with bulimic psychopathology, the psychological mechanisms that account for that link are not clear. This study explores the hypothesis that shame acts as a mediator in that relationship, whereas shame-proneness is a moderator variable.

METHOD

The participants were 139 nonclinical women. Each completed measures of perceived family function, shame-proneness, internalized shame, and bulimic psychopathology. Regression analyses were used to test for the mediating and moderating effects of shame.

RESULTS

The findings were compatible with a model where shame-proneness acts as a moderator and internalized shame is a perfect mediator in the link between paternal overprotection and bulimic attitudes.

CONCLUSIONS

The experience of shame appears to be a critical element in understanding the relationship between perceived family dysfunction and bulimic psychopathology. Where individuals perceive their families as problematic, it may be clinically valuable to focus on shame as a psychological consequence of that experience.

The power of place: space and time in women's and community health centres in South Australia

This paper focuses on the importance of time and space in an Australian medical setting. It draws on research findings from a one year project that aimed to explore community perspectives of, and experiences of medical services in three South Australian women's and community health centres. Both qualitative and quantitative methods of data collection and analysis were used in order to address these objectives. A significant finding was the way in which participants described the organisation and experience of time and space in these centres and how this impacted on their health and well being and that of the community. In analysing these spatio-temporal dimensions and the underlying philosophical structures of women's and community health centres, this paper argues that experiences associated with space and time have a positive effect on health status by: diminishing barriers to health services, improving quality of care, increasing community participation, providing safe places for social interaction and strengthening people's sense of belonging or attachment to a particular community and place. Based on these findings, the authors conclude that the spatio-temporal dimensions of health care provision have empowering and positive impacts on a community's health, a significant finding that has implications for the maintenance and future funding of this style of health service.

Social constructions of breast cancer

In contrast to other life-threatening diseases, in which mortality is understood as the fundamental threat, much popular and professional discourse about breast cancer focuses on such issues as the identity, body image, and self-worth of the afflicted woman. Within the Western biomedical tradition, the meaning ascribed to breast cancer has been strongly influenced by competing social interpretations. In this paper, we contend that such social constructions shape the manner in which women experience breast cancer, including their decision making in response to treatment options as well as their strategies for coping with and making sense of breast cancer illness. We argue that an appreciation of the historical and cultural contexts in which breast cancer imagery has been constructed helps to explain the confusing array of ideologies that confront contemporary women diagnosed with breast cancer.

Despite the internucleosomal cleavage of DNA, reactive oxygen species do not produce other markers of apoptosis in cultured neurons

The cell death induced by hydroxyl radicals generated by Cu-phenanthroline and peroxynitrite generated by 3-morpholinosydnonimine hydrochloride (SIN-1) in rat primary cortical neuronal cultures was compared with the apoptotic death induced by staurosporine and the necrotic death induced by glutamate. Both SIN-1 and Cu-phenanthroline were capable of generating internucleosomal cleavage of DNA-a hallmark of apoptosis. Other characteristics of this cell death, such as nuclear morphology by light microscopy; DNA breaks by single-cell gel electrophoresis; the effects of the apoptotic inhibitors cycloheximide, aurintricarboxylic acid, and tosyl-l-lysine chloromethyl ketone; the measurement of caspase activity; and the effects of antioxidants, were then analyzed. The conclusion from these hallmarks of apoptosis is that the cell death induced by these reactive oxygen species is not apoptosis.

Initiatives in primary health care: evaluation of a South Australian program

In 1994 the Primary Health Care Initiatives Program was established as part of the South Australian government's hospital service improvement strategy. In its first year, the program funded 34 demonstration projects, of which half were concerned with improving continuity of care and discharge planning, and half with health promotion or illness prevention. Evaluation of the program has shown that it achieved significant improvements in links and communication between the services involved, in the development of systems and procedures for facilitating discharge-planning and continuity of care, and in enhancing the capacity of organizations to undertake health promotion and illness prevention. Overall, it was not possible to determine whether the program had shortened or avoided hospital stays due to a range of factors, including the many changes occurring in the health system at the time. The program's strong emphasis on evaluation has produced a rich source of information and helped to develop the evaluation skills of project staff.

Evaluation of standard haemodynamic tests of autonomic function and HbA1c as predictors of delayed gastric emptying in patients with type 1 diabetes mellitus

We examined the relation between chronic glycaemic control (using glycosylated haemoglobin), haemodynamic autonomic function and rate of gastric emptying in 16 patients with type 1 diabetes mellitus. Gastric emptying was measured using a paracetamol absorption technique. Parameters of gastric emptying include area under the plasma paracetamol concentration time curve. Patients were classified as diabetic autonomic neuropathy positive or negative using five standardized haemodynamic reflex tests. Area under the plasma paracetamol concentration time curve in the neuropathy positive (10.36 (4.5) mmol.-1. min) and negative (9.84 (3.0) mmol.-1. min) groups were similar (.P.=0.42) using unpaired Student's.t. -tests. Glycosylated haemoglobin concentration and area under the plasma paracetamol concentration time curve (.n.=16) demonstrated a Pearson's correlation co-efficient of 0.24. Neither tests of haemodynamic autonomic function, nor concentration of glycosylated haemoglobin, are predictive of diabetic gastroparesis.

Persistent acquired lobar overinflation complicating bronchopulmonary dysplasia

Persistent acquired lobar overinflation (PALO) may complicate bronchopulmonary dysplasia (BPD). From infants admitted to the regional neonatal intensive care unit or who had been followed up at the chronic lung disease clinic in Liverpool over a 6.5-year period, 11 children with BPD and PALO were identified and details of their neonatal and subsequent outcome obtained. Their median gestational age was 29 weeks (range 24-33) and median birth weight was 1317 g (range 676-1968 g). All had received ventilatory support for severe neonatal respiratory distress syndrome for a median of 26 days (range 5-86). The median age the acquired lobar overinflation was detected was 82 days (range 45424 days). Nine patients required continued neonatal or paediatric intensive care re-admission for deteriorating respiratory function. Six children have subsequently died at a median age of 9.5 months (range 6.5-20). Five patients underwent bronchoscopy, four suggesting the presence of bronchomalacia. Three patients had ventilation-perfusion scans all showing that the overinflated lobe had no mismatch defect unlike other areas of the lung.

CONCLUSION

The place of specific therapies for persistent acquired lobar overinflation is unclear. Surgery to remove the overinflated lobe in such cases may be inappropriate and the outcome of this complication of bronchopulmonary dysplasia appears to be poor.

Cisapride does not alter gastric volume or pH in patients undergoing ambulatory surgery

PURPOSE

To evaluate the efficacy of 20 mg cisapride p.o. in reducing residual gastric volume and pH in adult ambulatory surgical patients.

METHODS

Using a prospective randomised double-blind controlled design, we administered either 20 mg cisapride p.o. or placebo preoperatively to 64 ASA 1-2 ambulatory surgical patients. Following induction of anesthesia we measured volume and pH of residual gastric contents, using blind aspiration through an orogastric tube. Parametric data were analysed using unpaired, one tail Students' t test. Non-parametric data were analysed using Fishers Exact test and Chi square analysis. Statistical significance was accepted at the probability level of < 0.05.

RESULTS

Residual gastric volumes were similar in the two groups (19.5 +/- 23.8, 23.9 +/- 24.4 ml), in the cisapride and placebo groups respectively, P=0.24). Data shown are mean (+/- SD). The proportions of patients with a residual gastric volume exceeding 0.4 ml x kg(-1) were similar in the two groups (4 of 28, and 8 of 23 patients in the cisapride and placebo groups respectively, P=0.09). The pH of the residual gastric contents were similar in the cisapride and placebo groups (1.6 +/- 0.5, 1.4 +/- 0.5, respectively, P=0.26). The proportions of patients with pH < 2.5 was also similar in the cisapride and placebo groups (21 of 25, and 20 of 21 patients respectively, P=0.2).

CONCLUSIONS

Preoperative administration of 20 mg cisapride p.o. to patients scheduled for outpatient surgery does not alter either the volume or the pH of gastric contents. Its use in this setting is of no apparent clinical benefit.

Intensification of the stem cell transplant induction regimen results in increased treatment-related mortality without improved outcome in multiple myeloma

Randomized trials conducted by the Intergroupe Française du Myelome (IFM) demonstrate that the use of high-dose chemotherapy (HDCT) and stem cell transplantation (SCT) improves event-free (EFS) and overall survival (OS) in younger patients with multiple myeloma (MM). Nevertheless, current HDCT regimens remain inadequate as all patients ultimately relapse following SCT. In an attempt to improve the OS of MM patients post-SCT we used an escalated HDCT regimen incorporating both intensified melphalan (160 mg/m2) and fractionated total body irradiation (12 Gy) to maximize the dose response of myeloma cells to these agents and included infusional etoposide 60 mg/kg in an attempt to eradicate clonal B cells potentially contributing to the myeloma clone. One hundred patients with MM received this intensified SCT regimen. The 100-day treatment-related mortality was 12% predominantly reflecting the development of interstitial pneumonitis (IP) in 28% of patients of whom 7/28 (25%) died. The predicted 5-year OS and EFS following the diagnosis of MM were 60% and 35%, respectively. The median OS from the time of transplant is 41 months and the median EFS is 28 months. More than two prior chemotherapy regimens, previous radiation therapy (RT) and the presence of an abnormal karyotype involving chromosomes 11 or 13 were significantly predictive of poor outcome. Interferon maintenance was not associated with improved outcome. Intensification of the HDCT regimen utilizing etoposide together with escalated melphalan and TBI increases morbidity and mortality without increasing OS beyond that reported with less toxic regimens.

Local anesthesia and malignant hyperthermia: review of the literature and recommendations for the dermatologic surgeon

BACKGROUND

Malignant hyperthermia (MH) is a rare syndrome that is a major cause of anesthetic-related morbidity and mortality in otherwise well patients. The role of local anesthetics, stress, and epinephrine in inducing this syndrome has been subjected to controversy.

OBJECTIVE

To examine the role of local anesthetics, stress, and epinephrine in producing clinically relevant adverse effects in patients with MH.

METHODS

A critical review of the literature.

RESULTS

Local anesthesia is safe for use in usual doses in MH-susceptible patients. The role of stress and epinephrine in precipitating episodes of MH is likely minimal, but controversy remains in the anesthesia and dental literature.

CONCLUSION

Recommendations for diagnosis, treatment, and safety precautions to be taken by dermatologic surgeons when treating MH patients are made.

Consumers not confident about self-regulation

As the new Health Bill reaches its final stages in parliament the release of the National Consumer Council's (NCC's) report Self-regulation of Professionals in Health Care is timely as it sharpens the focus on public safety (NCC, 1999). It reveals a confused patchwork of self-regulatory systems which contain loopholes that can be exploited by quacks and incompetent practitioners. While making fascinating reading the implications are frightening for healthcare providers and the public.

The influence of nutritional and metabolic status on progression from asymptomatic HIV infection to AIDS-defining diagnosis

BACKGROUND

Changes in body weight and lean tissue increase morbidity and mortality during AIDS; however there are few data on the effect of alterations in nutrition and metabolism on disease progression at earlier stages of HIV infection.

OBJECTIVES

To assess whether change in weight, lean tissue or skeletal muscle affects progression to AIDS; to assess prospectively the effects of recognized alterations in nutrition and metabolism in asymptomatic HIV-seropositive men on disease progression; and to examine prospectively changes in nutrition and metabolism at AIDS-defining diagnosis.

METHODS

A group of 104 asymptomatic HIV-seropositive men were recruited and prospectively examined at 3-monthly intervals between April 1993 and September 1995. Nutritional status and metabolism were examined using indirect calorimetry, dual energy X-ray absorptiometry and urine excretion of simple sugars. Time-fixed and time-dependent Cox's proportional hazard models were fitted to calculate risks of developing a first AIDS diagnosis, weight loss or death.

RESULTS

During the study period, 31 subjects had a first AIDS diagnosis of whom 26 were fully assessed. Changes in nutrition and metabolism do not affect disease progression in asymptomatic HIV infection. However, subjects with a reduction in body weight and basal metabolic index tend to have a higher risk of progression to AIDS-defining diagnosis, independent of CD4 count. There is a significant decrease in all body tissue compartments, a decrease in excretion of urinary sugars and significant increase in resting energy expenditure and fat oxidation associated with a first AIDS diagnosis.

CONCLUSION

Change in metabolic and nutritional status at the asymptomatic stage of HIV infection does not influence disease progression significantly, although there is a trend suggesting weight loss has an independent effect on outcome. There is a cachectic response to AIDS-defining opportunistic infection or tumour.

Social versus biological parenting: family functioning and the socioemotional development of children conceived by egg or sperm donation

By investigating egg donation families, donor insemination families, adoptive families, and families created by in vitro fertilization, the aim of the present study was to examine parents' emotional well-being, the quality of parenting, and childrens' socioemotional development in families with a child who is genetically unrelated to the mother or the father. The differences that were found to exist between families according to the presence or absence of genetic ties between parents and their children reflected greater psychological well-being among mothers and fathers in families where there was no genetic link between the mother and the child. The families did not differ with respect to the quality of parenting or the psychological adjustment of the child.

Timeliness of Salmonella notifications in South Australia

OBJECTIVE

To evaluate the timeliness of Salmonella serotype and phage type notifications in South Australia.

METHOD

We surveyed all notifications of Salmonella to the South Australian Department of Human Services between July 1995 and June 1996. We entered data onto an Epi Info 6.02 database and calculated the time interval between various stages of typing notification.

RESULTS

The median time taken between collection of a faecal specimen and receipt of serotype notification was 10 days (range, 5-38), while phage type notification took a further seven days (range 0-40). The time interval between collection of a specimen and notification of a Salmonella final identity was 14 days (range 6-49). The internal mail system of the Department of Human Services delayed notification a median of two days. Environmental Health Officers supplied reports for 224 (58%) of 384 cases, 71% of which occurred before the final Salmonella isolate was known.

CONCLUSIONS

We found that the internal departmental mail system delayed the notification of Salmonella. In South Australia, investigations should focus on clusters of cases of known Salmonella identity, rather than all notified cases.

IMPLICATIONS

To improve communicable disease investigations, health agencies should evaluate the timeliness of surveillance systems and examine the feasibility of transferring laboratory data electronically.

Melanosis in association with metastatic malignant melanoma: report of a case and a unifying concept of pathogenesis

An unusual case of melanosis associated with metastatic malignant melanoma is reported. This was characterized by progressive blue/gray discoloration of the skin of the chest and abdomen in an elderly patient, 1 year after removal of a polypoid malignant melanoma from the right arm. A biopsy of involved skin revealed perivascular aggregates of melanin-laden histiocytes throughout the dermis, the histopathologic hallmark of melanosis. An unusual aspect of the case was the coincidental finding of a tumor embolus within a small dermal vessel, probably a lymphatic. To date, neoplastic melanocytes have been detected in only a small minority of skin biopsies with features of melanosis. This case and a distillation of related information in the literature lead to the conclusion that the essence of melanosis, and the feature that distinguishes this from conventional metastatic melanoma, is the persistent and cumulative dissemination of melanin, via the bloodstream, throughout the body. This in turn leads to progressive pigmentation of all internal organs and the skin. Only continuous access to the circulation by neoplastic melanocytes could explain such a phenomenon. Potential mechanisms by which this could arise are discussed in the context of existing knowledge.

Respiratory symptoms and lung function in aborigines from tropical Western Australia

To estimate the prevalence of respiratory symptoms, bronchial hyperresponsiveness, smoking, and atopy in a population of Australians of Aboriginal descent (AAD), to determine the association of these and other factors with lung function, and to compare levels of lung function of AAD with Australians of European descent (AED) according to age and height, and to explore reasons for their differences, we conducted a study of 96 male (41 of whom were under 18 yr of age) and 111 female (48 of whom were under 18 yr of age) AAD living in a single remote tropical community in 1993. This population provided data on age, height, and lung function. A modified British Medical Research Council (MRC) questionnaire on respiratory symptoms and smoking was administered. FEV1, FVC, height, age, and bronchial responsiveness to inhaled methacholine were measured. Atopic status was assessed by skin prick tests for eight common allergens. Age- and sex-adjusted lung function was similar to that of other AAD groups and lower than in AED. For children, lung function increased less with increasing height in AAD than in AED. Lung function was reduced in adult AAD as compared with adult AED, although it was not possible to determine statistically whether lung function started to decline at an earlier age or declined faster with increasing age in AAD. A history of asthma, smoking, dyspnea, cough, or sputum production; atopic status; and increased bronchial responsiveness were all associated with lower levels of lung function. Differences in lung function between AAD and AED appear to be determined by characteristics that may be inherited, as well as by adverse external influences.

How can the clinical credibility of nurse lecturers be improved?: 2

The movement of nurse education into the university sector has put further tension on the theory-practice gap and the clinical credibility of nursing lecturers. If the ideal is for the lecturer to guide the learner in applying theory to practice and vice versa (Jarvis and Gibson, 1985), this can only realistically be achieved if lecturers of nursing have experience as practitioners within the field(s) they teach and are viewed as being clinically credible (ENB, 1996). In the first article (Vol 7(8): 490-2) an innovative way of enabling lecturers of nursing to engage in practice was presented. In this second article a variety of other approaches which enable lecturers to engage in clinical practice will be explored.

Will higher level practice help the profession?

The UKCC has recently released its consultation document on a higher level of practice (UKCC, 1998). The proposals include setting a UK-wide generic standard for a higher level of practice, a mechanism of marking practitioners who reach this level with a prefix letter after their initial registration, introducing a system of assessment based on current competence and future development plans and the initiation of a charge for the whole process.

The psychosocial impact of bone marrow transplantation: a review of the literature

Bone marrow transplant (BMT) is a procedure used for the treatment of a variety of cancers and malignant diseases. Recovery from this intensive process requires a long-term course, often accompanied by acute morbidity which includes various distressing physical symptoms. Recent literature has begun to explore the impact of this procedure on quality of life and psychosocial issues. While survivorship is often associated with a highly rated global quality of life, recovery from BMT is accompanied by several psychosocial difficulties which negatively impact patients. Fatigue is a common complaint, often hindering recipients for several years following their transplant. As well, reports of psychological distress, psychiatric symptoms, and/or mood disturbances such as anxiety or depression are not uncommon. Many patients also indicate interruption of sexual activity and increased sexual difficulty for several months following BMT. While some investigators have begun to examine hormone replacement therapy (HRT) as a treatment option for reducing sexual dysfunction, there is a general paucity of literature evaluating interventions for BMT survivors. This article reviews the literature examining various quality of life aspects including fatigue, psychosocial difficulties, and sexual functioning of patients during recovery from BMT. Limitations of past research are discussed and directions for future research suggested.

A South Australian Salmonella Mbandaka outbreak investigation using a database to select controls

Between April and June 1996, 15 persons with Salmonella enterica serovar Mbandaka infection were reported in South Australia (population 1.6 million) compared with 12 over the previous five years. To identify a possible source for the infections a case control study was conducted.

METHODS

Trained interviewers asked 15 cases and 45 controls about their consumption of 105 foods. Controls were matched to case residential location and age. They were selected from a previously constructed database of 3,014 randomly selected South Australian households.

RESULTS

Thirteen of the 15 cases ate 'generic' or 'retail store' brands of peanut butter produced by the same factory in another state, compared with five of the 45 controls (p < 0.01). Salmonella Mbandaka was isolated from three opened jars of peanut butter from case households, and from three unopened jars from retail outlets. Further investigation implicated roasted peanuts from a third Australian state as the source of the Salmonella contamination.

DISCUSSION

This is the first recorded outbreak of salmonellosis resulting from the consumption of peanut butter. The SA outbreak investigation comprised a matched case control study to identify possible common food sources. Such investigations need be conducted rapidly to maximise public health benefits, and the utility of selecting controls from a population based database can improve timeliness.

Memory for faces and objects by deaf and hearing signers and hearing nonsigners

The memory of 11 deaf and 11 hearing British Sign Language users and 11 hearing nonsigners for pictures of faces of and verbalizable objects was measured using the game Concentration. The three groups performed at the same level for the objects. In contrast the deaf signers were better for faces than the hearing signers, who in turn were superior to the hearing nonsigners, who were the worst. Three hypotheses were made: That there would be no significant difference in terms of the number of attempts between the three groups on the verbalizable object task, that the hearing and deaf signers would demonstrate superior performance to that of the hearing nonsigners on the matching faces task, and that the hearing and deaf signers would exhibit similar performance levels on the matching faces task. The first two hypotheses were supported, but the third was not. Deaf signers were found to be superior for memory for faces to hearing signers and hearing nonsigners. Possible explanations for the findings are discussed, including the possibility that deafness and the long use of sign language have additive effects.

The need to clarify levels of specialist practice

The UKCC has released its latest document on standards for specialist practice (UKCC, 1998a), the purpose of which, and the accompanying Registrar's Letter (UKCC, 1998b), is to draw together all previous correspondence on specialist practice.

CD6+ T cell-depleted allogeneic bone marrow transplantation for non-Hodgkin's lymphoma

For patients with non-Hodgkin's lymphoma (NHL) undergoing blood or bone marrow transplantation (BMT), the use of autologous grafts has often been preferred to that of allogeneic stem cells because of a significantly lower incidence of non-relapse mortality. If complications associated with allo-BMT could be minimized without compromising efficacy, then it might become a preferred strategy for certain subsets of patients. In this report, we describe the toxicity and long-term efficacy of T cell-depleted allogeneic BMT using anti-CD6 monoclonal antibody and complement alone to reduce the risk of GVHD and its sequelae. Twenty-two patients, aged 18-60 years, with high (n = 10), intermediate (n = 9), or low (n = 3) grade NHL underwent HLA-identical allogeneic BMT from siblings. Patients had either relapsed after at least one remission or never achieved a full remission with chemotherapy. Twenty patients had a history of marrow involvement. Bone marrow was depleted of CD6+ T cells with T12 monoclonal antibody and complement as the sole form of GVHD prophylaxis. Stable hematopoietic engraftment occurred in all 22 patients. Four patients developed grade 2 and 1 patient grade 3 GVHD (23% grades 2-4 GVHD). Chronic GVHD has occurred in three patients. Treatment-related mortality was very low. Only one patient died while in remission. Thirteen patients are alive and free of disease with a median follow-up of 30 months. Estimated event-free and overall survivals are 54 and 59%, respectively. CD6 allogeneic marrow transplantation is associated with a low risk of transplant-related complications and may offer advantages for certain patients with recurrent NHL felt to be at high risk for relapse after autologous transplantation.

Teaching the clinical interpretation of peripheral blood smears to a second-year medical school class using the PeripheralBlood-Tutor computer program

The interpretation of peripheral blood smears has an important role in the diagnosis of hematologic diseases and is, therefore, part of the education of physicians and technologists. We describe a computer program, PeripheralBlood-Tutor (Lippincott-Raven, Philadelphia, Pa), that teaches the morphologic features of normal and abnormal peripheral blood smears; we also describe the evaluation of the effectiveness of the program in 133 second-year medical students who were required to use the program in their hematology course. The version of the PeripheralBlood-Tutor used in the study had 2 distinct but equivalent 20-question examinations; one examination, the pretest, was taken before the students viewed the contents of the program, and the other examination, the posttest, was taken after completing the program. The mean score on the pretest was 61% (SD, 14%), the mean on the posttest was 91% (SD, 10%), and the improvement was significant. In addition, 4 questions about peripheral blood smears, which were based on printed images, were administered at the end of the hematology course. The students scored an average of 2.75 (SD, 0.86), and a positive correlation was found between these scores and the scores on the Tutor posttest. The results of the study suggest that PeripheralBlood-Tutor is feasible to implement, and it helps students learn to interpret peripheral blood smears. The use of PeripheralBlood-Tutor is now a requirement in the medical school curriculum, the medical technology program, and the pathology residency at the University of Washington, Seattle.

Effective caregiving approaches for patients with Alzheimer's disease

To address the need for nonpharmacologic approaches to managing difficult behaviors in patients with dementia, a repeated measures design was used to test the effectiveness of educational and behavioral intervention on behavioral and functional outcomes in home-dwelling patients with dementia and their caregivers' knowledge of dementia. Baseline and 6-month postintervention data were collected for 108 subjects (54 caregiver/patient pairs) following random assignment to an intervention or comparison group. Findings included increases in caregiver knowledge in two treatment groups and patient self-care ability in one treatment group and ratings of the most effective behavioral interventions by caregivers.

How can the clinical credibility of nurse lecturers be improved?

The last 10 years has seen a surge in the development of academic pre- and postregistration courses. With the movement of colleges of nursing and midwifery into higher education it has become difficult for lecturers of nursing to remain engaged in clinical practice. However, the professional bodies, the students themselves and their employers expect lecturers of nursing to be clinically able, clinically credible and knowledgeable about contemporary practice in order to produce practitioners who are 'fit for purpose'. This article outlines one innovative approach employed by an educational organization to enable lecturers of postregistration specialist nursing programmes to achieve clinical credibility by undertaking a minimum of 300 contracted hours of clinical experience. This approach was found to be beneficial to the lecturers, the students and the ongoing relationships between the trusts and the department of nursing.

Effects of pirfenidone and dermoid cyst fluid on adhesion formation

OBJECTIVE

To evaluate the effects of pirfenidone and human dermoid cyst fluid on adhesion formation in a rat model.

DESIGN

A prospective, blinded, controlled study.

SETTING

Sprague-Dawley white rats in a conventional laboratory setting.

INTERVENTION(S)

Rats were divided into four groups according to the type of solution tested (dermoid fluid, 0.05 mg of pirfenidone, normal saline, and a combination of dermoid fluid and pirfenidone). In the first experiment, the solution (0.5 mL) was injected intraperitoneally. In the second experiment, the solution was instilled intraperitoneally after a standardized injury to the right uterine horn. The degree of adhesion formation was evaluated 2 weeks after the initial surgery.

RESULT(S)

Human dermoid cyst fluid caused adhesion in 4 of 10 intact rats and in 9 of 10 standardized injured rats. Pirfenidone did not decrease adhesion formation. No adhesion was found after injection of saline or pirfenidone in intact rats. The mean +/- SEM adhesion score in standardized injured rats was higher in the dermoid group (4.6 +/- 0.6) than in the pirfenidone group (2.8 +/- 0.7) or the saline group (3.8 +/- 0.5). The mean +/- SEM adhesion score in intact rats was 0.6 +/- 0.3 after dermoid fluid injection and after dermoid instillation in standardized injured rats was 4.6 +/- 0.6.

CONCLUSION(S)

Human dermoid fluid causes adhesion formation even in intact rats, and the adhesion is worse in the presence of serosal injury. Intraperitoneal pirfenidone does not decrease adhesion formation.

A study of enhanced management in patients with treatment-resistant schizophrenia

The clinical efficacy of two intensive treatment packages (one including the new antipsychotic risperidone and the other not doing so) was compared with that of standard management in 43 patients with long-standing treatment-resistant schizophrenia. Significant differences between the groups in terms of total positive or total negative symptoms were not demonstrated, but the pattern of change between the treatment groups differed, so that benefit in positive symptomatology was seen in both intensive treatment groups and in negative symptomatology in the intensive treatment/risperidone group and the standard group. Changes in general psychopathology were most marked in the risperidone group and were compatible with a relatively non-sedative profile. Using the Disability Assessment Schedule, substantial significant advantages for the intensive treatment groups were found.

Nurses may end up being jacks of all trades

There is increasing pressure to create new clinical roles within the health service in response to ongoing organizational changes and greater consumer expectation. The publication of the research report (NHSP, 1997) Innovative Job Design for Clinical Roles in the NHS is therefore both welcome and timely. Ten roles are presented covering a variety of specialties, e.g. emergency nurse practitioner in A&E, laparoscopic nurse practitioner in surgery, and medical support nurse in acute and mental health.

Reading and metaphonological outcomes in late talkers

Children with a history of slow expressive language development (SELD) were followed to second grade, at which point outcomes in terms of speech, language, cognitive skills, reading achievement, and metaphonological performance were evaluated. Although there were some statistically significant differences between groups, children with a history of SELD generally performed within the normal range on the measures collected. Relations among speech, reading, and metaphonology in the SELD cohort appeared to operate in a manner similar to that seen in groups with typical language development. The implications of these findings for understanding the nature of specific language impairments and for treating early circumscribed language delays are discussed.

Children raised in fatherless families from infancy: family relationships and the socioemotional development of children of lesbian and single heterosexual mothers

The aim of the study was to investigate family functioning and the psychological development of children raised in fatherless families from their first year of life. Thirty lesbian mother families and 42 families headed by a single heterosexual mother were compared with 41 two-parent heterosexual families using standardised interview and questionnaire measures of the quality of parenting and the socioemotional development of the child. The results show that children raised in fatherless families from infancy experienced greater warmth and interaction with their mother, and were more securely attached to her, although they perceived themselves to be less cognitively and physically competent than their peers from father-present families. No differences were identified between families headed by lesbian and single heterosexual mothers, except for greater mother-child interaction in lesbian mother families.

Should we reshape nurse education yet again?

The RCN Education and Training Policy Committee has circulated a leaflet Shaping the Future of Nursing Education (RCN, 1997) which proposes a new structure to the ways in which nurses become qualified, The Committee is boldly opening up the debate at a time when some individuals in the profession are questioning whether the current system of preparing nurses is meeting the future health care needs of the country.

Evaluation of leaves as a litter material

The suitability of leaves for use as broiler litter was evaluated in four 49-d floor pen trials of 150 Avian x Avian female chickens each. In each trial, 25 broiler chicks were weighed and randomly assigned to one of six pens at a density of 1.2 m2 per bird. There were two replicates of each of the following three treatments: 1) pine wood shaving (control), 2) a mix of 50% pine wood shaving and 50% leaves, and 3) leaves. Litter materials had no significant (P > or = 0.05) influence on live weight, feed conversion, breast blisters, dressed carcass weight, carcass yield percentage, or mortality. Mortality of birds reared on leaves tended to be higher than the other treatments, but it was found to be nonsignificant at the P < 0.05 level. No significant differences were observed for percentage litter moisture among treatments. Body weight gain was significantly (P < or = 0.05) higher for the broilers reared on the leaf litter. Leaves alone or mixed with wood shavings have potential as an alternate litter material without compromising production or processing parameters at a low placement density.

Intense muscle uptake of Tc-99m MDP and Ga-67 citrate in massive rhabdomyolysis

A 6-year-old boy had an Addisonian crisis with hyponatremic shock and required resuscitation after cardiac arrest. Severe renal failure necessitated continuous dialysis. Rhabdomyolysis was identified because of myoglobinuria and gross elevation of creatinine kinase. In the course of his treatment, bone infection was suspected. A bone scan with Tc-99m MDP showed intense uptake in numerous major muscle groups throughout the body in keeping with massive rhabdomyolysis. Similar gross muscle uptake of Ga-67 citrate was less expected. In an additional bone scan obtained 15 days later, the MDP uptake showed less intense accumulation.

Management of knee deformity in classical arthrogryposis multiplex congenita (amyoplasia congenita)

We describe the management of significant knee deformity in 44 knees of 22 patients suffering from classical arthrogryposis multiplex congenita (amyoplasia congenita). Follow-up ranged from a minimum of 18 months to 19 years 3 months, with an average 7 years 8 months. Thirteen patients showed fixed flexion of the knees at birth and 9 showed fixed extension. All were treated initially by physiotherapy and splintage, which was successful in all except 1 patient in the extended-knee group, whereas only 7 to 26 knees responded to physiotherapy and splintage alone in the flexed-knee group. Walking ability in the extended-knee group was high; 8 of 9 were community walkers with or without walking aids and orthoses and only one was a therapeutic walker. By contrast, in the flexed-knee group, despite posterior release surgery, which sometimes had to be repeated, only to 6 of 13 patients were community walkers at follow-up, 2 were household walkers, 3 were therapeutic walkers, and 2 had stopped walking in adolescence and preferred to use a wheelchair full time. Long-term splintage is recommended but does not always prevent recurrence of deformity. Bony surgery was used only toward the end of growth or in one case when very severe deformity necessitated its use at an early age and it subsequently had to be repeated. Despite their severe handicap and multiple deformities, this group of children show a remarkable determination to walk with or without walking aids and orthoses.

Advanced nursing practice: role or concept?

In March 1997, the UKCC finally released its position statement on advanced practice (UKCC, 1997a). Despite an extensive national consultative process no clear consensus has emerged on either a definition of or criteria for advanced practice.