Visualization of diagnostic heteroduplex DNAs from cystic fibrosis deletion heterozygotes provides an estimate of the kinking of DNA by bulged bases

Previous studies (Hsieh, C.-H., and Griffith, J. D. (1989) Proc. Natl. Acad. Sci. U.S.A. 86, 4833-4837) of DNAs containing extra or bulged bases on one of the two strands of a duplex showed that they exhibit slower electrophoretic mobility than non-bulged DNAs, indicating that bulges create stiff kinks in the DNA. Here we paired a 97-base single-stranded DNA from the intact cystic fibrosis (CF) gene with a complementary 94-base strand containing a central 3-base deletion (delta F508), common to many CF patients. This produced a 94-base pair DNA with a central 3-base bulge. Visualization of these DNAs by electron microscopy showed that twice as many bulge-containing DNAs had a central kink as compared with the non-bulged controls. Examination of the distribution of kinking angles showed that the bulged population contained 5-7-fold more molecules with a central kink of 80 +/- 10 degrees than did the control molecules. When the 3-base bulge was replaced by a 3-base gap, the resulting duplex DNA showed central kinks with a somewhat lower frequency but greater range of kinking angles.

Effect of prior administration of cold saline on pain during propofol injection. A comparison with cold propofol and propofol with lignocaine

A single-blind, randomised, controlled study was undertaken to compare the efficacy of three methods of preventing pain during injection of propofol on induction of anaesthesia. Patients were allocated randomly to receive unmodified propofol, propofol with 0.05% lignocaine, propofol at 4 degrees C and unmodified propofol preceded by 10 ml of 0.9% saline at 4 degrees C. Prior injection of cold saline reduced the incidence of pain and discomfort significantly (22%) compared with unmodified propofol (75%; p less than 0.005) and was similar to that after cold propofol (33%) and propofol with lignocaine (44%). There was no significant difference between the treatment groups.

Computerised axial tomography of the trachea. A useful investigation when a retrosternal goitre causes symptomatic tracheal compression

Case histories are reported of three patients who had large retrosternal goitres which were responsible for significant abnormalities of the airway. Computerised axial tomography demonstrated the exact anatomy. The site of tracheal compression was shown and accurate measurements of the diameter of the trachea at its narrowest point were made. This information was useful when the management of the patient was planned.

Relationships between skin temperature and perfusion in the arm and leg

Relationships between skin temperature (Tsk) and perfusion have been studied to provide a basis for the use of Tsk in the non-invasive assessment of limb circulation in peripheral vascular disease. Raising the ambient temperature (Ta) from 20 to 30 degrees C increased the perfusion of the glabrous skin of the hands and feet without changing that of the skin of the forearm or calf. On a fractional basis the response in the hand and foot was the same. Tsk was higher in the arms than the legs and in the proximal than distal parts of the limbs. A fall in Tsk was often seen when Ta rose from 20 to 25 degrees C and was attributed to counter-current cooling. Subsequently Tsk rose even in regions where there was no increase in skin perfusion. Tsk can only be related to its perfusion in the fingers, palm and toes. Forearm Tsk was related to the perfusion of the digits. This relationship implies a link with the arterial inflow to the limb which determines the size of its thermal core. Heat conduction from the core seemed important for the skin of areas like the forearm and calf where the constant, low perfusion limited the amount of heat which could be transported to it directly by the blood. The importance of conduction was supported by studies, at Ta 20 degrees C, on subjects during calf muscle exercise and on patients with arterio-venous fistulae. Here an increase in the arterial inflow to the limb was associated with a rise in Tsk of the forearm/calf unrelated to the perfusion of its skin.

Coagulation screening before epidural analgesia in pre-eclampsia

A questionnaire survey of current practice at a small cross-section of obstetric units, covering 22% of all United Kingdom deliveries, revealed a marked lack of standard practice regarding requests for coagulation screens on pre-eclamptic patients who require epidural procedures. A retrospective audit was therefore carried out on 434 coagulation screens requested for pre-eclamptic patients in whom epidural analgesia might have been considered. Borderline abnormalities of coagulation were found in only 10 patients (2%). Platelet counts of less than 150 x 10(9)/litre were present in 28% of cases. 'Significant' thrombocytopenia (less than 100 x 10(9)/litre) and all coagulation abnormalities were only encountered in severe pre-eclampsia (diastolic blood pressure of greater than 110 mmHg and proteinuria of + + or greater). Furthermore, coagulation abnormality was always associated with a reduced platelet count (mean, 97 x 10(9)/litre). This study would therefore support anaesthetic practice which restricted any requests for coagulation testing to severe pre-eclamptic patients only. For these patients first line testing could be limited to a platelet count.

The philosophy of psychiatric nursing

In this panoramic overview of the meanings of mental health care, Philip Barker maps out the birth (or rebirth) of the philosophy of psychiatric nursing. The time is ripe for a fundamental re-examination of the main premises and values of the nursing culture, and for the rejection of concepts which have outlived their usefulness. Returning the focus of psychiatric nursing to the identity of the person in care, the 'binding' of the nurse and patient, regardless of conventional and expected roles, is the most important issue on the psychiatric agenda. Dr. Barker's brilliant analysis challenges psychiatric nurses to review their own values and practices, and acts as a catalyst for change.

Are obstetric spinal headaches avoidable?

In a prospective study of one hundred obstetric patients given spinal anaesthesia using either a 25 or 26 gauge spinal needle, a significantly greater incidence of spinal headache and blood patch was found in the 25-gauge group. It is concluded that a 26-gauge needle should be used when performing spinal anaesthetics for obstetric procedures.

The Leicester experience

Clinical directorates have been successfully working at Leicester Royal Infirmary for five years. Paul Barker charts their progress and looks forward to the next stages of resource management.

Reflections on the philosophy of caring in mental health

The trend towards definition of the role of the nurse as 'therapist' in mental health has resulted in clarification of what some nurses might do, with some patients, to resolve fairly specific problems of living. Not all psychiatric nurses are, however, satisfied that the developments which arise from this role definition will necessarily benefit the service overall. Indeed, the concept of the nurse-as-therapist has led, indirectly, to an expression of anxiety over the balance of 'care' versus 'therapy'. This is manifested at a time when nurses outwith the mental health setting are describing the need for a stronger emphasis upon therapeutic factors in nursing care, especially involving psychosocial variables.

The Foster Care Research Project: summary and analysis

This paper analyzes and summarizes five more detailed papers describing the Foster Care Research Project (F.C.R.P.). This compared two (individual and group) models of foster care as to their effects on foster parent satisfaction, placement breakdowns and several indices of children's adjustment in care. The group model is described and contrasted with other "extended family" models, and the results of the project, which were mixed, are summarized. A critique of the experimental design suggests why clinical gains noted in the children were not borne out experimentally. Following a clinician's analysis of the process by which the group model operated (illustrated by clinical vignettes), the paper ends by describing the content and process of two support groups for the natural children of the foster parents.

Partial amino acid sequence analysis and variable subgroup determination (VH and VL) of a monoclonal rheumatoid factor derived from a rheumatoid arthritis patient

Continuous cell lines secreting monoclonal rheumatoid factors (RF) were derived from rheumatoid arthritis (RA) patients by cloning Epstein-Barr virus (EBV) transformed B cells and by hybridoma techniques. We studied five different clones with stable RF secretion. All were IgM, 4 kappa and 1 lambda. One of these clones, RFAN was extensively studied, and the partial amino acid sequences of the variable regions of both heavy and light chains were determined. After affinity purification, the IgM lambda RF antibody derived from the EBV clone was run under reducing conditions on SDS-polyacrylamide gel electrophoresis. The separated heavy and light chains were blotted and then sequenced by a gas-phase sequenator. The N-terminal sequence of the lambda light chain corresponded to that of the V lambda III subgroup. The heavy chain of the same IgM RF clone had a blocked N-terminus, but a cyanogen bromide peptide starting after methionine at position 82 showed a sequence typical of the VHIII subgroup. Heavy and light chains were also prepared by gel filtration after reduction and carboxymethylation from the same EBV clone made into a hybridoma. After this preparation, the heavy chain was not blocked and the N-terminal sequence confirmed that the heavy chain variable region belonged to the VHIII subgroup. We believe this to be the first amino acid sequence study of a monoclonal RF derived from the repertoire of an RA patient.

Milton Erickson's contribution to psychiatry

Milton H. Erickson, MD. was born in 1901 in a cabin in a desolate part of Nevada where his father was a gold miner. When he reached school age his family returned to rural Wisconsin, where they had previously lived. As a child Milton experienced the world differently from other children in that he had red-green colour blindness, was tone deaf and, probably, also dyslexic. At 17 he had a severe attack of poliomyelitis. He was extensively paralysed but rehabilitated himself, largely by his own efforts, during the following two years.

A small-group approach to teaching family medicine

The authors describe a method for teaching preclinical medical students some important family medicine concepts utilizing a seminar format which allows for improved student-teacher interaction and individualization of material. These seminars, on family health behavior, compliance, behavioral interventions for life-style change, and managing stress, were designed to encourage freshman medical students to understand and apply concepts concerning health behavior and attitudes, both personally and professionally. The format of these sessions included the use of self-assessment instruments, discussion, role play, and case studies. Results of student evaluations indicate they perceived the seminars positively. Specific areas of positive value included the content and small-group related processes. The seminars also provided data useful for developing programs for students.

Breast biopsy: long term follow up of three methods of skin closure

A consecutive series of 102 breast biopsies were randomly allocated to skin closure by either subcuticular Prolene, subcuticular Dexon or Op-Site wound closure adhesive membrane. Fourteen were withdrawn because malignancy was found on biopsy. Follow up was at one week, 3 months, 6 months and 12 months or more. No significant difference was found in the appearance of the wound at the end of the follow up period. There was no clear patient preference for any particular method, so operator preference and demands on nursing time may determine the method of skin closure.

Residential treatment for disturbed children: its place in the '80s

The value and place of residential treatment for disturbed children and adolescents have been increasingly questioned in recent years. Possible reasons for this are examined. The place of residential treatment, and its value as a specialized form of therapy, are discussed. The treatment of disturbed young people in residential settings should only be undertaken as part of a wider therapeutic plan. The need for placement away from home, for the protection of the community or for other reasons not directly concerned with the child's treatment, must be distinguished from the need for residential treatment. The rationale and goals of treatment must always be defined in advance, and the needs of the system to which the child belongs must be considered along with those of the presenting patient.

Training standards for career child psychiatrists

The two main components of child psychiatric training should be supervised clinical work of high quality and training in the questing, scientific approach to the subject. These should be combined so that residents consider the assessment and management of all their clinical cases in a critical way, at the same time looking critically also at the pertinent literature. Management and treatment methods should be selected in the context of discussion of the current state of knowledge in the area. Trainees should see and treat children and adolescents of all ages and with the full range of psychiatric disorders. Ten percent of their caseload should consist of mentally retarded children. It may be necessary to teach about some rare syndromes by the use of videotapes. Residents should be familiar with the uses, and drawbacks, of a wide range of therapies, including residential treatment, but can only be expected to develop special expertise in a few. Didactic teaching unrelated to clinical work is probably of limited value.