How counselling services can help deal with loss and change

Transferring people with learning disabilities from hospitals to community-based homes is generally a positive experience. But some people undergo feelings of loss during the process and need special support. This paper explores the issues and describes how a new counselling service helped one woman come to terms with her new lifestyle outside hospital.

Dried blood spots collected on filter paper: an international resource for the diagnosis and genetic characterization of human immunodeficiency virus type-1

The collection of dried blood spots (DBS) on filter paper provides a powerful approach for the development of large-scale, population-based screening programs. DBS methods are particularly valuable in developing countries and isolated rural regions where resources are limited. Large numbers of field specimens can be economically collected and shipped to centralized reference laboratories for genetic and (or) serological analysis. Alternatively, the dried blood can be stored and used as an archival resource to rapidly establish the frequency and distribution of newly recognized mutations, confirm patient identity or track the origins and emergence of newly identified pathogens. In this report, we describe how PCR-based technologies are beginning to interface with international screening programmes for the diagnosis and genetic characterization of human immunodeficiency virus type 1 (HIV-1). In particular, we review recent progress using DBS specimens to resolve the HIV-1 infection status of neonates, monitor the genetic evolution of HIV-1 during early infancy and establish a sentinel surveillance system for the systematic monitoring of HIV-1 genetic variation in Asia.

Helping people with learning disabilities to grieve

Historically, it was believed that people with a learning disability did not grieve. Today, however, new and creative ways of working with and supporting the bereft individual who has a learning disability are being sought. This article addresses the current issues for both the individual with a learning disability who has experienced a bereavement and his/her carers, it advocates the importance of competence in the carer to enable effective support, acknowledges proactive educational approaches to enable the individual to cope more healthily with loss, addresses the education and training forum from a pre- and postregistration perspective, and explores the current deficits and potential research areas within this specialist field.

Time course of detection of viral and serologic markers preceding human immunodeficiency virus type 1 seroconversion: implications for screening of blood and tissue donors

BACKGROUND

Almost all human immunodeficiency virus (HIV) transmission via blood or tissues that has occurred since anti-HIV screening was implemented in 1985 is traceable to blood given after infection but before antibody seroconversion, a time that is referred to as the window period. In this study, the performance of newer assays designed to detect viral and serologic markers soon after infection is assessed, and the reduction in the window period achieved by these assays is estimated.

STUDY DESIGN AND METHODS

Three cohort studies of persons at high risk for acquiring HIV infection were identified. These studies included well-controlled HIV type 1 (HIV-1) polymerase chain reaction (PCR) analyses of serial preseroconversion specimens from HIV-1-seroconverting homosexual men or intravenous drug users. Of 81 enrollees with anti-HIV-1 seroconversion documented by a viral lysate anti-HIV-1 enzyme immunosorbent assay (EIA) available in 1989, 13 (16%) had PCR-positive preseroconversion specimens. In the present study, sera from these 13 PCR-positive samples were further tested for anti-HIV by 10 contemporary EIAs and 6 supplemental assays, as well as being tested for plasma p24 antigen and HIV-1 RNA. Preseroconversion sera from 38 HIV-1 DNA PCR-negative cohort participants were also tested by selected anti-HIV EIAs and tested for p24 antigen and HIV-1 RNA. On the basis of these laboratory data and the intervals between blood drawing in all 81 men, the reduction in the preseroconversion window period achieved by these new assays was estimated with a mathematical model developed to analyze seroconversion data.

RESULTS

Nine (69%) of the 13 preseroconversion PCR-positive samples had anti-HIV that was detectable by one or more contemporary anti-HIV-1 or anti-HIV type 2 EIA. Supplemental antibody assays were negative on all four EIA-nonreactive preseroconversion samples and negative or indeterminate on a high proportion of the nine EIA-reactive PCR-positive samples. Eight (61%) of the 13 samples were p24 antigen-positive, and 11 (85%) were HIV-1 RNA-positive. The estimated reductions in the window period (relative to the index viral lysate-based anti-HIV EIA) were as follows: contemporary anti-HIV-1/2 EIAs, 20.3 days (95% Cl, 8.0-32.5); p24 antigen and DNA PCR, 26.4 days (95% Cl, 12.6-38.7); and RNA PCR, 31.0 days (95% Cl, 16.7-45.3).

CONCLUSION

Recent improvement in the sensitivity of anti-HIV assays has resulted in significant shortening of the preseroconversion window period. Consequently, the incremental reduction in the window period that could be achieved by implementing direct virus-detection assays has diminished significantly.

Interferon alfa treatment of chronic hepatitis B: randomized trial in a predominantly homosexual male population

BACKGROUND/AIMS

It has been suggested that human immunodeficiency virus (HIV) coinfection and male homosexuality predict poor response to interferon alfa therapy of chronic hepatitis B. The aim of this study was to examine the effect of HIV coinfection on the response of chronic hepatitis B virus (HBV) infection to interferon alfa therapy in a predominantly homosexual male population.

METHODS

Fifty patients (82% male homosexuals, 50% HIV positive) with evidence of chronic HBV infection were randomized, stratified by HIV status, to undergo either treatment with interferon alfa (10 MU/m2 three times weekly for 12 weeks) or no treatment. Response was predefined as loss of serum HBV DNA, loss of hepatitis B e antigen, and the appearance of antibody to hepatitis B e antigen. HIV status and the interferon alfa-associated enzyme, 2',5'-oligoadenylate synthetase, were evaluated as potential predictors of response to therapy.

RESULTS

Six treated patients responded with development of antibodies to hepatitis B e antigen (P < 0.05). HIV-positive patients were about one-fifth as likely to respond to interferon alfa therapy (relative risk, 0.22; 95% confidence interval, 0.03-1.78). Pretreatment alanine aminotransferase levels were significantly higher in responders than in nonresponders (P = 0.0005). Pretreatment 2',5'-oligoadenylate synthetase levels did not predict response.

CONCLUSIONS

Interferon alfa, 10 MU/m2 three times weekly for 12 weeks, is effective in eradicating HBV replication in a predominantly homosexual male population not coinfected with HIV.

Outcome of deliberate self-poisoning. An examination of risk factors for repetition

BACKGROUND

One of the most important outcomes following an episode of non-fatal deliberate self-poisoning is its repetition.

METHOD

In a prospective follow-up study the subjects were 992 people responsible for 1096 consecutive episodes of deliberate self-poisoning recorded at a teaching hospital accident and emergency department. Risk factors examined were socio-demographic variables, psychiatric and self-harm history, aspects of the self-poisoning episode, and appearance and behaviour at accident and emergency; the frequency of each was compared between those patients who repeated within one year (n = 116) and those who did not (n = 876).

RESULTS

Those who repeated were more likely to have ingested more than one drug, to report a previous episode of self-poisoning, to be aged 25-54, and to have experienced previous psychiatric care or psychiatric admission. They were less likely to be in paid employment, or to have expressed a threat to another person or written a note. The best predictor--previous psychiatric contact--only had a positive predictive value of 21% (95% confidence interval 16-25%).

CONCLUSIONS

Risk factors for repetition of self-poisoning should be kept up-to-date despite modest predictive power. More attention might be paid to clinical rather than socio-demographic aspects of self-harm.

Rapid screening for early detection of mother-to-child transmission of human immunodeficiency virus type 1

The testing of dried blood spots (DBSs) for the presence of human immunodeficiency type 1 (HIV-1) proviral DNA by PCR was first described in 1991. The technology has proven to be particularly valuable for resolving the infection status in HIV-1-indeterminate infants born to HIV-1-seropositive mothers. To broaden the applicability of DBS PCR, we adapted it to a standardized, commercially available microwell plate amplification and detection kit, Amplicor HIV-1, produced by Roche Diagnostic Systems. The microwell assay is rapid and easy to perform and uses equipment that is readily available in routine diagnostic laboratories. The high level of performance of the assay was demonstrated in 1,168 duplicate tests performed on 584 DBSs from 178 uninfected and 100 HIV-1-infected individuals, including 56 children with perinatally acquired HIV-1. Of 12 infants who were followed prospectively from birth, 3 (25%) were infected in utero (PCR positive at birth) and 9 (75%) were infected intrapartum (PCR negative, culture negative at birth). Overall, HIV-1 DNA was identified in 3 of 11 (27.3%) DBSs collected from infected infants during the first 4 days of life, 8 of 9 (88.9%) DBSs collected between 10 and 15 days postpartum, and 166 of 167 (99.4%) DBSs collected after 15 days of age. All 320 DBSs from uninfected children were PCR DNA negative. These findings indicate that use of the Roche microwell DBS PCR assay provides a powerful new approach for large-scale perinatal screening programs and population-based studies of vertical transmission.

Alcoholism and rapid progression to AIDS after seroconversion

Rapid progression of infection with human immunodeficiency virus type 1 (HIV-1) to AIDS after seroconversion is rare; it has been associated with coinfection by cytomegalovirus or human T lymphotrophic virus type I. We describe an alcoholic patient whose condition progressed to AIDS 3 months after HIV-1 seroconversion occurred. Culture of peripheral blood mononuclear cells yielded a syncytium-inducing variant of HIV-1. T lymphocytes showed no spontaneous cytotoxic activity against HIV-infected cells, nor could such activity be demonstrated following stimulation with HIV-1 antigen in the presence of recombinant interleukin-2. We hypothesize that our patient's accelerated course was due to alcohol abuse, which may have suppressed T cell function and stimulated HIV replication.

Canadian national survey of perinatal HIV infection 1991-1992. Canadian Paediatric AIDS Research Group (CPAR)

OBJECTIVE

To define the burden of illness and the demographic characteristics of perinatally HIV exposed children in Canada.

METHODS

Two national surveys of children born to HIV-infected mothers were conducted. The first survey captured information on all known cases up to March 1991, and the second, additional cases between April 1991 and May 1992.

RESULTS

220 children born to 204 HIV-infected mothers were identified. Quebec cases increased by 20% compared with 33% in Ontario (p < .003) and 50% in the rest of the country (p < .001). Quebec has a higher proportion of black mothers than the rest of Canada (p < .001). Sexual contact continues to be the major risk factor for maternal HIV infection.

CONCLUSIONS

This survey confirms a substantial case load and provides an initial demographic profile of diagnosed HIV exposed infants in Canada.

Do formal controls always achieve control? The case of triage in accident and emergency departments

Triage is the term used to describe the formal process of assigning urgency categories to patients arriving in a hospital accident and emergency department. This paper uses insights from literature on management control, medical sociology and nursing to illuminate the results of a research study comparing formal triage with an informal prioritisation process carried out by nurses. Topics discussed include whether triage is a bureaucratic process, whether it allows nurses' intuition to be expressed, whether it masks the urgency of the condition of the small number of seriously injured or ill patients, and whether responsibility for decisions on urgency should be separated from responsibility to act on those decisions. It is concluded that managers must consider these questions in the light of arrangements in their own hospital; departmental layout as well as the nursing staff's experience and commitment need to be taken into account.

Nurse triage in theory and in practice

'Nurse Triage' refers to the formal process of early assessment of patients attending an accident and emergency (A&E) department by a trained nurse, to ensure that they receive appropriate attention, in a suitable location, with the requisite degree of urgency. The benefits claimed for nurse triage include better patient outcomes, through clinical management reaching those in greatest need of it first. A recent study of nurse triage in a British A&E department failed to demonstrate the benefits claimed: patients undergoing triage were delayed, especially those in the most urgent groups. No differences were noted between the two study groups in levels of satisfaction with the A&E process. The results brought forth criticism from all quarters. In this paper the points made by the critics are considered, and an attempt to answer them is made.

Differences in priorities assigned to patients by triage nurses and by consultant physicians in accident and emergency departments

STUDY OBJECTIVES

To investigate whether the greater urgency assigned to accident and emergency patients by triage nurses than by accident and emergency doctors was uniform across all patient groups.

DESIGN

Patients attending an accident and emergency department between 8.00 am and 9.00 pm over a six week period were assessed prospectively for degree of urgency by triage nurses, and retrospectively for urgency by one of two consultant accident and emergency doctors. Patients were grouped according to their clinical mode of presentation.

SETTING

An accident and emergency department of a district general hospital in the Midlands, UK, in 1990.

PATIENTS

1213 patients who presented over six weeks.

MEASUREMENTS AND MAIN RESULTS

As might be expected, patients' conditions were assessed as being more urgent prospectively than retrospectively. This finding, however, was not uniform across all patient groups. Nurses' assessments of urgency tended to favour children and patients who presented with eye complaints and gave less priority to medical cases, particularly those with cardiorespiratory symptoms.

CONCLUSIONS

These findings have implications for all those involved in the organisation of triage systems and in the training of nurses in accident and emergency departments. It is essential that judgements on how urgently patients need to be seen are made in a completely objective manner.

Dopamine regulates D2 receptor gene expression in normal but not in tumorous rat pituitary cells

Abnormalities of dopamine D2 receptors may be implicated in the development of some pituitary tumours. Previously we have identified dopamine D2 receptor gene expression both in normal rat pituitaries and in dopamine resistant GH3 rat pituitary tumour cells. In this study we have examined the effect of dopamine on D2 receptor gene expression in these cells using a probe specific for both D2 receptor isoforms. Normal rat pituitary cells were maximally stimulated by 100 nM dopamine at which concentration D2 receptor mRNA concentrations were 400% greater than that measured in controls. No increase in D2 receptor gene expression was observed in GH3 pituitary tumour cells.

Piloting an evaluation of triage

This paper takes a broad view of the work involved in pilot studies of evaluation research. Drawing on their experience of preparation for a field experiment in a British Accident and Emergency department, which was to evaluate the effectiveness of a nurse triage system, the authors stress the importance of careful observation of the system to be studied, in the environment in which it is to be studied. In addition, the usual evaluations of research instruments which comprise formal pilot studies are included.

Rapid DNA fingerprinting to control for specimen errors in HIV testing by the polymerase chain reaction

Variable-number-tandem-repeats (VNTRs) are highly polymorphic and provide informative genetic markers for distinguishing between individuals. We have used PCR amplification of VNTR locus pMCT118 to identify mislabelled specimens submitted for HIV PCR testing. The method is rapid, can be applied to large numbers of samples and eliminates the need for radioactive probes. DNA samples (10 ng) are amplified for 25 cycles using fluorescence-labelled oligonucleotide primers (blue dye). An aliquot of the PCR product is then combined with an internal lane size standard (labelled with a red dye), electrophoresed through a 2% agarose gel on an automated fluorescence DNA fragment analyser and the size and quantity of the fragments determined automatically relative to the internal standard. Fifteen alleles, ranging in size from 398 tp 709 bp were readily identified in a random sampling of DNA from 63 unrelated HIV-infected patients. Fragment size was reproducible and corresponded to alleles containing from 16 to 35 repeats of a 16 bp unit. VNTR genotyping will prove useful for resolving discordant results due to specimen mix-up and ensuring that the correct samples have been analyzed.