Triumvirate nursing for personality disordered patients: crossing the boundaries safely

As the issue of the treatment and effective management of personality disordered patients comes under close scrutiny in the wake of the Fallon Inquiry, we offer a brief overview of the nature of the challenges involved in nursing this difficult group of patients. Traditional methods of setting limits and defining boundaries are no longer convincing amidst the allegations of multidisciplinary staff being culpable, at one level or another, for their contribution in this tragic inquiry. In this paper we offer a strategic mechanism of constructing nursing care for this difficult group of patients and provide a framework for crossing boundaries safely through a multidisciplinary framework. We term this triumvirate nursing. Nursing management of those patients considered to have personality disorders is traditionally very difficult. This difficulty, in part, stems from the inability of nurses to strategically develop therapeutic relationships in a safe manner. Crossing boundaries is a necessary part of therapeutic exploration and relationship building; triumvirate nursing offers a safe mechanism for undertaking this. Creative thinking is a necessary part of the future development of the nursing management of these disorders.

PCR-mediated recombination: a general method applied to construct chimeric infectious molecular clones of plasma-derived HIV-1 RNA

A PCR-based approach was developed that provides a powerful tool for engineering recombinant molecules without reliance on restriction sites. DNA sequences were first amplified by high-fidelity PCR using Pfu polymerase; they were then used both as 'megaprimers' and templates in subsequent asymmetric long PCR amplifications to form chimeric clones. To demonstrate the technique, we constructed chimeric full-length HIV-1 clones derived from reverse-transcribed plasma viral RNA and proviral LTRs. Biologic characterization of these clones showed that most were infectious in tissue culture and sequence analysis demonstrated an error rate of only one base change in 20 kb of DNA sequence. For PCR-mediated recombination, it is necessary to know the sequence of the 3' and 5' overlapping regions of the desired PCR products. This method may be extended to include construction of chimeras between any DNA fragments lacking sequence homology. Such chimeras may be constructed by introducing overlapping sequences to one of the fragments. To ensure that unwanted mutations have not been introduced into the clones constructed by this method, each clone should be sequenced. Our results demonstrate that by using a high-fidelity polymerase and highly controlled PCR conditions, the PCR-introduced error rate can be greatly minimized. This new procedure may be used to construct infectious chimeras of HIV or SIV for studies of vaccines and pathogenesis. Moreover, the method is designed to exchange viral genes at precise boundaries to study individual gene products from different HIV genomes. It can also be used to construct expression vectors for production of specific proteins or delivery vectors for gene transfer and gene therapy. Finally, the technique described here provides a versatile tool to transfer genes or gene fragments from different sources for genetic investigation and engineering.

Ignorance is not bliss

The inanimate, little 1.5-g pieces of matter carry far more import than they should. Worse, they tend to multiply, like aggressive malignancies, to form paperwork--that dreaded, colossal barrier between physicians and weightier matters. Growing mounds of it demand physicians' attention and steal time away from healing the sick and saving the dying.

Let the patients speak

The 1997 Texas Legislature directed the Office of Public Insurance Counsel (OPIC) to issue annual report cards comparing Texas health maintenance organizations (HMOs). OPIC released its first statewide consumer survey in August, conducted by The University of Texas Office of Survey Research.

Informed consent in a multicultural cancer patient population: implications for nursing practice

Obtaining informed consent, an ethical obligation of nurses and other health care providers, occurs routinely when patients make health care decisions. The values underlying informed consent (promotion of patients' well-being and respect for their self-determination) are embedded in the dominant American culture. Nurses who apply the USA's cultural values of informed consent when caring for patients who come from other cultures encounter some ethical dilemmas. This descriptive study, conducted with Latino, Chinese and Anglo-American cancer patients in a large, public, west-coast clinic, describes constraints on the informed consent process in a multicultural setting, including language barriers, the clinical environment, control in decision making, and conflicting desired health outcomes for health care providers and patients, and suggests some implications for nursing practice.

Development and characterization of monoclonal antibodies specific for the murine thyrotropin receptor

We have characterized 10 monoclonal antibodies (Mabs) to recombinant murine thyrotropin receptor extracellular domain (mTSHR-ecd). Affinity purified mTSHR-ecd (amino acids 22-415), expressed in a baculovirus-insect cell system, was refolded in vitro and used to hyperimmunize female Balb/c mice. Spleens were removed 10 days after a final boost of 25 microg mTSHR-ecd intraperitoneally and intravenously, and the cells were fused to SP-2 cells and cloned. Hybridoma supernatants were screened by enzyme-linked immunosorbent assay (ELISA) with folded mTSHR-ecd antigen. Ten of 18 higher affinity hybridomas were selected at random and ascites fluids prepared. Nine of the monoclonals were of IgG 1 isotype, and one was IgM. Five Mabs (M3, M4, M5, M6, and M9) inhibited the binding of 125I-TSH to functional hTSHR expressed on Chinese hamster ovary (CHO) cells, and four (M1, M3, M5, and M9) blocked the TSH-stimulated generation of cyclic adenosine monophosphate (cAMP), using the same cells. The remaining Mabs appeared to be neutral in their interaction with native TSHR. The Mabs were also compared for their reactivity to mTSHR-ecd under folding (ELISA) and unfolding (reducing sodium dodecyl sulfate-polyacrylamide gel electrophoresis [SDS-PAGE]) conditions. Most Mabs demonstrated reactivity to both conformational (folded) and linear (unfolded) forms of mTSHR-ecd, suggesting that they were generated primarily against linear epitopes although one Mab (M4) showed affinity for only folded antigen indicating a preference for a conformational epitope. Mapping the Mab epitopes using 26 overlapping peptides spanning the human (h)TSHR-ecd showed that 6 bound peptide 397-415, 1 bound peptide 352-371, and 1 peptide 22-41. These epitope mapped Mabs to the mTSHR-ecd, both receptor blocking and receptor neutral, will provide further insight into the structure-function of the TSHR ectodomain.

Antigen presentation by B7-nonprofessional APC does not prevent responses to solid tumor cells

The growth of tumors in vivo often is associated with immune suppression. In this report we tested whether the expression of a known antigen by tumor cells would inhibit the development of antitumor responses when the antigen was subsequently expressed in an immunogenic form. For this, we expressed a well-characterized surrogate tumor antigen, the nucleoprotein (NP) of the PR8 virus, in solid tumor cells. Although the NP+ tumor cells were not rejected in vivo and stimulated nondetectable CTL response in vitro, T cells from these mice differentiated into CTL following i.p. inoculation of PR8 virus and their tumors regressed. The results suggested that prior presentation of tumor antigens by tumor cells does not necessary preclude a response if the peptide is subsequently presented appropriately.

Pregnancy and delivery in a patient with recent peripartum cardiomyopathy

We present a case of successful pregnancy and delivery in a patient with peripartum cardiomyopathy who conceived only 3 months after a vaginal delivery complicated by peripartum cardiomyopathy. Following the onset of labor, an arterial pressure catheter and pulmonary artery catheter were placed. A combined epidural spinal technique was performed without difficulty for labor analgesia. After a few hours of labor, the fetal heart rate tracing revealed repetitive variable decelerations, and a decision was made to proceed with operative delivery. The mother's hemodynamic changes are presented, and the specifics of the anesthetic care are outlined.