The absence of the transcription activator TFE3 impairs activation of B cells in vivo

TFE3 is a ubiquitously expressed member of the TFE3/mi family of basic helix loop helix zipper transcription factors. TFE3 binds to muE3 sites located in the immunoglobulin heavy-chain (IgH) intronic enhancer, heavy-chain variable region promoters, the Ig kappa intronic enhancer, and regulatory sites in other genes. To understand the role of TFE3 in Ig expression and lymphoid development, we used embryonic stem (ES) cell-mediated gene targeting and RAG2-/- blastocyst complementation to generate mice which lack TFE3 in their B and T lymphocytes. TFE3- ES cells fully reconstitute the B- and T-cell compartments, giving rise to normal patterns of IgM+ B220+ B cells and CD4+ and CD8+ T cells. However, TFE3- B cells show several defects consistent with poor B-cell activation. Serum IgM levels are reduced twofold and IgG and IgA isotypes are reduced three- to sixfold in the TFE3- chimeras even though in vitro, the TFE3- splenocytes secrete normal levels of all isotypes in response to lipopolysaccharide activation. Peripheral TFE3- B cells also show reduced surface expression of CD23 and CD24 (heat-stable antigen).

Exploring the everyday world of the patient in isolation

PURPOSE/OBJECTIVES

To explore the phenomenon of isolation from the perspective of patients cared for in reverse isolation for bone marrow transplant (BMT).

DESIGN

Interpretive, phenomenologic.

SETTING

Hematology and bone marrow transplant unit of a large teaching hospital in Brisbane, Australia.

SAMPLE

Seven patients undergoing BMT.

METHODS

Phenomenologic interviews and thematic analysis of transcribed data.

MAIN RESEARCH VARIABLE

Patient's day-to-day experiences of reverse isolation.

FINDINGS

Although appreciative of the physical care and attention given to them, participants did not convey a sense that healthcare professionals understood the experience of the BMT recipient's isolation or illness from their perspective. Major themes elicited from analysis of the transcripts included (a) striving to take charge, which refers to participants' attempts to maintain control in a seemingly out-of-control situation. (b) intellectualizing the need for isolation, and (c) being in touch: contact with family and staff.

CONCLUSIONS

Elements of caring for the patient appeared to dominate the comments associated with staff contact. Other forms of care (e.g., caring about) emphasize the importance of nurses understanding and connecting with peoples' meanings and experiences of their illness and treatment.

IMPLICATIONS FOR NURSING PRACTICE

Although all participants were aware that they could ask for information about their diagnosis and treatment at any time, most had not been offered the opportunity to describe their feelings or experiences before. Unless nurses take more initiative to gain insight and a greater appreciation of the patient's understanding of his or her situation, they will continue to focus on unidimensional aspects of care and neglect the multidimensional or holistic nature of nursing care.

Fungal transformations of antihistamines: metabolism of cyproheptadine hydrochloride by Cunninghamella elegans

1. Metabolites formed during incubation of the antihistamine cyproheptadine hydrochloride with the zygomycete fungus Cunninghamella elegans in liquid culture were determined. The metabolites were isolated by hple and identified by mass spectrometric and proton nmr spectroscopic analysis. Two C elegans strains, ATCC 9245 and ATCC 36112, were screened and both produced essentially identical metabolites. 2. Within 72 h cyproheptadine was extensively biotransformed to at least eight oxidative phase-I metabolites primarily via aromatic hydroxylation metabolic pathways. Cyproheptadine was biotransformed predominantly to 2-hydroxycyproheptadine. Other metabolites identified were 1- and 3-hydroxycyproheptadine, cyproheptadine 10,11-epoxide, N-desmethylcyproheptadine, N-desmethyl-2-hydroxycyproheptadine, cyproheptadine N-oxide, and 2-hydroxycyproheptadine N-oxide. Although a minor fungal metabolite, cyproheptadine 10,11-epoxide represents the first stable epoxide isolated from the microbial biotransformation of drugs. 3. The enzymatic mechanism for the formation of the major fungal metabolite, 2-hydroxycyproheptadine, was investigated. The oxygen atom was derived from molecular oxygen as determined from 18O-labelling experiments. The formation of 2-hydroxycyproheptadine was inhibited 35, 70 and 97% by cytochrome P450 inhibitors metyrapone, proadifen and 1-aminobenzotriazole respectively. Cytochrome P450 was detected in the microsomal fractions of C. elegans. In addition, 2-hydroxylase activity was found in cell-free extracts of C. elegans. This activity was inhibited by proadifen and CO, and was inducible by naphthalene. These results are consistent with the fungal epoxidation and hydroxylation reactions being catalysed by cytochrome P450 monooxygenases. 4. The effects of types of media on the biotransformation of cyproheptadine were investigated. It appears that the glucose level significantly affects the biotransformation rates of cyproheptadine; however it did not change the relative ratios between metabolites produced.

Adult intensive care in an environment of resource restriction: how should the unit director respond?

Adult intensive care touches the lives of very few while consuming a disproportionately high level of resources. To survive in the future environment of resource restriction and accountability, the unit director must rapidly acquire a wide range of professional management skills. The intensive care unit director must be able to demonstrate to colleagues, health managers and the community that the large amount of resources provided to intensive care, and the remarkable freedom given to intensivists to use those resources, are justified in terms of compassionate evidenced-based care, efficiency, efficacy and appropriateness. While many outcomes may be subjected to audit, intensive care units must publish minimal performance data indexed to severity of illness and including their mortality, hospital mortality and length of stay and an overall indicator of patient acuity to identify patients at low risk who need not be admitted to an expensive intensive care bed.

Nature of decision-making in the terminally ill patient

The increasing emphasis on the consumer's choice in health care treatment has contributed to the growing trend for decision-making to be shared between the patient and the health care team. If responsibility is to be shared, then it is important that health professionals identify the degree to which patients wish to participate in the decision-making process, in order that they can assist patients to achieve this goal. The seven patient case studies in this pilot study explored terminally ill patients' perceptions of their own participation in the decision-making process. A simple strategy, through the use of picture cards, established patients' actual and preferred forms of decision-making. These cards were presented to the patients at various stages of their illnesses, which permitted a longitudinal analysis of the decision-making process. Patients initially stated that they did not want much input into the decision-making process. In this study, however, as patients became more knowledgeable about their conditions, they desired greater input into the decision-making process. These findings also revealed that, although there was consistency between patients' preferred and actual forms of decision-making when they were initially admitted to hospital, discrepancies became apparent during the later phases of their illness. This emphasises the need for communication between all parties involved in health care decisions.

The use of the lidocaine-monoethylglycinexylidide test in the liver transplant recipient

The lidocaine-monoethylglycinexylidide (MEGX) test is used to monitor liver function in liver transplant recipients. Serial studies have been undertaken after 155 allografts. The initial MEGX concentration is significantly correlated with the donor MEGX concentration. It is also influenced by the recipient's pretransplant bilirubin concentration, being lowest among patients with very high bilirubin levels. Use of segmental grafts is also accompanied by low MEGX concentrations. The flow-dependent clearance of lidocaine makes it a sensitive indicator of disturbed liver blood flow, with decreased MEGX concentrations occurring in hepatic artery thrombosis and rejection and as a result of cardiac failure and pulmonary effusions. Significant hepatic ischemia resulting in delayed initial function or cholestasis also is associated with low MEGX concentrations. The initial median MEGX concentrations were lowest among patients who required retransplantation or who died within 2 months of allografting.

Cardiovascular syndromes X, endothelial dysfunction and insulin resistance

Cardiac Syndrome X (microvascular angina) and the more recently described metabolic Syndrome X (an epidemiological association between insulin resistance and atheroma, dyslipidaemia, and hypertension) may have more in common than the chance of their common sobriquet, in view of evidence that microvascular angina too is characterised by insulin resistance and endothelial dysfunction. The implications are discussed.

Becoming an orthopaedic surgeon: background of trainees and their opinions of selection criteria for orthopaedic training

A questionnaire survey of registrars in training in Australia in orthopaedic surgery was used to profile successful applicants and to ascertain what entry criteria they considered appropriate for the Orthopaedic Training Scheme. Typically, trainees were male, average age 31 years, married with children, born in Australia, privately educated and from a traditional family background. Respondents believe that referees' reports, performance as a resident and a registrar, and experience as a non-accredited registrar are the most appropriate selection criteria. Trainees held the opinion that too much emphasis may currently be placed on the support of influential surgeons and hospitals, and too little emphasis on medical school performance and surgical expertise. Academic achievement was considered to be of little relevance. The implications of these findings are discussed.

Theatre in AIDS education--a controlled study

Theatre is now widely used in HIV and AIDS education for young people. However, research concerning its effectiveness has largely been conducted without using comparison or control groups and there is little evidence that other types of intervention are more or less effective. The present study was designed to measure the effects of a theatre production on HIV knowledge, attitudes and risk behaviour of young people compared with that of a standard health education seminar which used group work techniques. Both interventions were designed for young people between the ages of 12 and 18 and held in 10 youth projects in socially deprived areas of Glasgow. Five youth projects were randomly assigned to each intervention. All participants were asked to complete a self-administered HIV knowledge, attitude and behavioural questionnaire immediately before and after the event and 2 months later. Research focus groups were also used. A total of 35 young people attending the standard seminars completed three self-administered questionnaires, and 18 participated in all three focus groups. Forty-two young people attending the theatre performances completed three self-administered questionnaires and 16 participated in all three focus groups. There was little impact on the knowledge and attitudes of either audience, although there was some evidence of attitudinal change among those exposed to the health education discussion session. More of the theatre group reported a behavioural change 2 months after attending the play but only in relation to buying and carrying condoms. It is uncertain whether this led to safer sex practices. This study does not support the view that theatre in AIDS education has a significant impact on HIV knowledge, attitudes and risk behaviour.

The smoke-free policies of Lanarkshire general practices

A telephone survey was performed to examine the smoke-free policies at Lanarkshire general practices sited outwith health centres. Forty-nine practices were contacted and all agreed to take part. Thirty-three practices (67%) reported that there was a complete ban on smoking within the building. The remaining 16 practices (33%) reported that the building was largely no-smoking with smoking by staff restricted to designated smoking areas. No practices permitted patients to smoke within the main practice premises. Few practices reported experiencing any difficulties with either the implementation or operation of the smoke-free policies. Although it is possible that problems may not have been recognised or not reported, these results are encouraging. They suggest that smoking in surgeries is the exception rather than the rule. The finding that patients largely respect the smoking ban in practice premises also suggests that the health service exemplar role is being recognised by the public. Practices that currently have no smoking restrictions should review their policy. Practices that do impose restrictions must recognise the needs of staff who smoke and offer appropriate support to help them to stop.

Sudden deafness as the sole presenting symptom of diabetes mellitus--a case report

This paper reports an undiagnosed diabetic presenting to an otolaryngologist with sudden deafness of six days duration as the only symptom. Appropriate investigative and treatment measures resulted in recovery of hearing.

Endothelium, for example

Endothelial nitric oxide production contributes at many levels to cardiovascular efficiency (considered as tissue perfusion relative to cardiac work). Endothelial dysfunction is found in many conditions, including all known risk factors for atheroma, and is usually generalised, when present, involving microvessels as well as large arteries, impairing cardiovascular efficiency and potentially initiating atheroma. Loss of flow-related dilation is a manifestation of endothelial dysfunction and can be measured non-invasively, thereby providing a potential marker of reversible atherogenic susceptibility.

Ig/EBP (C/EBP gamma) is a transdominant negative inhibitor of C/EBP family transcriptional activators

Analysis of cDNA and genomic clones shows that the murine Ig/EBP (C/EBP gamma) gene encodes a small protein with a predicted molecular weight of 16.4 kDa which contains C/EBP family basic and leucine zipper domains but lacks the transcriptional activation domains present in C/EBP (C/EBP alpha) and NF-IL6 (C/EBP beta). In transfection assays Ig/EBP is neither an activator nor a repressor of transcription; however, Ig/EBP inhibits the transcriptional ability of NF-IL6 (C/EBP beta) and C/EBP (C/EBP alpha), acting as a transdominant negative regulator. Thus Ig/EBP resembles LIP, another negative regulator of the C/EBP family, in both structure and transcriptional activity. Of the three known C/EBP family inhibitors, Ig/EBP, LIP and CHOP-10, only Ig/EBP is ubiquitously expressed. Therefore, Ig/EBP may act as a general buffer for C/EBP activators in many cell types.

Morbidity and mortality after abdominal aortic surgery in a population of patients with high cardiovascular risk

Postoperative myocardial infarction is a major risk factor in patients undergoing abdominal aortic surgery. Correction of cardiac ischaemia prior to abdominal aortic surgery improves outcome. The morbidity and mortality of 639 consecutive patients were reviewed from an area with poor access to cardiac surgery, operated upon in a single tertiary referral hospital for aortic aneurysm or aortobifemoral grafting. A total of 101 patients with ruptured aortic aneurysm who survived to reach the intensive care unit experienced a hospital mortality of 29%. Multiorgan failure was the cause of death in 48% and postoperative myocardial infarction in 31%. Of the 253 patients with intact aortic aneurysm, which included elective and urgent resection, the mortality was 9%. There was a high incidence of uncorrected pre-operative ischaemic heart disease and myocardial infarction was the major cause of death (62%). Pre-operative myocardial infarction was predictive of postoperative cardiac morbidity and mortality. Of the 285 patients undergoing aortobifemoral grafting the mortality was 3% despite a high incidence of pre-operative ischaemic heart disease. Further reductions in postoperative death from ruptured aortic aneurysm must await improved screening to diagnose and treat the aneurysm before rupture. In patients operated upon electively, improved pre-operative cardiac screening and coronary bypass grafting where appropriate, especially for patients with aortic aneurysm and previous myocardial infarction, may further reduce peri-operative mortality.

Abused women and peer-provided social support: the nature and dynamics of reciprocity in a crisis setting

Research has demonstrated clearly the positive effect social support can have on health. Peer-provided social support, in the forms of both one-on-one peer counseling and peer support groups, is encouraged by health care providers as an effective and inexpensive way to enhance mental health in at-risk client populations. This article examines data from two studies that included information about the use of social support by abused women during their stay in a transition house. Analysis revealed a potential for problems when vulnerable clients offer support to other vulnerable clients. The ability to offer support was viewed by the "givers" to be evidence of their own recovery. Women needed to give this support, and, therefore, it was often difficult to know whose needs were being met. The complexities of these relationships are discussed. An understanding of the issues involved will ensure that maximum benefit with minimum risk can be derived by participants in supportive exchanges between peers.

The effects of short and long-term growth hormone replacement therapy in hypopituitary adults on lipid metabolism and carbohydrate tolerance

The effects of replacement with biosynthetic human GH on carbohydrate tolerance and lipid metabolism were studied in 40 hypopituitary adults during a randomized double blind, placebo-controlled trial for 6 months, followed by a 12-month open trial. The daily GH dose was 0.04 +/- 0.01 IU/kg. Fasting plasma glucose, serum fructosamine, plasmid lipids, lipoproteins, and plasma C-peptide concentrations were measured, and an oral glucose tolerance test was performed every 6 months. There was no change in fasting triglyceride levels at any stage of the study. There was no significant change in fasting total or LDL cholesterol, total HDL cholesterol, high density lipoprotein2 (HDL2) cholesterol, HDL3 cholesterol, apoprotein-A1, or apoprotein-B during GH or placebo treatment in the placebo-controlled 6-months study. In the open phase of the trial, total and low density lipoprotein cholesterol showed a sustained downward trend during GH therapy. Compared to the pretreatment level, the HDL cholesterol concentration was significantly higher at 18 months. Cholesterol subfractions HDL2 and HDL3 and apoprotein-A1 and -B were not different from the pretreatment levels. The total/HDL cholesterol ratio decreased significantly at 12 and 18 months. During the controlled phase, fasting plasma glucose was similar during GH and placebo administration, but fasting insulin and C-peptide increased during GH therapy, but not during placebo treatment. The mean area under the curve (AUC) for glucose increased by a small, but significant, extent over the 6 months of GH treatment and was higher at 6 months than during placebo treatment. The AUC for insulin also increased during GH treatment. During the open trial, the fasting plasma glucose level increased at 6 and 12 months, and the fasting plasma insulin level increased at 6, 12, and 18 months of GH treatment. The plasma glucose AUC during the oral glucose tolerance test was significantly higher at 6 months, and the plasma insulin AUC was significantly higher at 6, 12, and 18 months of GH therapy. In conclusion, GH therapy has some metabolic effects that are considered beneficial and others that are less desirable.

Post-heparin plasma lipase activity in hypopituitary adults

Twenty-six hypopituitary patients on conventional replacement therapy were compared with 31 matched normal controls. Plasma lipoprotein lipase (LPL) and hepatic lipase (HL) activities were measured 15 min after a bolus of intravenous heparin (100 IU/kg body weight). Fasting plasma lipids, lipoproteins, glucose and insulin and triceps to subscapular skin fold ratio and waist to hip circumference ratio were also measured. Total and low density lipoprotein cholesterol were significantly higher in patients than in controls. Plasma activity of both LPL and HL was significantly higher in hypopituitary patients than in controls (p < 0.005 and p < 0.04 respectively). When men and women were analysed separately, significant differences between HP patients and controls remained for total cholesterol and LPL in women and for HL in men.

Necrotizing pancreatitis: operating for life

Infected necrotizing pancreatitis is the most fulminant variety of this disease. Colonic involvement and retroperitoneal fasciitis are particularly lethal. The reported mortality is up to 50%. The purpose of this study is to review our combined experience at the Princess Alexandra Hospital and the Royal Brisbane Hospital, Brisbane, to determine whether patient survival was related to a particular etiology, treatment, or complication. All patients treated since 1986 with infected pancreatitis who required surgical necrosectomy and then ventilation in the intensive care unit (ICU) were studied. There were 48 patients so managed. The median age of survivors was 52 years, and for those who died it was 64 years (p = 0.001). The etiology was gallstones in 22 and alcoholism in 12. Of the alcoholics, 11 survived and 1 died. Of the patients with gallstones, 13 survived and 9 died. There was an overall mortality of 31%. Survivors were in hospital for a median of 73 days, whereas deaths occurred after a median of 35 days (p = 0.04). Seven patients underwent hemofiltration; five survived, and two died. N-Acetylcysteine has been used in four patients, of whom three survived and one died. The abdomen was left open in 38 patients and kept closed in 10. Although Ranson's criteria at admission to the ICU did not predict survival, it was found that the median APACHE II score in survivors was significantly lower than in those who died (p = 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)

Power and knowledge in nursing practice: the contribution of Foucault

This paper explores the implications of Michel Foucault's philosophical analyses for understanding nursing practice. Foucault describes power within a given society as unfolding not through large-scale events but rather through a complex 'micro-physics'. Power operates upon the human body. With the increasing use of observation, in understanding both the natural and social world, the body has become the subject of the 'gaze'. The body as object, however, is neither a universal belief nor truth but a product of ways of perceiving and examining it. In relation to nursing, the subjection of the body to the 'gaze' and the practices of the institutional environment of the hospital are important for understanding the knowledge formulated. The power of practice is in the generation of knowledge. The nature and form of knowledge is instrumental in establishing the quality of nurse-patient relationships. This paper explores, through the particular exemplar of the patient in intensive care, the power of present practices to shape knowledge, and thereby dictate and limit the quality of the nurse-patient relationship.