An investigation into the aspirations and experiences of newly appointed dual diagnosis workers

This qualitative, exploratory study was designed to explore a sample of eight recently appointed dual diagnosis workers' (DDWs) perceptions of their new role and function in Northern Ireland (NI). A semi-structured interview was used and respondents were assured that their anonymity/rights would be protected. All of the narratives were shown to the respondents for their approval prior to going to press. The transcripts were analysed by using a tried and tested analytical framework. Seven key categories emerged from the findings relating to the DDWs perceptions of their: (1)understanding of the term dual diagnosis; (2) hopes; (3) fears; (4) support in their new role; (5) key clinical issues; (6) the positioning of the service; and (7) their overall role and function. This is a new and important area of work in NI. However, to date, no research has been carried out on the topic in the province. Consequently, the findings from this small study could go some way towards helping to shape the future direction of, and bring about some universality to the provision of the dual diagnosis service within different National Health Service Trusts in NI. Further research is required on this new and growing service as well as on the service users' perceptions of the care provided by DDWs. The study will be followed up on an annual basis for 3 years to provide longitudinal data. Generalization of findings requires caution because of the small sample size.

Early life experiences and their impact on our understanding of depression

This paper presents part of a larger Grounded Theory study, which was designed to capture a sample of people's perceptions of living with or, caring for, individuals with depression. Data were collected from a focus group consisting of people with depression (n = 7). In-depth one-to-one interviews were undertaken with eight further respondents (n = 8). Purposeful sampling was used initially. Thereafter, in keeping with one of the key tenets of grounded theory, theoretical sampling was used. The emergent concepts were pursued until saturation occurred. The constant comparative approach was used to analyse the data together with the NVivo qualitative analysis software package. This paper focuses on the respondents' perceptions of the pre-diagnosis, depression encounter. The key category that emerged was 'the pre-diagnosis phase of depression and the now experience'. Five key themes surfaced within this category: (1) negative impact significant life events; (2) self-blame; (3) personal characteristics; (4) pre-diagnosis, depression unknowingness; and (5) pre-help seeking. The findings suggest that those in the field of human services need to better understand the lived experience of people with depression, in order to provide holistic treatment and care.

Naming of depression: nursing, social and personal descriptors

This paper explores descriptors of depression and begins by exploring nursing descriptors including the nature of assessment and nursing diagnosis and progresses to underpin these major processes by considering social descriptors such as cultural and spiritual constructs. The role and influence of stigma is discussed and an examination of gender influences and experiences is undertaken. The paper concludes by examining personal descriptors in the literature. The overall aim of the paper is (1) to add to nursing knowledge by depicting the grounded realities of the experience of depression and (2) stimulate discussion on the need to provide holistic care pathways that are responsive to the uniqueness of this lived experience and finally to (3) encourage further research on key psycho-social factors associated with depression and the concurring advancement of nursing care. This paper has been completed in the context of an ongoing study into the grounded experience of 'Depression' and the development of a psychiatric nursing theory of connectivity.

[The best of vascular medicine in 2006]

Peripheral arterial disease (PAD) remains an under-diagnosed affection, and the ankle-brachial index (ABI), a simple diagnostic method, is poorly known and seldom used, and the vascular patient's prescription list is frequently insufficient regarding results obtained in large trials with good methodology. The French ATTEST study underlines the fact that ABI is measured in less than 1 out of 3 patients with PAD. In ATTEST study, less than 10% have the triple therapy validated in PAD : antiplatelet drugs, statins and ACE-inhibitors. The international REACH registry included more than 60 000 patients suffering from atherosclerosis, including 8 000 cases with PAD. This survey evidences that in PAD patients, the annual cardiovascular complication rate is significantly higher than in patients with coronary artery disease (18 vs 13%); again PAD appears systematically under-treated when compared to CAD. These epidemiological surveys highlight the importance of screening of atherosclerotic lesions with the aim of setting an active prevention of CV complications. The new guidelines insist on the screening of PAD in patients at risk, as well as on the importance of the global management after initiating the triple therapy, independent of the CV risk factors. In a 5-year longitudinal study from an initial cohort of 2265 subjects, Aboyans et al. studied the progression of PAD by repeated measurements of ABI at the level of ankles and toes. Factors of progression for large-vessels PAD were active smoking, the total/HDL-cholesterol ratio, Lp(a) and CRP. Importantly, diabetes was not associated to the PAD progression in large vessels, but in contrast, it was the sole factor associated to the progression of PAD in small vessels. In an Austrian study published this year in the NEJM, Schillinger et al. compared balloon angioplasty versus the use of Nitinol stent for the treatment of long stenoses of the superficial femoral artery. In case of claudication, these lesions are usually treated medically, whereas surgery is required for more severe cases. The fact that stenting these long lesions of the superficial femoral artery provides benefits in terms of restenosis opens a approach for the endovascular therapy, to be confirmed by larger trials.

Establishment of an immunoglobulin�A?deficient blood donor registry with a simple in-house screening enzyme-linked immunosorbent assay

BACKGROUND

Transfusion of blood products to immunoglobulin A (IgA)-deficient patients who have developed IgA antibodies can result in serious adverse reactions. To prepare compatible blood components for these patients, blood centers usually maintain a list of IgA-deficient blood donors. An in-house enzyme-linked immunosorbent assay (ELISA) was used to identify new IgA-deficient blood donors.

STUDY DESIGN AND METHODS

An in-house ELISA was used to screen blood samples. IgA-deficient samples, defined as an IgA level below 0.05 mg per dL, were sent to the American Red Cross for confirmatory testing.

RESULTS

Seventy-three confirmed IgA-deficient blood donors were identified among 38,759 screened blood donor samples (frequency, 1:531). IgA antibodies were found in 39 of these 73 blood donors (53%), although only 9 donors had a history of adult IgA exposure (transfusion or pregnancy).

CONCLUSIONS

With a simple in-house ELISA, 73 blood donors were identified as IgA-deficient. From this number, 34 donors, without detectable anti-IgA in their plasma, were added to our IgA-deficient blood donor panel to maximize the management of our inventory of IgA-deficient frozen blood components.

[Carotid endarterectomy: current indications]

Indications for carotid endarterectomy have been clarified after the publication of European and North American randomised controlled trials between 1990 and 2004. Recent analysis of pooled data concerning symptomatic carotid stenosis has enhanced the initial results. Surgery in complement to best medical treatment is indicated for stenosis equal or superior to 70% (American calculation of degree of stenosis), especially if the patient is a man, older then 75 years, during the first 2 weeks after the initial neurological event. Benefit of surgery for stenosis between 50 and 69% appears only after 2 years. Surgery is also beneficial for asymptomatic severe stenosis but the precise threshold of carotid stenosis remains unclear. The benefit is lower for women and would be greater in case of stenosis more than 70%, and for patients less than 75 years.

Recent Canadian experience with targeted hepatitis C virus lookback

BACKGROUND

Targeted hepatitis C virus (HCV) lookback studies have been performed in Canada since 1995. The yield of HCV lookback has not been reassessed since the introduction of improved HCV screening tests.

STUDY DESIGN AND METHODS

Data were combined from the two Canadian blood suppliers to determine the yield of targeted HCV lookback performed on donors found to be HCV-positive by antibody screening and/or nucleic acid testing (NAT) from the introduction of NAT in 1999 until January 1, 2005.

RESULTS

Lookback was performed on 498 donations from 176 HCV-seropositive and two NAT-only-positive donors; 494 components had been transfused, and 160 components were traced to living recipients who underwent HCV testing. Seventy-two percent of recipients of components derived from donations given before the introduction of second-generation enzyme immunoassay (EIA) testing were HCV-seropositive. Four recipients of components derived from donations tested by second- or third-generation EIA, with or without NAT, were HCV-seropositive. Two of these recipients tested HCV-seropositive before transfusion, and a third was probably infected by transfusions before the introduction of HCV testing. The fourth recipient likely received a noninfectious transfusion, since five other recipients of components from subsequent donations made by this donor were seronegative.

CONCLUSION

When previous donations had been tested by second- or third-generation EIA, the yield of HCV lookback was likely zero. Because HCV infection is relatively common in the general population and patients in Canada do not undergo pretransfusion testing, coincident infections in recipients may be erroneously attributed to transfusion. The regulatory requirement for HCV lookback should be reassessed.

Suicide: a literature review and its implications for nursing practice in Taiwan

In recent years the suicide rates have been increasing gradually in many countries. In order to reduce the number of suicides, further research on suicide and the nursing care of suicidal people is required to enhance and advance the quality of suicide nursing care provided. Statistical evidence shows that the most common method of completing suicide in many countries is hanging. Other evidence demonstrates that some suicides could be prevented if all patients were assessed for suicide risk and if psychiatric nurses provided effective nursing care, which centres on therapeutic communication skills. This paper explores the literature on suicide and on the nursing care of people who are suicidal, and also on the importance of integrating theory with practice.

Compliance of abdominal aortic aneurysms evaluated by tissue Doppler imaging: Correlation with aneurysm size

OBJECTIVES

Several studies have shown that an increase in abdominal aortic aneurysm (AAA) growth rate occurs when the diameter reaches 40 to 50 mm. AAA expansion is related to remodeling of the parietal extracellular matrix. The parietal mechanisms involved in this critical phase of sudden increase remain unexplained. Analysis of AAA wall movements and determination of AAA compliance may provide information about the constitution of the arterial wall. If a change in parietal wall motion somewhere between 40 and 50 mm could be shown, this would contribute to the understanding of the growth of AAA. Furthermore, it would provide a valuable additional parameter for AAA monitoring. This study had two aims: first, to evaluate the relationship between AAA compliance and maximum diameter using the tissue Doppler imaging system; and second, to test the hypothesis of a change in AAA behavior at around 45 mm in diameter.

METHODS

Fifty-six patients with AAA (mean diameter, 39 mm) were prospectively investigated using the tissue Doppler imaging system, which provides information concerning arterial wall motion. Maximum mean segmental dilation (MMSD), segmental compliance, pressure strain elastic modulus (Ep), and stiffness were determined and related to the maximum diameter of AAA. Results After natural log transformation of all variables, there was a significant positive linear relationship between maximum diameter and both MMSD (P < .001) and segmental compliance (P < .001) but not with Ep or stiffness (P = .37 and .22, respectively). MMSD and segmental compliance were significantly higher in AAA > or = 45 mm than in AAA < 45 mm (P < .0002 and <. 004, respectively). Ep and stiffness tended to decrease in larger AAAs, but this was not statistically significant (P < .43 and .24, respectively). Dispersion of Ep and stiffness values seemed to be wider among AAA < 45 mm compared with those > or = 45 mm.

CONCLUSION

Compliance parameters can easily be measured during routine AAA ultrasound monitoring using the tissue Doppler imaging system. The study showed an increase in MMSD and segmental compliance as well as a nonsignificant trend toward increased distensibility (decreased Ep and stiffness) with increased AAA diameter. A change in dispersion of AAA distensibility may appear around 45 mm in diameter, but a larger study will be needed to clarify this.

Nursing people who are suicidal on psychiatric wards in Taiwan: action/interaction strategies

Suicide is a major mental health problem in Taiwan. Estimations revealed that approximately 41% of people who committed suicide had a previous history of psychiatric inpatient care. To date, a suicide nursing care theory has not been developed. Consequently, the aim of this study was to formulate a suicide nursing care theory with the aim of enhancing and advancing the nursing care provided to people who attempt suicide or have suicidal thoughts. A qualitative approach using grounded theory was adopted. A total of 15 peoples who had either suicidal ideas or had attempted suicide and 15 psychiatric nurses were interviewed and observed. Data were analysed using open, axial and selective coding and the NUD*IST software program. A substantive theory of suicide nursing care was developed from the emergent findings. Four categories surfaced in the nursing care theory relating to the nurses' 'action/interaction strategies'. They were: the holistic assessment of people who are suicidal; providing protection; providing basic care; and providing advanced care. The findings from this study could be used to influence and advance nurse education and training, clinical practice, management and further research.

Mucosal melanoma: case report and review

Mucosal melanoma is a rare form of cancer that results from an abnormal proliferation of melanocytes within mucosal surfaces of the body. Due to the limited number of cases in the general public and even fewer cases in the reported literature, it is difficult to conduct research on this cancer. The following is a case presentation of a sinonasal mucosal melanoma followed by a review of the current literature detailing the epidemiology, signs and symptoms, diagnostic methods, and various methods of treatment that are currently used to combat this illness.

The effects of conjugated linoleic acid supplementation on immune function in healthy volunteers

OBJECTIVE

To assess the effects of dietary supplementation using two isomeric blends of conjugated linoleic acid (CLA) on immune function in healthy human volunteers.

DESIGN

Double-blind, randomised, placebo-controlled intervention trial.

SUBJECTS AND INTERVENTION

A total of 55 healthy volunteers (n=20 males, n=35 females) were randomised into one of three study groups who received 3 g/day of a fatty acid blend containing a 50:50 cis-9, trans-11: trans-10, cis-12 CLA isomer blend (2 g CLA), and 80:20 cis-9, trans-11: trans-10, cis-12 (80:20) CLA isomer blend (1.76 g CLA) or linoleic acid (control, 2 g linoleic acid) for 8 weeks.

RESULTS

Supplementation with the 80:20 CLA isomer blend significantly (P< or =0.05) enhanced PHA-induced lymphocyte proliferation. CLA decreased basal interleukin (IL)-2 secretion (P< or =0.01) and increased PHA-induced IL-2 and tumor necrosis factor alpha (TNF(alpha)) production (P< or =0.01). However, these effects were not solely attributable to CLA as similar results were observed with linoleic acid. CLA supplementation had no significant effect on peripheral blood mononuclear cells IL-4 production, or on serum-soluble intercellular adhesion molecule-1 (sICAM-1) or plasma prostaglandin E2 (PGE2) or leukotreine B4 (LTB4) concentrations.

CONCLUSIONS

This study shows that CLA supplementation had a minimal effect on the markers of human immune function. Furthermore, supplementation with CLA had no immunological benefit compared with linoleic acid.

Compliance of abdominal aortic aneurysms: evaluation of tissue Doppler imaging

Expansion of abdominal aortic aneurysms (AAA) is due to remodeling of the parietal extra-cellular matrix and may lead to rupture. This remodeling is reflected by compliance which may be an indicator of AAA behavior and thus useful for clinicians. Tissue Doppler Imaging (TDI) is an ultrasonographic modality which allows wall motion measurements along an arterial segment. It has previously been evaluated in normal aortas and was then evaluated in thirty-five patients with AAA. Mean values (+/-standard deviation) characterizing maximum diameter AAA compliance were dilation 809 mum (+/-465), strain 2.2% (+/-1), pressure strain elastic modulus 3.94 10(5) Pa [3.25; 4.8] and stiffness 28.8 [24; 34.5], last values being expressed as geometric mean [interquartile range]. They were in accordance with those previously obtained with other systems. Segmental parameter values were maximum mean segmental dilation 534 mum (+/-305) and segmental compliance 14.6 (+/-8.3) 10(-2) mum/Pa. Reproducibility was appropriate for clinical studies. The TDI system is simple and reliable for measurement of AAA compliance, and compliance can easily be recorded during routine ultrasound control.

Aortic compliance in healthy subjects: evaluation of tissue Doppler imaging

Increased compliance of abdominal aortic aneurysms at maximum diameter over time might be related to rupture. Compliance could, therefore, be valuable in their management. However, such measurement requires a sophisticated system. An original arterial wall-motion measurement technique, based on tissue Doppler imaging (TDI) and providing segmental exploration, was applied to the study of aorta walls. We report its validation in healthy subjects. Technical feasibility was reliable. The time required for sequence acquisition and transfer was suitable for routine clinical use and the quality of the sequences provided precise identification of the aorta wall/lumen interface and accurate segmentation. The values characterising normal aortic compliance were similar to those previously published, and the initial results concerning reproducibility were appropriate for clinical studies. Further refinements may improve it. This study validates the TDI system for measurement of abdominal aortic compliance in healthy subjects. Study of application to aneurysm compliance is in progress.

Imagerie des pathologies vasculaires spécifiques

The diagnosis of vascularitis should be proposed when a concentric and regular thickening of the wall of the aorta or one of its branches is observed or when there is late enhancement of the arterial wall, on sites which are usually free from atheromatous lesions and in a young patient. The radiologist must be aware of the associated clinical signs: oral and genital ulcerative lesions in the Behçet syndrome; finger necrosis in a young male smoker in Buerger disease; hip and shoulder arthropathy and headache in a 70 Year old female and Horton disease; pulseless upper limbs and inflammatory syndrome in a young adult for the Takayasu arteritis. The diagnosis of popliteal entrapment or adventitial cyst should be proposed in young patients without atheromatous lesions.

Quand, comment et pourquoi réaliser une imagerie des carotides extracrâniennes ?

The indications for treating carotid artery stenosis are related to the symptomatic nature of the lesion and the degree of stenosis. Duplex sonography is adequate for screening. While some groups believe that Duplex US alone or in combination with transcranial Doppler imaging may be sufficient for presurgical evaluation, it often is recommended to complete the evaluation with either MRA or CTA. Both techniques are advantageous since they allow evaluation of the cervical and intracranial arteries as well as cerebral parenchyma hence providing valuable information prior to definitive management. Catheter angiography remains indicated in patients with multi-vessel disease and ischemic cardiomyopathy, when results at non-invasive evaluation are discordant or in an emergency setting. Duplex US is used for routine follow-up of non-surgical lesions and after endarterectomy. Transcranial Doppler as well as advances in MRA and CTA techniques will be reviewed. Even though the treatment of atherosclerotic carotid artery stenoses remains primarily surgical, specific considerations related to angioplasty will be reviewed. Finally, diseases of the intracranial carotid artery and non-atherosclerotic diseases (dissection...) will also be discussed.

[Carotid artery angioplasty: where are we in 2004?]

Carotid artery stenting (CAS) is currently being investigated as an alternative treatment to carotid endarterectomy (CEA). Cerebral embolism is the most serious risk of CAS. Carotid artery stenting is still not reimbursed and unauthorised not authorised in routine in France (excepted in trials with ethical committee approval). CAS is now feasible, with a high technical success, which may improves with learning curve and with a better patient selection of the patients. A number of higher risk situations for CEA represents ideal indications for CAS, such as restenosis after CEA, stenosis due to prior neck radiation and radical neck surgery, and lesions in the distal internal carotid artery or involving high, retromandibular bifurcation.

Thrombose veineuse plantaire interne et anticorps anticardiolipine. Cas clinique

We report a case of isolated plantar venous thrombosis in a young female with no recent history of surgery or trauma who complained of spontaneous left talalgia. She was treated with aspirin for a lupus anticoagulant. The diagnosis was established on the basis of color duplex ultrasonography. The patient was given long-term oral anticoagulants in accordance with international recommendations. Veins other than the usually examined regions, such as plantar veins, should be explored in patients with a known thrombophilic condition who present spontaneous talalgia. Presence of an isolated plantar venous thrombus in a patient with no known coagulation abnormality is suggestive of thrombophilic disease.

Pharmacokinetics and tolerability of a bioadhesive buccal testosterone tablet in hypogonadal men

OBJECTIVE

A phase I single centre, open label study of the pharmacokinetics and tolerability of a buccal testosterone tablet (COL 1621) was carried out.

DESIGN

Twelve testosterone-deficient males were treated with the buccal tablet twice daily for 7 consecutive days. Multiple blood samples were drawn for testosterone, dihydrotestosterone (DHT), bioavailable testosterone and sex hormone-binding globulin (SHBG).

RESULTS

After COL 1621, means+/-S.D. serum testosterone level increased to a peak concentration of 26.6+/-5.8 nmol/l (7.7+/-1.7 ng/ml) at 4.8+/-5.8 h and stayed in the eugonadal range. Steady state was achieved within the first 24 h and was maintained in the normal range. The bioavailable testosterone, DHT and free testosterone index followed a pattern very similar to that of testosterone. The mean serum testosterone to DHT ratio was within the normal male range throughout treatment. There was only one treatment-related adverse event (headache). Two-thirds of patients indicated that treatment with COL 1621 was acceptable and that the tablet was convenient to use. Six patients (50.0%) preferred COL 1621 to their previous testosterone replacement therapy, two patients gave preference to their previous treatment and three patients found both treatments to be equally acceptable. Data for one patient was not available.

CONCLUSION

We conclude that COL 1621 can efficiently elevate serum testosterone and DHT levels in hypogonadal men within the first day of application, achieve a steady state within 24 h and maintain serum testosterone in the normal range with a twice-daily treatment regimen. COL 1621 provides an effective alternative oral testosterone replacement therapy that gives physiological levels of testosterone and is well tolerated by the patients.

Glutamate causes a loss in human cerebral endothelial barrier integrity through activation of NMDA receptor

l-Glutamate is a major excitatory neurotransmitter that binds ionotropic and metabotropic glutamate receptors. Cerebral endothelial cells from many species have been shown to express several forms of glutamate receptors; however, human cerebral endothelial cells have not been shown to express either the N-methyl-D-aspartate (NMDA) receptor message or protein. This study provides evidence that human cerebral endothelial cells express the message and protein for NMDA receptors. Human cerebral endothelial cell monolayer electrical resistance changes in response to glutamate receptor agonists, antagonists, and second message blockers were tested. RT-PCR and Western blot analysis were used to demonstrate the presence of the NMDA receptor. Glutamate and NMDA (1 mM) caused a significant decrease in electrical resistance compared with sham control at 2 h postexposure; this response could be blocked significantly by MK-801 (an NMDA antagonist), 8-(N,N-diethylamino)-n-octyl-3,4,5-trimethyoxybenzoate (an intracellular Ca2+ antagonist), and N-acetyl-L-cystein (an antioxidant). Trans(+/-)-1-amino-1,3-cyclopentanedicarboxylic acid, a metabotropic receptor agonist (1 mM), did not significantly decrease electrical resistance. Our results are consistent with a model where glutamate, at excitotoxic levels, may lead to a breakdown in the blood brain barrier via activation of NMDA receptors.

Human neuroepithelial cells express NMDA receptors

L-glutamate, an excitatory neurotransmitter, binds to both ionotropic and metabotropic glutamate receptors. In certain parts of the brain the BBB contains two normally impermeable barriers: 1) cerebral endothelial barrier and 2) cerebral epithelial barrier. Human cerebral endothelial cells express NMDA receptors; however, to date, human cerebral epithelial cells (neuroepithelial cells) have not been shown to express NMDA receptor message or protein. In this study, human hypothalamic sections were examined for NMDA receptors (NMDAR) expression via immunohistochemistry and murine neuroepithelial cell line (V1) were examined for NMDAR via RT-PCR and Western analysis. We found that human cerebral epithelium express protein and cultured mouse neuroepithelial cells express both mRNA and protein for the NMDA receptor. These findings may have important consequences for neuroepithelial responses during excitotoxicity and in disease.