Living with haemophilia and HIV/AIDS: support and coping

This paper describes sources and types of support, appraisal of support, and use of social support as a strategy for coping with Acquired Immune Deficiency Syndrome (AIDS)-related stresses. Thirty people with haemophilia, 23 family caregivers and 17 bereaved relatives participated. The study was conducted in two stages: individual interviews and mailed questionnaires. The key coping strategies used were 'normalizing personal relationships' and 'seeking informational support'. Informational support was provided by health professionals and practical aid by relatives. Respondents reported insensitivity, prejudice and avoidance from others. Participants needed peers for emotional and affirmational support, and professionals for informational support. The preferred intervention was support groups, co-led by professionals and peers.

Gay men's accounts of unsafe sex

This paper provides a qualitative analysis of the explanations given by a sample of 78 gay men in England of the most recent occasion on which they engaged in anal intercourse without a condom. Explanations are analysed and interpreted from the sociological perspective of 'accounts': that is, they are not viewed as exact descriptions of the 'real' motives for behaviour but are seen as a powerful resource that can illuminate the knowledge, assumptions and values that inform behaviour. Four distinct types of accounts were identified from the men's descriptions of the circumstances and motivations surrounding their most recent unsafe sexual encounter. These related to: (i) their emotional needs and drives; (ii) the calculus of risk; (iii) issues of trust; and (iv) lapses of control. Each of these types of account is described and the implications of the typology are considered, both for our understanding of the meanings, considerations and constraints surrounding high-risk sexual behaviour and for developing more relevant health education interventions.

Can academic medical centers compete in a managed care system?

The authors review characteristics of successful group practices, health maintenance organizations, and integrated service networks and then identify the critical actions that academic medical centers must take in order to compete with such service-oriented community providers. Centers must (1) form the clinical faculty into a competitive medical group that offers more price-competitive and user-friendly services; (2) restructure clinical training to be more relevant to the emerging practice situation; and (3) clearly delineate funding streams and identify the cross-subsidies taking place in the teaching, research, and patient care enterprises. These changes have the potential to strengthen clinical training and improve the financial positions of both the faculty and the university hospitals. The authors maintain that centers can make these and other necessary changes while still providing high-quality care and maintaining their educational and research functions; they cite organizations that have succeeded in these ways. However, as with all complex, large-scale organizations, public and private alike, the major factor limiting centers' ability to make the organizational changes required to successfully compete in the new health care environment is the lack of political will. It will be very difficult for academic medical centers to unite their powerful internal interest groups and take action without first experiencing a rather severe external jolt. The challenge for the leaders of academic medical centers is to prepare for the managed care jolt so that they can then guide their institutions to a new, more competitive position.

In vitro oxidative damage to tissue-type plasminogen activator: a selective modification of the biological functions

OBJECTIVE

Tissue-type plasminogen activator (t-PA) is an important component of the blood fibrinolytic system responsible for thrombus dissolution. It is often required to function under oxidative stress, and exogenous t-PA is used clinically in the treatment of acute myocardial infarction (AMI). The aim of this study was to examine alterations in the residual activity of t-PA pre-treated with certain oxidants.

METHODS

Recombinant t-PA (rt-PA) and native t-PA (nt-PA) were pre-treated with freshly generated hypochlorous acid (HOCl) and chloramine T at varying concentrations. The amidolytic activity, the plasminogenolytic activity and the fibrin-binding affinity were then examined using chromogenic assays based on S-2288 and S-2251.

RESULTS

The amidolytic activity of t-PA was surprisingly found to be rather sensitive (IC50 1 and 12 mumol/1, respectively), and the plasminogenolytic activity rather resistant to pre-treatment with HOCl and chloramine T. The fibrin binding study of treated t-PA revealed substantial loss of binding to CNBr-digested fibrinogen (FDP-CNBr). The velocity of t-PA in reaction with plasminogen remained the same as non-treated t-PA. The possible mechanisms of this asymmetrical oxidative modification of the biological functions are also discussed.

CONCLUSIONS

(1) The catalytic activity of t-PA and the binding affinity for its large-molecule substrate plasminogen, rather than the small-molecule substrate S-2288, are highly resistant to oxidative damage; (2) the fibrin-binding affinity of t-PA can be selectively and asymmetrically damaged by exposure to these oxidants. Thus it is possible that the characteristic advantage of thrombus selectivity of t-PA in both spontaneous thrombolysis and thrombolytic therapy may be diluted in circumstances where toxic and reactive oxidants exist.

Sexually transmitted diseases in Australia: a decade of change. Epidemiology and surveillance

Survival data in the last decade for sexually transmitted diseases (STDs) other than human immunodeficiency virus (HIV) are uneven across the states/territories. The incidence of gonorrhoea decreased by more than 80%, but at different times in different patient groups, different states, and different anatomical sites. There was a resurgence of rectal gonorrhoea in homosexual men in 1989-1991. Resistance to penicillin steadily increased, and partial resistance to quinolones has emerged. There was a marked decline in syphilis in most states. Lymphogranuloma venereum is rare, and chancroid seen mostly in returning travellers from Southeast Asia; however, hundreds of cases of donovanosis are seen annually among rural Aborigines. The prevalence of genital infections with Chlamydia trachomatis remained stable at 2.5%-14% in STD clinics, and 5% in family planning clinics. The numbers of cases of clinical genital herpes and warts are mostly unavailable. However, specific serology for herpes simplex virus type 2 (HSV-2) indicates that 14% of antenatal clinic patients, and 40%-60% of STD patients have been exposed. Pap smears have detected the presence of human papilloma virus (HPV) in 14%-40% of various clinic populations. Exposure to hepatitis B in the non-Aboriginal population decreased markedly. Hepatitis C infection occurred in a high percentage of injecting drug users; the evidence for sexual transmission is not strong. An epidemic of hepatitis A infection occurred in male homosexuals in 1989-1991. Changes in the Australian sex industry resulted in marked improvements in the sexual health of local (but not international) sex workers. The high levels of STDs in Aboriginal communities continues to cause concern.

Breast-carcinoma cell-lines with metastatic potential in mice

We established and characterized three human breast carcinoma cell lines (two with metastatic potential) by in vivo-in vitro propagation of tumor tissues. Tissues were processed in culture as i) direct explants (n = 185); ii) cell suspensions obtained after enzymic digestion (n = 29); or iii) explants of xenografts established in vivo (n = 18). Tissues processed as explants or cell suspensions generated no viable cell lines. However, three cell lines (MAXF-401, MAXF-583 and OHSTMAM-4) were established from xenografts. All three showed characteristic features of human breast tumor tissue. All were tumorigenic in mice and MAXF-401 and MAXF-583 showed frequent distant metastasis following s.c. transplantation. All three overexpressed EGFR, p53 and c-erbB2 proteins.

Clinical nurse specialist: walking the wire

Considered by many to be the panacea for all nursing's problems, the clinical nurse specialist (CNS) has only recently gained widespread recognition as a legitimate role in Australia. The CNS is the equivalent in other states and territories of the clinical nurse consultant, the charge nurse or the nurse unit manager. Implementation of the role has been complicated by inadequately delineated role functions, unrealistic expectations and limited recognition of clinical expertise. Using both quantitative and qualitative exploratory techniques it was found that three critical themes impinged in a negative way on the effectiveness of the CNS. These were role ambiguity, role overload and the 'paradox of power'. Maintaining clinical expertise in the practice setting is essential for high quality cost effective and autonomous nursing care and this can be provided through the effective implementation of the CNS role.

The clinical learning environment: nurses' perceptions of professional development in clinical settings

Although the complexity of the working environment of Registered Nurses has been acknowledged, the relationship between the social context of work and perceptions of professional development have not been systematically studied. This research was designed to identify and explore the attributes of effective learning environments in clinical settings. Following an initial exploratory study of perceptions and experiences of registered and student nurses, a conceptual framework was developed and tested. The findings of the study ware based on responses to a questionnaire (n = 516) which was developed as a tool for assessing organisational and social factors associated with perceived professional development in clinical settings. There was a significant and positive correlation between professional development and six independent variables: Autonomy and Recognition, Role Clarity, Job Satisfaction, Quality of Supervision, Peer Support and Opportunities for Learning. These variables accounted for almost 40% of the variance in perceived professional development. There were differences between hospitals and wards on most of the independent variables suggesting that some wards and institutions are more conducive to learning than others. The implications of the findings in terms of further research and practice are discussed.

Prospective evaluation of cerebral angiography and computed tomography in cerebral haematoma

One hundred and two consecutive patients with cerebral haematoma were prospectively allocated to one of two groups according to their CT on admission. Group 1 patients were thought to have a high probability of an underlying structural lesion and underwent cerebral angiography acutely. If normal, this was repeated at three months. Group 2 patients were thought not to have such a lesion and underwent angiography at three months. Patients older than the mean age of the study population, and hypertensive patients were much less likely to harbour an aneurysm or arteriovenous malformation than younger or normotensive patients (p < 0.01; sensitivity 87.9%, specificity 88.6%). An aneurysm or arteriovenous malformation was the cause of haemorrhage in 12.8% of hypertensive patients, in 30.9% of patients with haematoma involving the basal ganglia, and 18.2% of those with posterior fossa haemorrhage. Features of CT in isolation give a sensitivity of 77.2% and a specificity of 84.2%. Follow up angiography in group 1 showed an arteriovenous malformation in one of seven patients in whom the original study was normal. These results contrast sharply with data from previous retrospective studies. The decision to investigate a patient with cerebral haematoma should be primarily based on the patient's clinical condition, rather than on the site of haemorrhage.

Nurses' responses to patient anger: from disconnecting to connecting

Caring for angry patients can be a threatening experience. Grounded theory research was used to explore female nurses' reactions and feelings as the recipients of patient anger. The data were collected by interviewing nine female registered nurses in two hospitals in south-western Nova Scotia. The participants were asked to discuss their feelings and responses to an intense encounter with an angry patient. Anger was defined as a multi-dimensional concept with negative cogitations. The concept of self-efficacy emerged as the major area of concern for the participants. The findings suggest that when the threat to self was high, nurses managed anger situations by disconnecting from the angry patient. Low or controllable threats were generally managed by connecting with the angry patient.

Random-amplified-polymorphic DNA markers in sorghum

Conditions have been identified that allow reproducible amplification of RAPD markers in sorghum. High resolution of RAPD markers was accomplished by radiolabeling PCR-amplified DNAs followed by separation on denaturing 5% polyacrylamide gels. Reaction parameters including MgCl2 concentration and temperature significantly influenced yield and the type of amplification products synthesized. Unexplained amplified DNAs increased when more than 35 cycles of PCR amplification were used. Under standard conditions, approximately 80% of the primers tested amplified DNA, and most revealed 1-5 polymorphisms between BTx 623 and IS 3620C. Primers were used to amplify RAPDs in 32 genotypes of sorghum. In addition, 8 primers detected RAPDs in a population previously used to create an RFLP map for sorghum. These RAPDs were mapped successfully using a population of 50 F2 plants.

Regular partners and risky behaviour: why do gay men have unprotected intercourse?

Studies in both the UK and the USA continue to show that gay and bisexual men put themselves at risk of exposure to HIV through unprotected intercourse, most often with regular partners. As part of a larger study of homosexually active men, 310 men who had had unprotected anal intercourse with a man in the previous year were asked to describe the last occasion on which this had happened. The majority of men had had unprotected intercourse with a regular partner and did not perceived it as risky, although most did not know the HIV status of their partner. Regular and non-regular partners were perceived differently. Men were more likely to be emotionally involved in regular partners and to perceive unprotected penetrative sex with a regular partner as not risky. Future health education initiatives must take into account men's emotional involvement in regular partners and their perception of unprotected intercourse with such partners as not risky.

QT interval dispersion in chronic heart failure and left ventricular hypertrophy: relation to autonomic nervous system and Holter tape abnormalities

OBJECTIVE

To study QT dispersion in left ventricular hypertrophy and chronic heart failure and to determine the relation to ventricular arrhythmias.

SETTING

Investigational laboratory of a tertiary referral centre.

STUDY DESIGN

Patients with left ventricular hypertrophy and normal systolic function (n = 14) and patients with chronic heart failure (n = 18) were matched with controls (n = 17). The QT dispersion was examined in relation to abnormalities in resting mechanical and autonomic function and to the findings of 24 hour Holter monitoring.

MAIN OUTCOME MEASURES

QT dispersion is the difference between the maximum and the minimum QT values from the 12 lead electrocardiogram. Mean(SD) QT dispersion from the 10 lead electrocardiogram was also examined once the 12 lead minimum and maximum values had been removed. The QT distribution is the curve describing the distance from the mean for all QT intervals (ms).

RESULTS

All measures of QT dispersion were increased significantly in left ventricular hypertrophy and tended to increase in those with heart failure. The QT distribution was abnormal in both heart failure and left ventricular hypertrophy. There was no relation between the degree of change in QT dispersion and the incidence of ventricular arrhythmia on 24 hour Holter monitoring. Also there was no relation between QT dispersion and autonomic or mechanical abnormalities. The QT dispersion was related to QRS duration.

CONCLUSION

Though QT dispersion and distribution are abnormal in left ventricular hypertrophy these findings do not support the hypothesis that QT dispersion reflects arrhythmic risk in either hypertrophy or heart failure.

The best and the worst: students' experiences of clinical education

This paper reports on a component of a research project that was designed to identify the attributes of clinical settings which support learning. Thirty final semester nursing students were interviewed and asked to describe their best clinical learning experience. Students valued positive relations with ward staff and appreciated recognition for their contribution to patient care. The need to belong and be accepted by the ward staff was a common theme throughout all the interviews. Students enjoyed being busy and having an appropriate level of autonomy but found this difficult to achieve unless their role as students was clear to ward staff. The clinical lecturers' role appeared to be one of facilitation rather than instruction. The findings emphasise the importance of the culture of the workplace in determining the success of the learning experience. Implications for clinical education and directions for future research are discussed.

Perceptions of general practice among homosexual men

BACKGROUND

Primary care has an important role to play in the prevention and management of the human immunodeficiency virus (HIV). It has been suggested that homosexual men experience a variety of problems in relation to primary care.

AIM

As part of a larger study, it was decided to examine the extent to which a sample of homosexually active men experienced difficulties in general practice and whether they consulted their general practitioner for problems related to HIV or the acquired immune deficiency syndrome (AIDS).

METHOD

Homosexual men were recruited for interview in 1991-92 from a variety of sources including genitourinary clinics and homosexual organizations.

RESULTS

Of 623 men registered with a general practitioner 44% had not informed their general practitioner of their sexual orientation and 44% of the 77 men who were HIV antibody positive, as confirmed by the study, had not informed their general practitioner of this fact. Men who viewed their practice as unsympathetic towards homosexual men were less likely to have informed their general practitioner of their sexual orientation or HIV status. The majority of men (87%) nevertheless viewed primary care as an appropriate source of HIV/AIDS advice.

CONCLUSION

There is considerable scope for improvement in the acceptability of general practice to homosexual men.