Protecting vulnerable adults from abuse: a case study

Sadly, Ann’s situation is not uncommon. Elder abuse is on the increase. The Health Select Committee of the House of Commons recently reported that an estimated 500 000 older people suffer abuse; equivalent to between 5–9% of the older population (HC 111-1, 2004). The committee also found that the majority of abuse, approximately 67%, occurs in the person’s home. These statistics are confirmed by the results of a Community and District Nurse Association (CDNA) study which found that 88% of community nurses had encountered elder abuse in their caseload (CDNA, 2003).

The law of negligence and community nursing: a case study

Liability for carelessness is given its legal expression in the law relating to negligence. It is undoubtedly a frightening prospect for any professional to face a negligence claim. As well as any damages that may be awarded, Julia faces having her professional integrity and good name challenged in court and the prospect of further action being taken against her by her employer and regulatory body. This article considers the elements of a negligence action and how these are applied to health care.

Legal requirements for safe handling in community care

CASE STUDY

Andrea, a district nurse, together with home carers from the local social services department, has been caring for a wheelchair-bound patient with multiple sclerosis for 3 years. The patient requires assistance with going to the toilet and going to bed. She has always been reluctant to be moved using a hoist because of sudden spasms and this causes her great anxiety. Now the patient is refusing to be move mechanically and will only consent to being lifted manually. Andrea and the home care staff are concerned that this might place them at risk of injury and argue that it is against the trust and local authority moving and handling policy, which has a no-lift clause. Andrea would like to refuse to manually lift the patient but decides to check the legal position first.

Keeping secrets: confidentiality and the community nurse

The dilemma faced by Lucy Russell is one that is frequently faced by nurses in primary care, although generally the facts are far less dramatic. The common concern is what course of action is open to nurses when faced with a demand for information concerning a patient. In particular, under what circumstances can the professional duty of confidence be breached?

Putting the record straight: the importance of documentation

A nurse from Coventry was recently removed from the national register after failing to keep accurate records for patients in her care. She was found guilty of seven charges of misconduct. The committee heard that she failed to ensure care plans were prepared for several patients covering issues such as diabetes, pain management and dietary needs. On one occasion, she failed to notify staff of a patient's increased risk of haemorrhage following a drug error. The Nursing and Midwifery Council (NMC) found the nurse had systematically neglected a basic and crucial duty to keep proper records for the management of patient care.

Manual handling and the lawfulness of no-lift policies

Recent discussions over the plight of a woman who had spent a year sleeping in her wheelchair because the local NHS trust refused to allow her to be lifted into bed highlight the dilemma facing nurses when they are required to manually handle patients (Andrews and Robinson 2003). Nurses are acutely aware that the manual handling of patients can result in back injury (McGuire and Dewar 1993). Yet they are also aware that they owe a duty to patients to provide nursing care to meet their needs and that might only be achieved through manual handling. There is evidence that hospitals in particular have still not met the requirements of the Manual Handling Operations Regulations (Trevelyan 2000). The hazards of working in the community environment have generally been better addressed as part of the assessment for and delivery of individual care packages. This article considers the law's approach to balancing the opposing needs of nurses' and patients' health needs.

Senior Executive Adopt-a-Work Unit: A Model for Safety Improvement

BACKGROUND

At The Johns Hopkins Hospital (JHH), the patient safety committee created a safety program that focused on encouraging staff in selected units to identify and eliminate potential errors in the patient care environment. As part of this program, senior hospital executives each adopted an intensive care unit and worked with the unit staff to identify issues and to empower staff to address safety issues. JHH PATIENT SAFETY PROGRAM: The program consisted of eight steps, which together require six months for implementation: (1) conduct a culture survey; (2) educate staff on the science of safety; (3) identify staff safety concerns through a staff safety survey; (4) implement the senior executive adopt-a-work unit program; (5) implement improvements; (6-7) document results, share stories, and disseminate results; and (8) resurvey staff.

RESULTS

The senior executive adopt-a-work unit program was successful in identifying and eliminating hazards to patient safety and in creating a culture of safety.

DISCUSSION

The program can be broadly implemented. The keys to program success are the active role of an executive advocate and staff's willingness to openly discuss safety issues on the units. Regular meetings between the advocates and the units have provided a forum for enhancing executive awareness, increasing staff confidence and trust in executive involvement, and swiftly and effectively addressing areas of potential patient harm.

Court appearance 2: Presenting oral evidence in court

Mary Harris, a community children's nurse, has been concerned for sometime that two of her patients are being abused. She is required to give evidence at the family proceedings court. Mary is very apprehensive as this is her first court appearance. Last month Mary prepared for her appearance by looking at the structure and rules of the court. She also considered the criteria that had to be satisfied before magistrates could grant an order.

Court appearance 1: the English and Welsh court system

It is not surprising that Mary finds the prospect of appearing in court daunting. The process is very formal and steeped in tradition. The language, rules and etiquette are unfamiliar. However, courts and tribunals are a key part of the legal system. In child protection proceedings the court ensures fairness and is required to consider the child’s welfare as paramount (Children Act 1989, s1). With knowledge of what to expect and some simple planning Mary will be able to make a valuable contribution to this process to the benefit of the court.

Generosity or stealing? When accepting a gift can be theft

Patients often give gifts as a way of showing their gratitude for the care and support they have received from others. It is not unusual for a nurse or doctor to receive small gifts as a thank you or to commemorate a traditional anniversary such as a birthday or Christmas.

Administration of medicines. Part 2: Pharmacology

In the second part of this article, the authors examine the biological consequences for patients of changes in drug formulation, non-adherence to drug administration schedules and failure to accommodate drug/food interactions.

The right to refuse life-saving treatment: Who decides?

District nurse Alison has a patient, Nigel, who has type 1 diabetes that remains unstable. Nigel’s eyesight has deteriorated, his sexual function has dramatically reduced and he has now developed an infection in his right foot which requires immediate treatment. Nigel refuses the treatment and any further insulin declaring he would rather die than live the rest of his life like this. The GP says he will have Nigel detained under the Mental Health Act for assessment and enforced treatment, as his decision to refuse treatment amounts to suicide. Alison is concerned that Nigel will die without treatment, but also worries that to force treatment would be unlawful.

Administration of medicines. Part 1: The law and nursing

The authors outline the legal and professional consequences for nurses of failing to adhere to the law relating to the administration of medications. Part 2, next week, will look at the biological consequences for patients of non-adherence to drug administration schedules.

Tablet crushing and the law: the implications for nursing

The practice of crushing tablets is thought to be widespread. Whether this is done to make swallowing a medication easier for a patient with physical difficulties or to disguise the administration of a drug, there are several legal implications for nurses. Health professionals must be very sure that their reasons for crushing tablets could be justified in a court of law.

Accountability and drug administration in community care

Medicines are a key therapeutic intervention in community care but their adverse effects can give rise to concern for patient safety. This article considers the legal regulation of medicines with emphasis on the right to administer medicines and the standard of administration. It further considers the consequences for primary care staff of the inappropriate use of widespread practices such as tablet crushing and covert administration of medicine.

Impact of commercial pre-harvest processes on the prevalence of Salmonella enterica in cull sows

This study examined the impact of transport and lairage on Salmonella enterica prevalence in cull sows held under commercial conditions. Five sampling periods over 10 weeks yielded 181 selected culls. Fecal sample positives at the farm and collection point were 2% and 3%, respectively. After transport and lairage 41% of cull sows yielded S. enterica in one or more sampled tissues. A significant increase in cecal isolations was observed. The two S. enterica serotypes found at the production site and collection point were found at the abattoir, as were 13 other serotypes. Transport and lairage practices may contribute to an increased S. enterica contamination immediately prior to slaughter.

Ligand design for alpha(1) adrenoceptors

An area of continuing interest in medicinal chemistry is the design, synthesis and pharmacological evaluation of ligands which bind at adrenoceptor subtypes, which include alpha(1A), alpha(1B), alpha(1D); alpha(2A), alpha(2B), alpha(2C); beta(1), beta(2), beta(3) and possibly beta(4) subtypes. The selective blockade or stimulation of these receptor subtypes is of on-going pharmacological and medicinal interest. However, the design principles for ligand differentiation at these subtypes still need further development. This review focuses on alpha(1) adrenoceptors with a concentration on literature over the past five years. Structural, physiological and therapeutic aspects of the alpha(1A), alpha(1B) and alpha(1D) subtypes are discussed together with ligands binding to these receptor subtypes. Approaches to alpha(1) adrenoceptor ligand design based on known ligands and on receptor docking are evaluated. A new combined approach using pharmacophores and receptor docking affords possibilities for deeper insights into achieving small molecule binding selectivity.

A new technique for intraoperative graft angiography utilizing the radial artery stump

BACKGROUND

Angiographic visualization is the gold standard in evaluating the patency of newly constructed bypass grafts. With the growth of beating heart bypass grafting procedures, there is a need to confirm patency and document the success of the operative techniques.

METHODS

We have developed a new technique for performing intraoperative graft angiography following off-pump coronary artery bypass grafting (OPCABG) when utilizing the left radial artery as a free graft. Once the radial artery is removed, the proximal radial artery stump is cannulated using a standard femoral introducer sheath passed over an appropriately sized guide wire. The introducer is secured by simple ligature and the arm remains abducted during the construction of the grafts. Prior to heparin reversal, standard coronary angiographic catheters are introduced through the sheath and intraoperative images of the grafts obtained.

RESULTS

Transsternal OPCAB was performed in 7 patients using the left radial artery as a free graft followed by transradial artery completion angiography. A total of 18 grafts (2.5 per patient) were examined with an immediate patency rate of 100% and TIMI grade 3 flow in all grafts. Mean fluoroscopy time was 8.21 minutes. No angiographic or surgical complications occurred in this group.

CONCLUSIONS

Beating heart coronary bypass grafting is evolving as a new standard that competes with the traditional technique of cardiopulmonary bypass and elective cardiac arrest. With newer digital portable fluoroscopy systems, excellent imaging of newly constructed grafts can be obtained prior to completion of the procedure using a transradial approach. Verification of graft patency is the essential element in protecting the quality of surgical coronary artery reconstruction in the new era of beating heart surgery.

(-)-Spiro[1-azabicyclo[2.2.2]octane-3,5'-oxazolidin-2'-one], a conformationally restricted analogue of acetylcholine, is a highly selective full agonist at the alpha 7 nicotinic acetylcholine receptor

Neuronal nicotinic acetylcholine receptors are members of the ligand-gated ion channel receptor superfamily and may play important roles in modulating neurotransmission, cognition, sensory gating, and anxiety. Because of its distribution and abundance in the CNS, the alpha 7 nicotinic receptor is a strong candidate to be involved in some of these functions. In this paper we describe the synthesis and in vitro profile of AR-R17779, (-)-spiro[1-azabicyclo[2.2. 2]octane-3,5'-oxazolidin-2'-one] (4a), a potent full agonist at the rat alpha 7 nicotinic receptor, which is highly selective for the rat alpha 7 nicotinic receptor over the alpha 4 beta 2 subtype. Preliminary SAR of AR-R17779 presented here indicate that there is little scope for modification of this rigid molecule as even minor changes result in significant loss of the alpha 7 nicotinic receptor affinity.

Development of computational and graphical tools for analysis of movement and flexibility in large molecules

We developed a computer program for the calculation and display of the difference distance matrices (DDMs) of macromolecules that has the ability to compare multiple structures simultaneously. To demonstrate its use, a data set of atoms for superimposition of the HIV-1 reverse transcriptase enzyme was defined using the coordinates for the 21 available crystal structures of this enzyme and its complexes. The DDM technique for superimposition data set generation allows selection of atoms that are invariant in all structures, is free from user bias, and represents the most accurate and precise method of producing such subsets. Comparison of this technique was made against other published methods of generating superimposition data sets, and it was found that significant differences in magnitude and trends of atom movements are observed depending on which data set was used.

Use and cost of hospital and community service provision for children with HIV infection at an English HIV referral centre

OBJECTIVE

To describe the use of hospital and community services for children infected with HIV and estimate the cost per patient-year by stage of HIV infection during the era of antiretroviral monotherapy.

DESIGN

Data on the use of hospital services were collected from case notes; the use of statutory and nonstatutory community services was recorded through diaries and interviews. Total cost estimates were calculated from unit costs from relevant hospital departments and community organisations.

SETTING

Children managed at St. Mary's Hospital (London, England) between 1 January 1986 and 31 December 1994, some of whom used statutory and nonstatutory community services in South East England between 1 November 1994 and 31 May 1996.

PATIENTS AND PARTICIPANTS

118 children with positive HIV antibody status.

MAIN OUTCOME MEASURES AND RESULTS

Mean inpatient days, outpatient visits, tests and procedures performed, drugs prescribed, community services used, associated unit costs and average cost estimates per patient-year by stage of HIV infection (1995/1996 values), and lifetime costs. Service provision during the study period was predominantly hospital-based. The use of services increased for different stages of HIV infection and increased with increasing severity of HIV infection. A shift from an inpatient-based to an outpatient-based service was seen between the periods 1986 to 1991 and 1992 to 1994. As symptoms evolved, children used more hospital inpatient services, with an accompanying shift in the use of community services from general services, such as schooling, to increased use of nurses, social care and home help. The estimated total cost of hospital and community care was 18,600 Pounds per symptomatic non-AIDS patient per year and 46,600 Pounds per AIDS patient per year. Similar estimates for children with indeterminate HIV infection and asymptomatic infection amounted to 8300 Pounds and 4800 Pounds per patient-year, respectively. Nondiscounted lifetime costs for hospital care amounted to 152,400 Pounds (44,300 Pounds to 266,800 Pounds) compared with discounted lifetime costs of 122,700 Pounds (42,000 Pounds to 182,200 Pounds); nondiscounted lifetime costs for community care amounted to 24,300 Pounds (7900 Pounds to 41,600 Pounds) compared with discounted lifetime costs of 21,000 Pounds (6800 Pounds to 32,000 Pounds).

CONCLUSIONS

The continued emphasis on the use of hospital services may be due to the small number of children infected with HIV, most of whom lived in the London metropolitan area where specialist care was concentrated in a few centres. A shift from an inpatient- to an outpatient-based service was observed over time; the advent of the use of combination antiretroviral therapy in this population may further facilitate a shift in service provision and promote shared care between specialist centres, local hospital and community-based services.

Ligand design for alpha1 adrenoceptor subtype selective antagonists

Alpha1 adrenoceptors have three subtypes and drugs interacting selectively with these subtypes could be useful in the treatment of a variety of diseases. In order to gain an insight into the structural principles governing subtype selectivity, ligand based drug design (pharmacophore development) methods have been used to design a novel 1,2,3-thiadiazole ring D analogue of the aporphine system. Synthesis and testing of this compound as a ligand on cloned and expressed human alpha1 adrenoceptors is described. Low binding affinity was found, possibly due to an unfavourable electrostatic potential distribution. Pharmacophore models for antagonists at the three adrenoceptor sites (alpha1A, alpha1B, alpha1D) were generated from a number of different training sets and their value for the design of new selective antagonists discussed. The first preliminary antagonist pharmacophore model for the alpha1D adrenoceptor subtype is also reported.

Regulation of microglial tyrosine phosphorylation in response to neuronal injury

The regulation and substrate specificity of microglial phosphotyrosine (ptyr) increases accompanying motor neuron degeneration in the rat spinal cord induced by injection of the cytotoxic lectin, ricin, into sciatic nerve were examined using specific enzyme inhibitors, immunohistochemistry, and Western blot analyses. Optical density measurements of immunostained sections show that microglial ptyr levels are elevated at 3 days postinjection. This period coincides with initial stages of neuronal degeneration, and ptyr levels are maximal at 7 days. We next asked whether this increase is due to increased tyrosine kinase or decreased tyrosine phosphatase activities by assaying ptyr immunostaining in animals that received osmotic pump infusion of the nonreceptor tyrosine kinase inhibitor, herbimycin A, for the 7-day survival period. When compared to the control ventral horn, microglial ptyr on the experimental side was attenuated by at least 45% in the presence of herbimycin A. In order to identify microglial substrates undergoing increased tyrosine phosphorylation, Western blot analysis was performed on hemicord and punch biopsy samples from control and experimental sides following ricin injection. A subset of two proteins was identified whose increased ptyr was almost completely attenuated in the herbimycin-A-treated animals. We conclude that the data support earlier indications that upregulation of microglial tyrosine phosphorylation is a key early event in response to neuronal injury. Further, this upregulation is due to turning on tyrosine kinase activities, particularly nonreceptor kinases, and the end product is phosphorylation of a very limited number of substrates. This suggests the activation of specific tyrosine phosphorylation pathways, which may represent critical therapeutic intervention points, rather than a global response. The results are discussed in terms of recent cell culture models of microglial activation and earlier data demonstrating elevated microglial ptyr in neurodegenerative disease.

Intramuscular rocuronium in infants and children: a multicenter study to evaluate tracheal intubating conditions, onset, and duration of action

BACKGROUND

This multicenter, assessor-blinded, randomized study was done to confirm and extend a pilot study showing that intramuscular rocuronium can provide adequate tracheal intubating conditions in infants (2.5 min) and children (3 min) during halothane anesthesia.

METHODS

Thirty-eight infants (age range, 3-12 months) and 38 children (age range, 1 to 5 yr) classified as American Society of Anesthesiologists physical status 1 and 2 were evaluated at four investigational sites. Anesthesia was maintained with halothane and oxygen (1% end-tidal concentration if <2.5 yr; 0.80% end-tidal concentration if >2.5 yr) for 5 min. One half of the patients received 0.45 mg/kg intravenous rocuronium. The others received 1 mg/kg (infants) or 1.8 mg/kg (children) of intramuscular rocuronium into the deltoid muscle. Intubating conditions and mechanomyographic responses to ulnar nerve stimulation were assessed.

RESULTS

The conditions for tracheal intubation at 2.5 and 3 min in infants and children, respectively, were inadequate in a high percentage of patients in the intramuscular group. Nine of 16 infants and 10 of 17 children had adequate or better intubating conditions at 3.5 and 4 min, respectively, after intramuscular rocuronium. Better-than-adequate intubating conditions were achieved in 14 of 15 infants and 16 of 17 children given intravenous rocuronium. Intramuscular rocuronium provided > or =98% blockade in 7.4+/-3.4 min (in infants) and 8+/-6.3 min (in children). Twenty-five percent recovery occurred in 79+/-26 min (in infants) and in 86+/-22 min (in children).

CONCLUSIONS

Intramuscular rocuronium, in the doses and conditions tested, does not consistently provide satisfactory tracheal intubating conditions in infants and children and is not an adequate alternative to intramuscular succinylcholine when rapid intubation is necessary.

What is the cost of getting the price wrong?

BACKGROUND

The objective of this study was to compare differences in cost estimates for paediatric HIV hospital service provision based on hospital prices with cost estimates obtained through a research-based service-specific costing exercise.

METHODS

Activity data on the use of hospital services of children by stage of HIV infection were collected from case-notes for 118 HIV antibody positive children, managed at St Mary's Hospital NHS Trust, London, 1 January 1986-31 December 1994. Hospital unit prices were obtained from the Hospital Trust Finance Department; unit cost estimates were obtained from relevant hospital departments through a research-based service-specific costing exercise. Financial data related to the 1993-1994 financial year, and were indexed to 1995-1996 prices. The main outcome measures were cost estimates per patient-year by stage of HIV infection. Three cost scenarios were calculated: first by linking activity data with hospital prices (Trust Prices); second by linking activity data with routinely available hospital prices plus units costs from the costing exercise where no relevant hospital prices existed (Supplemented Trust Prices); third, by linking activity data exclusively with unit costs from the hospital-specific costing exercise (Unit Costs).

RESULTS

There were substantial differences between unit cost estimates per patient-year based on Trust Prices and Supplemented Trust Prices compared with those based on Unit Costs. Differences increased with more intense use of services. The deficit based on Trust Prices compared with Unit Costs ranged from Pound Sterling 432 per patient-year for HIV negative children, Pound Sterling 574 for asymptomatic HIV-infected children, Pound Sterling 1288 for indeterminate children, Pound Sterling 1814 for children with symptomatic non-AIDS to Pound Sterling 7418 per patient-year for children with AIDS.

CONCLUSIONS

In this hospital, reliance on generic hospital prices to derive cost estimates for paediatric HIV services produced considerable underestimates of the cost of service provision compared with data derived through the costing exercise. If this occurs across all or most areas of service provision, this can lead to substantial financial deficits, which in turn may mean that the needs of specific client populations may not be met.

Identification of glutathionyl-3-hydroxykynurenine glucoside as a novel fluorophore associated with aging of the human lens

A novel fluorophore was isolated from human lenses using high performance liquid chromatography (HPLC). The new fluorophore was well separated from 3-hydroxykynurenine glucoside (3-OHKG) and its deaminated isoform, 4-(2-amino-3-hydroxyphenyl)-4-oxobutanoic acid O-glucoside, which are known UV filter compounds. The new compound exhibited UV absorbance maxima at 260 and 365 nm, was fluorescent (Ex(360 nm)/Em(500 nm)), and increased in concentration with age. Further analysis of the purified compound by microbore HPLC with in-line electrospray ionization mass spectrometry revealed a molecular mass of 676 Da. This mass corresponds to that of an adduct of GSH with a deaminated form of 3-OHKG. This adduct was synthesized using 3-OHKG and GSH as starting materials. The synthetic glutathionyl-3-hydroxykynurenine glucoside (GSH-3-OHKG) adduct had the same HPLC elution time, thin-layer chromatography R(F) value, UV absorbance maxima, fluorescence characteristics, and mass spectrum as the lens-derived fluorophore. Furthermore, the (1)H and (13)C NMR spectra of the synthetic adduct were entirely consistent with the proposed structure of GSH-3-OHKG. These data indicate that GSH-3-OHKG is present as a novel fluorophore in aged human lenses. The GSH-3-OHKG adduct was found to be less reactive with beta-glucosidase compared with 3-OHKG, and this could be due to a folded conformation of the adduct that was suggested by molecular modeling.

Patient satisfaction with HIV service provision in NPMS hospitals: the development of a standard satisfaction questionnaire. NPMS Steering Group

A self-completion satisfaction questionnaire evaluating the standard of care of HIV outpatient services was developed as part of the National Prospective Monitoring System on the Use, Cost and Outcome of HIV Service Provision in English Hospitals (NPMS). The questionnaire was designed in conjunction with service users and health care professionals, and piloted in three London and three non-London HIV clinics. In addition to testing alternative methods of administering the questionnaire, the pilot provided satisfaction scores on a variety of aspects of service provision for participating clinics. The questionnaire was completed by 548 respondents and was most effectively collected using a sealed box in the clinic waiting area. Mean satisfaction scores for the attitude and skills of staff members was 4.7 (95% CI 4.6-4.7) but satisfaction scores were significantly lower for the clinic environment with a mean of 4.1 (95% CI 4.1-4.2). Satisfaction scores did not differ significantly by gender, age, sexual orientation, ethnic group, employment status or severity of symptoms. London respondents were more satisfied with the clinic environment and seeing preferred members of staff than their non-London counterparts, however there were no other differences between clinics. The questionnaire functioned well in practice and provided meaningful and useful information for individual clinics as well as at aggregate level.

Docking experiments in the flexible non-nucleoside inhibitor binding pocket of HIV-1 reverse transcriptase

Docking experiments were undertaken using a number of published crystal structures of HIV-1 reverse transcriptase complexes with various non-nucleoside inhibitors. The docking method was validated by successfully docking each ligand, in the conformation found in the crystal structure of the complex with the enzyme, back into its binding pocket in the right orientation and position. Each ligand was then subjected to conformational searching and a database of unique low-energy conformations of all ligands established. Docking this database into each of the reverse transcriptase binding pockets showed that all inhibitors could be fitted into each different pocket, without alteration of the pocket geometry. This contradicts findings from earlier docking investigations and implies that the conformation of the binding pocket in each different complex is conserved sufficiently to allow particular uniform ligand binding modes. The inhibitor conformations selected by this docking process are mostly the same as the one the ligand adopts in its own pocket and the selected conformations and orientations exhibit an impressive degree of similarity in the arrangement of their steric and electronic features. A correlation has also been observed between inhibitor flexibility and tightness of fit into the pockets with the more flexible inhibitors achieving a tighter fit and thus fewer favourable orientations upon docking.

Modelling of adrenoceptor ligand targets based on novel medium- or macro-sized fused nitrogen heterocyclic systems

Novel medium- and macro-sized heterocyclic compounds were assessed for their potential as subtype-selective adrenergic ligands. Their conformational flexibilities were investigated and their geometric shapes were compared to rigid lead compounds of known selectivity. In the case of alpha 1A selective antagonists, interesting potential targets for synthesis and evaluation were identified by 'opening up' various rings of the fused-ring lead compound 1 by shared-bond cleavage. For alpha 2 selective ligands, compound 6 was the lead compound and the possibility of mimicking the fused-ring system via intramolecular hydrogen bonding was investigated. None of the potential targets were closely enough related in this case to the lead compound to warrant synthesis.

Incapable adults and informal admission: lifting the veil of deceit

Since 1959, informal admission has been used for the admission of non-resisting adults to hospital for treatment of their mental health problems. The Court of Appeal has ruled this practice unlawful. As a consequence, certain issues in relation to the admission and management of these patients will have to be reconsidered and while there will be positive repercussions for the management of patients there will also be some negative effects. This article considers the implications.

A quantitative investigation of the transannular amine-ketone (N...C=O) interaction in medium-sized heterocycles

The transannular N...C=O interaction in several medium-sized heterocycles has been investigated by force-field methods. Conformational searching has been performed at the molecular mechanics level using different methods and the conformers so generated have been reoptimized at RHF/6-31G(d). For selected conformers, N...C distances are reported, together with transannular bond orders and atomic charges. Good agreement with available X-ray crystallographic data is obtained for the transannular bond distance in cryptopine. Changes in the partial atomic charges derived from the electrostatic potential provide good support for the donor-acceptor model of transannular interactions. Partial charges derived with other methods do not give satisfactory results. Some force fields do not reproduce the transannular interaction very well. This is demonstrated and rationalized, and modifications are suggested and tested for these force fields with good results when comparing diagnostic geometric features with X-ray data.

Pharmacophore development for antagonists at alpha 1 adrenergic receptor subtypes

Many receptors, including alpha 1 adrenergic receptors, have a range of subtypes. This offers possibilities for the development of highly selective antagonists with potentially fewer detrimental effects. Antagonists developed for alpha 1A receptors, for example, would have potential in the treatment of benign prostatic hyperplasia. As part of the molecular design process, structural features necessary for the selective affinity for alpha 1A and alpha 1B adrenergic receptors have been investigated. The molecular modelling software (particularly the Apex module) of Molecular Simulations, Inc. was used to develop pharmacophore models for these two subtypes. Low-energy conformations of a set of known antagonists were used as input, together with a classification of the receptor affinity data. The biophores proposed by the program were evaluated and pharmacophores were proposed. The pharmacophore models were validated by testing the fit of known antagonists, not included in the training set. The critical structural feature for selectivity between the alpha 1A and alpha 1B adrenergic receptor sites is the distance between the basic nitrogen atom and the centre of an aromatic ring system. This will be exploited in the design and synthesis of structurally new selective antagonists for these sites.

Reactive astrocyte formation in vivo is regulated by noradrenergic axons

Beta adrenergic receptor antagonists greatly reduce reactive astrocyte formation induced by neuronal degeneration. To test the hypothesis that the density of noradrenergic innervation is a factor in the regulation of astrocytosis, we measured glial fibrillary acidic protein (GFAP) optical density after neuronal injury in central nervous system (CNS) regions with permanent noradrenergic sprouting or norepinephrine (NE) depletion. The injury model employs the injection of Ricinus communis lectin into a cranial or peripheral nerve to destroy CNS neurons without the blood-brain barrier disruption and lymphocyte infiltration associated with contusive or surgical lesions. We took advantage of the lack of an NE transporter in the terminals of certain classes of noradrenergic axons to produce noradrenergic sprouting in the trigeminal motor nucleus (MoV) with neonatal 6-hydroxydopamine (6-OHDA) treatment and to produce depletion of NE in the spinal cord dorsal horn with N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine hydrochloride (DSP-4) administration. In each of these regions, GFAP optical density in the region of reactive astrocytes on the Ricin lectin-treated side was compared with the untreated contralateral (control) side in animals with NE hyperinnervation or NE depletion. GFAP density was increased about 55% in the injured NE-hyperinnervated MoV and was decreased about 35% in the injured NE-depleted dorsal horn. The degree of reactive astrocyte formation to injury is known to vary in different regions of the CNS, and our results suggest that differences in noradrenergic innervation may contribute to this variation. Along with earlier findings that beta-adrenergic receptor blockade reduces reactive astrocyte formation, these data indicate that the noradrenergic innervation is a factor in the degree of astrocyte reactivity following injury.

Dealing with complaints: procedural changes

Many complaints can be dealt with by the staff immediately concerned. Complaints procedures have been criticised as being too complicated. New procedures will extend the terms of reference of the Health Service Commissioner and should simplify the complaints procedure.

HIV media campaigns and HIV-1 testing trends at London genitourinary medicine clinic, 1985-1993

OBJECTIVE

To describe HIV-related media events in the context of first-time HIV-1-antibody testing trends at a London genitourinary medicine clinic.

DESIGN

Demographic and behavioural data were collected prospectively for individuals tested for HIV-1 antibodies between September 1985 and September 1993, at the genitourinary medicine clinic of St Mary's Hospital, London.

RESULTS

A total of 19,242 individuals were tested of whom 37% were women. Of the men tested 60% were heterosexual. The women at first time of testing were significantly younger [29.3 years; 95% confidence interval (CI), 28.8-29.7] than the men (32.5 years; 95% CI, 29.2-35.8); mean ages for both sexes did not change significantly over time. Overall, 199 women and 1539 men tested HIV-antibody-positive. The proportions of women testing positive increased significantly over time (chi 2 = 21.7, degrees of freedom = 1; P < 0.001), whereas the proportion of HIV-positive men remained constant for all sexual orientation groups. The proportion of heterosexual women testing positive (2.8%) was similar to the proportion of HIV-positive heterosexual men (2.9%). HIV-positive individuals were significantly older for both sexes. Throughout the study period numerous education campaigns were run using a variety of media complemented by a number of other HIV-related media events.

CONCLUSIONS

Peak periods of attendance for HIV testing generally corresponded with increased HIV-related media activity and the greatest testing rates were observed when various HIV media events occurred concurrently. The increase in the number of heterosexuals tested suggests that the risk of heterosexual transmission of HIV has been recognized, at least among older individuals. The exact role of HIV-related media events, including celebrities disclosing their HIV-positive status, remains to be elucidated. Whether the relative under-representation of younger people is due to a lack of awareness, increased use of safer sex practices or reluctance to use the service also remains to be addressed. Given the increasing number of HIV-positive women and the relatively constant rate of HIV-positive tests in the male attendees an urgent need exists to assess the impact and effectiveness of specific HIV media campaigns.

Effect of standard-dose versus high-dose epinephrine on myocardial high-energy phosphates during ventricular fibrillation and closed-chest CPR

STUDY OBJECTIVE

To evaluate the effects of standard-dose versus high-dose epinephrine on myocardial high-energy phosphate metabolism during resuscitation from cardiac arrest.

DESIGN

Prospective, nonrandomized, controlled study using a swine model of cardiac arrest and resuscitation.

INTERVENTIONS

After anesthesia, intravascular pressure instrumentation, and ten minutes of ventricular fibrillation arrest, closed-chest CPR was begun. After three minutes of CPR, animals were allocated to receive either 0.02 mg/kg i.v. standard-dose epinephrine (eight) or 0.2 mg/kg i.v. high-dose epinephrine (nine). The animals underwent thoracotomy and rapid-freezing transmural myocardial core biopsy for high-energy phosphate analysis 3.5 minutes after epinephrine administration. High-energy phosphate values were blindly determined using high-pressure liquid chromatography.

RESULTS

Intravascular pressure (mm Hg) and high-energy phosphate (nmol/mg protein) results for standard-dose epinephrine versus high-dose epinephrine are, respectively, coronary perfusion pressure, 15.3 +/- 7.8 versus 23.7 +/- 5.5 (P = .0009); phosphocreatine, 0.4 +/- 0.8 versus 6.2 +/- 4.4 (P = .0003); adenosine triphosphate, 9.8 +/- 4.8 versus 12.7 +/- 5.7 (P = .30); adenosine diphosphate, 5.4 +/- 2.1 versus 6.1 +/- 1.3 (P = .41); and adenylate charge, 0.68 +/- 0.12 versus 0.72 +/- 0.12 (P = .87).

CONCLUSION

High-dose epinephrine does not deplete myocardial high-energy phosphate when given in this model of prolonged ventricular fibrillation. High-dose epinephrine increases coronary perfusion pressure compared with standard-dose epinephrine. High-dose epinephrine administration repletes phosphocreatine during closed-chest CPR, thereby increasing myocardial energy stores.

Beta-adrenergic receptor blockade suppresses glial scar formation

Several laboratories have shown that isoproterenol induces or accelerates cell process formation in primary astrocyte cultures. These observations, together with the demonstration of beta-adrenergic receptors in astrocytes isolated from adult rat brain, led us to test the hypothesis that beta-antagonists prevent astrocyte hypertrophy in the injured spinal cord. Since blood-borne macrophages express beta-adrenergic receptors and release cytokines acting on glial cells, we avoided physical trauma and induced glial scar formation indirectly by injecting the cytotoxic ligand Ricinus communis into the sciatic nerve. Seven days later sections of the lumbar spinal cord in regions of motor neuron degeneration were processed for glial fibrillary acidic protein (GFAP) immunocytochemistry. Astrocyte hypertrophy was evaluated by optical density measurements of immunolabeled GFAP. Seven days after ricin treatment there is a mean increase of GFAP in the ventral horn of 11.8 +/- 4.4% (P < 0.0001) compared to the intact side. When L-propranolol is continuously infused from a subcutaneously implanted osmotic pump at a concentration calculated to produce a free plasma level of 4.4 nM, the GFAP increase is only 3.2 +/- 3%, reflecting a 73% reduction in astrocyte hypertrophy (P < 0.001). Receptor autoradiography with the ligand [125I]iodocyanopindolol showed a 26% increase in beta-adrenergic receptor density on the gliotic side. After propranolol treatment, there was only a 3.5% increase in ventral horn beta-adrenergic receptor density in the region of the glial scar.(ABSTRACT TRUNCATED AT 250 WORDS)

Simultaneous amplification and detection of specific DNA sequences

We have enhanced the polymerase chain reaction (PCR) such that specific DNA sequences can be detected without opening the reaction tube. This enhancement requires the addition of ethidium bromide (EtBr) to a PCR. Since the fluorescence of EtBr increases in the presence of double-stranded (ds) DNA an increase in fluorescence in such a PCR indicates a positive amplification, which can be easily monitored externally. In fact, amplification can be continuously monitored in order to follow its progress. The ability to simultaneously amplify specific DNA sequences and detect the product of the amplification both simplifies and improves PCR and may facilitate its automation and more widespread use in the clinic or in other situations requiring high sample throughput.

HLA-DR, DQ and DP typing using PCR amplification and immobilized probes

A simple, rapid, and precise method of typing HLA class II polymorphism would be valuable in the areas of disease susceptibility, tissue transplantation, individual identification and anthropological genetics. Here we describe a method of analysing class II sequence polymorphism based on polymerase chain reaction (PCR) amplification and hybridization with oligonucleotide probes. One valuable property of sequence-based HLA typing strategies, like oligonucleotide probe hybridization, is that they reveal how and where two alleles differ, not simply that they can be operationally distinguished. The nature and location of HLA polymorphisms appears to be critical in disease association studies and are likely to be important in tissue typing for transplantation. New alleles at the DRB1, DPB1 and DQB1 loci are likely to be identified as this technology is applied to more and more samples, particularly in non-Caucasian ethnic groups. A new allele is uncovered as an unusual pattern of probe binding and then confirmed by sequencing. This pattern is observed because class II polymorphism is localized to specific regions and virtually all 'new' alleles have polymorphisms in the region of probe binding. Obviously, any new allele with a new polymorphic sequence in a region for which typing probes are not available would not be revealed by oligonucleotide typing. With the PCR primers and probes described here, 7 DQA1 alleles, 15 DQB1 alleles, 18 DPB1 alleles, and 32 DRB1 alleles are distinguished. Additional primers and/or probes can, of course, increase the allelic discrimination of oligonucleotide dot blot typing. These horseradish peroxidase (HRP)-labelled oligonucleotide probes are stable (greater than 2 years when stored at 4 degrees C) and the typing system is simple and robust. Over 500 samples from the CEPH pedigrees (unpublished data; A. B. Begovich, et al., manuscript in preparation) and greater than 1000 unrelated samples have been typed by this procedure. Although this dot blot/oligonucleotide hybridization procedure is a powerful and precise method of HLA class II typing, the complexity of the procedure increases as the number of probes required for analysis increases. The reverse dot blot method, based on an array of immobilized probes, allows the typing of individual samples in one single hybridization reaction. In this approach, a panel of unlabelled oligonucleotides are immobilized to a nylon membrane. The PCR product is labelled during the amplification reaction by using biotinylated primers and hybridized to the membrane. The presence of bound PCR product specifically hybridized to a given probe is detected using streptavidin-HRP conjugates and either chromogenic or chemiluminescent substrates.(ABSTRACT TRUNCATED AT 400 WORDS)

Hemodynamic effects of 1-[3,4-dihydroxyphenyl]-1,2-diaminoethane versus norepinephrine during ventricular fibrillation and cardiopulmonary resuscitation

We hypothesized that substitution of the hydroxyl group (OH) on the beta carbon of norepinephrine (NE) with an amino group would yield a compound, 1-(3,4-dihydroxyphenyl)-1,2-diaminoethane (DHPDAE), that would maintain the hemodynamic properties of NE during CPR, but would decrease the rate of post-defibrillation dysrhythmias. Six mixed breed swine weighing greater than 28 kg were studied. The animals were instrumented for cerebral (CBF) and myocardial blood flow (MBF) measurements. Ventricular fibrillation (VF) was induced. After 10 min of VF, CPR was begun. After 3 min of CPR, 2.5 mg/kg of DHPDAE was administered and CPR continued. Defibrillation was attempted 3.5 min after drug administration. CBF, MBF and defibrillation rates were compared to an historical control group receiving 0.16 mg/kg of NE. Outcome variables were compared using a Wilcoxon Rank Sum test and Fisher-exact test. NE significantly improved CBF and MBF compared to DHPDAE. All the animals in the NE group were successfully defibrillated into a perfusing rhythm. Sixty percent of the NE treated animals experienced post-defibrillation ventricular dysrhythmias. None of the animals in the DHPDAE were successfully defibrillated into a perfusing rhythm. Substitution of the hydroxyl group on the beta-carbon of NE with an amino group significantly decreases the hemodynamic properties of the parent molecule.

Cell surface changes during electromagnetic field exposure

Fibroblasts from 5 1/2-day-old chick embryos go through a sequential series of changes when exposed to a constant electromagnetic field (EMF) of 10 V/cm. These changes include rounding up, becoming bipolar in shape, assuming a cylindrical profile, elongating perpendicular to the EMF, and migrating to the cathode. These morphological changes are associated with changes of the cell surface, which include the formation of filopodia and extensive sheet-like contacts on the cathodic cell surface, the retraction of processes and the formation of focal contacts on the anodic cell surface.