The perceived expressed emotion in staff scale

Recent research has highlighted the role of expressed emotion by ward staff in determining the well-being of psychiatric inpatients. Existing methods of assessing staff expressed emotion involve standardized interviews and are expensive and time-consuming. We report the development of a questionnaire measure of expressed emotion in staff as perceived by patients. In study 1, factor analysis of items administered to patients in a variety of settings led to the development of a questionnaire with three subscales: supportiveness, criticism and intrusiveness. In study 2, the test-retest reliability of the questionnaire was found to be adequate, and some evidence of concurrent validity for the scale was obtained against expressed emotion rated from staff speech samples. In study 3, the scale was shown to have good concurrent validity against the ward atmosphere scale, and scores were found to be independent of insight or experience of admission to hospital. The perceived expressed emotion in staff scale is a convenient measure, which may have utility for both research and clinical purposes.

Helicobacter cetorum sp. nov., a urease-positive Helicobacter species isolated from dolphins and whales

A novel helicobacter with the proposed name Helicobacter cetorum, sp. nov. (type strain MIT 99-5656; GenBank accession number AF 292378), was cultured from the main stomach of two wild, stranded Atlantic white-sided dolphins (Lagenorhynchus acutus) and from the feces of three captive cetaceans (a Pacific white-sided dolphin [Lagenorhynchus obliquidens]; an Atlantic bottlenose dolphin [Tursiops truncatus]; and a beluga whale [Delphinapterus leucas]). The infected captive cetaceans were either subclinical, or clinical signs included intermittent regurgitation, inappetance, weight loss, and lethargy. Ulcers were observed in the esophagus and forestomach during endoscopic examination in two of the three captive animals. In the third animal, esophageal linear erosions were visualized endoscopically, and histopathological evaluation of the main stomach revealed multifocal lymphoplasmacytic gastritis with silver-stained spiral-shaped bacteria. Helicobacter cetorum is a fusiform gram-negative bacterium with a single bipolar flagellum. The isolates grow under microaerobic conditions at 37 and 42 degrees C but not at 25 degrees C. H. cetorum is urease, catalase, and oxidase positive, and it is sensitive to cephalothin. The isolates from the wild, stranded dolphins were sensitive to nalidixic acid, whereas the isolates from the collection animals were resistant. By 16S rRNA sequencing it was determined that H. cetorum represented a distinct taxon that clusters most closely with H. pylori. Further studies are necessary to determine the role of H. cetorum in the development of gastric ulcers and gastritis of cetaceans. This is the first description and formal naming of a novel Helicobacter species from a marine mammal.

The internal migration patterns of the foreign-born and native-born populations in the United States: 1975-80 and 1985-90

"The focus of this article is on an examination of the influence of birthplace on the internal migration and spatial redistribution patterns of the foreign-born and native-born populations in the United States during the 1975-80 and 1985-90 periods. The analyses presented here consider the following principal questions: (1) What are the internal migration patterns of the foreign-born population in the United States, and how do they differ from those of the native-born population? (2) How do the relocation choices of various birthplace-specific foreign-born and native-born subpopulations differ from each other? (3) Are the internal migration patterns generating an increased or a decreased geographical concentration of such birthplace-specific subgroups?"

Evaluation of the 3D BacT/ALERT automated culture system for the detection of microbial contamination of platelet concentrates

Bacterial transmission remains the major component of morbidity and mortality associated with transfusion-transmitted infections. Platelet concentrates are the most common cause of bacterial transmission. The BacT/ALERT 3D automated blood culture system has the potential to screen platelet concentrates for the presence of bacteria. Evaluation of this system was performed by spiking day 2 apheresis platelet units with individual bacterial isolates at final concentrations of 10 and 100 colony-forming units (cfu) mL-1. Fifteen organisms were used which had been cited in platelet transmission and monitoring studies. BacT/ALERT times to detection were compared with thioglycollate broth cultures, and the performance of five types of BacT/ALERT culture bottles was evaluated. Sampling was performed immediately after the inoculation of the units, and 10 replicates were performed per organism concentration for each of the five types of BacT/ALERT bottles. The mean times for the detection of these 15 organisms by BacT/ALERT, with the exception of Propionibacterium acnes, ranged from 9.1 to 48.1 h (all 10 replicates were positive). In comparison, the time range found using thioglycollate was 12.0-32.3 h (all 10 replicates were positive). P. acnes' BacT/ALERT mean detection times ranged from 89.0 to 177.6 h compared with 75.6-86.4 h for the thioglycollate broth. BacT/ALERT, with the exception of P. acnes, which has dubious clinical significance, gave equivalent or shorter detection times when compared with the thioglycollate broth system. The BacT/ALERT system detected a range of organisms at levels of 10 and 100 cfu mL-1. This study validates the BacT/ALERT microbial detection system for screening platelets. Currently, the system is the only practically viable option available for routinely screening platelet concentrates to prevent bacterial transmission.

Circulating estradiol and osteoprotegerin as determinants of bone turnover and bone density in postmenopausal women

Osteoprotegerin (OPG) is a recently identified cytokine that acts as a decoy receptor for the receptor activator of NF kappa B ligand. OPG has been shown to be an important inhibitor of osteoclast differentiation and activation in rodent models. Estrogen is known to suppress bone resorption, and the action of estrogen on bone may be mediated by OPG. The relationship between endogenous estrogen and circulating OPG levels and bone status in human populations is unclear. Thus, the aim of this study was to investigate the relationship between biochemical markers of bone turnover and bone density and circulating OPG and endogenous estradiol levels in a population-based cohort of postmenopausal women. Subjects were 180 women ages 55-91 yr (mean age, 67 yr). Serum estradiol was measured using an auto-analyzer. Serum concentrations of OPG were determined by ELISA. Markers of bone formation and resorption were measured by standard methods. Bone mineral density at total body, total hip, femoral neck, and lumbar spine was measured by dual energy x-ray absorptiometry. There was a significant inverse relationship between estradiol and all bone turnover markers (r-values from -0.46 to -0.23; P < 0.05). Serum estradiol was positively related to absolute bone density at all sites and to change in bone density at the hip and femoral neck by univariate analysis (r-values from 0.15-0.29; P < 0.05). We observed a weak inverse association between OPG and serum-based bone turnover markers (r-values -0.18 and -0.16; P < 0.05). There was a significant positive relationship between OPG and bone mineral density at total body, total hip, and femoral neck (r-values from 0.17-0.2; P < 0.05) by univariate analysis, which was lost after adjustment for age and body mass index. There was a significant weak positive relationship between circulating OPG and serum estradiol (r = 0.18; P < 0.02). We observed no significant relationships between OPG and bone turnover markers measured in urine. We conclude that the variation in circulating endogenous estradiol levels is an important factor contributing to levels of bone turnover and bone density at the menopause. Our observations also suggest that circulating levels of OPG may reflect OPG activity in bone and are related to circulating endogenous levels of estradiol. We have previously reported high levels of variability in urine markers of bone resorption, and we suggest that this could account for the absence of a significant association between these markers and circulating OPG.

Activation of bovine peripheral blood gammadelta T cells for cell division and IFN-gamma production

Bovine peripheral blood gammadelta T cells have been evaluated for effector function (IFN-gamma production) and clonal expansion in a variety of systems including following activation by mitogens, IL-12, and stimulation, through the T cell receptor (TCR) with anti-CD3 monoclonal antibody (mAb), a cell-bound molecule and a soluble antigenic extract. To evaluate cell division, carboxyfluorescein succinimidyl ester (CFSE) loading of cells and flow cytometric analysis were used, while IFN-gamma production was evaluated by intracytoplasmic staining. It was found that bovine gammadelta T cells produced IFN-gamma and clonally expanded when stimulated through the TCR/CD3 complex by a cell-associated autologous molecule on monocyte, by bacterial components following in vivo sensitization of gammadelta T cells with a leptospira vaccine or by anti-CD3 mAb. In addition, gammadelta T cells were activated efficiently for effector function but not clonal expansion by culturing with IL-12. In contrast, stimulation by Con A or PMA/ionomycin induced efficient replication but only low level IFN-gamma production which was not enhanced by the presence of IL-12. In several systems the amount of IFN-gamma produced per cell by gammadelta T cells was less than that produced by CD4 T cells in the same cultures.

Implementing clinical governance in English primary care groups/trusts: reconciling quality improvement and quality assurance

OBJECTIVES

To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care.

DESIGN

Qualitative case studies using semi-structured interviews and documentation review.

SETTING

Twelve purposively sampled PCG/Ts in England.

PARTICIPANTS

Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members.

MAIN OUTCOME MEASURES

Participants' perceptions of the role of clinical governance in PCG/Ts.

RESULTS

PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment).

CONCLUSION

PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

Genetic perspectives on human origins and differentiation

This is a review of genetic evidence about the ancient demography of the ancestors of our species and about the genesis of worldwide human diversity. The issue of whether or not a population size bottleneck occurred among our ancestors is under debate among geneticists as well as among anthropologists. The bottleneck, if it occurred, would confirm the Garden of Eden (GOE) model of the origin of modern humans. The competing model, multiregional evolution (MRE), posits that the number of human ancestors has been large, occupying much of the temperate Old World for the last two million years. While several classes of genetic marker seem to contain a strong signal of demographic recovery from a small number of ancestors, other nuclear loci show no such signal. The pattern at these loci is compatible with the existence of widespread balancing selection in humans. The study of human diversity at (putatively) neutral genetic marker loci has been hampered since the beginning by ascertainment bias since they were discovered in Europeans. The high levels of polymorphism at microsatellite loci means that they are free of this bias. Microsatellites exhibit a clear almost linear diversity gradient away from Africa, so that New World populations are approximately 15% less diverse than African populations. This pattern is not compatible with a model of a single large population expansion and colonization of most of the Earth by our ancestors but suggests, instead, gradual loss of diversity in successive colonization bottlenecks as our species grew and spread.

Musculoskeletal pain is more generalised among people from ethnic minorities than among white people in Greater Manchester

OBJECTIVE

To assess the prevalence of musculoskeletal symptoms among the major ethnic minority populations of Greater Manchester.

METHOD

The study group was a community sample of 2117 adults from the Indian, Pakistani, Bangladeshi, and African Caribbean communities. Questionnaires administered by post and by an interviewer were used to assess the presence of any musculoskeletal pain, pain in specific joints, and the level of physical function. Ethnicity was self assigned. The results were compared with those from a recent study in the local white population using the same methodology.

RESULTS

Overall response rate was 75% among the south Asian (Indian, Pakistani, and Bangladeshi community and 47% among the African Caribbean community. The profile of musculoskeletal pain among the ethnic minority groups differed from that in the white population. Although musculoskeletal symptoms were slightly more prevalent among people from ethnic minority groups than among the white population, pain in multiple sites was considerably more common among ethnic minorities.

CONCLUSIONS

The finding that musculoskeletal pain is more widespread among ethnic minority communities in the UK has not previously been reported. This may reflect social, cultural, and psychological differences. The cause of the differences in the profile of pain and the health needs that follow need further investigation.

The effect of shiftwork on driving to and from work

A questionnaire study was conducted to obtain information from shiftworkers on the levels of tiredness experienced on the drive to and from work at different times of the day. The results demonstrated that, compared to non-shiftworkers, shiftworkers were more tired on the drive between their home and the workplace and more at risk of falling asleep behind the wheel. The main factors contributing to this increased level of sleepiness and associated driving impairment were the length of the sleep period prior to work, the type of shift and the travelling time. There was some evidence to suggest that on working days shiftworkers were more likely to be involved in an accident than non-shiftworkers. However, there were insufficient data to determine whether accidents were correlated with driver sleepiness.

Diabetic amyotrophy masquerading as quadriceps tendon rupture: a word of caution

Diabetic amyotrophy is predominantly a motor condition that involves various elements of the lumbosacral plexus but particularly that related to the femoral nerve. (1,3) It can present acutely as unilateral thigh pain followed by the development of weakness and later wasting in the femoral muscles, usually first seen in the quadriceps. We report on two cases of diabetic amyotrophy from different hospitals that presented with clinical signs and symptoms of quadriceps rupture. These patients underwent surgical exploration but in both the quadriceps tendons were found to be intact. Post-operative neurological consultations established the diagnosis as diabetic amyotrophy, which was confirmed with electrodiagnostic studies. We conclude that any quadriceps rupture in diabetics should be viewed with caution. Electrodiagnostic studies and imaging with ultrasound and magnetic resonance imaging should be carried out before exploratory surgery.

Binding to and hemolysis of human erythrocytes by pyrularia thionin and Naja naja kaouthia cardiotoxin: inhibition by prothrombin

Pyrularia thionin and snake venom cardiotoxin are strongly basic proteins which bind to and induce hemolysis of erythrocytes, cause depolarization of muscle cells, and influence the order and properties of phospholipids in cellular membranes. Earlier studies showed a competition between the thionin and cardiotoxin for a common binding site on erythrocytes, and the present study extends these studies to show a similar competition between prothrombin and both basic proteins. The competition between the thionin and prothrombin for binding sites on erythrocytes was shown by direct binding experiments using radiolabeled thionin. Whereas binding of thionin or cardiotoxin induces hemolysis as a consequence of membrane perturbation, prothrombin does not induce hemolysis. Although it binds to the same site, there is no penetration into and perturbation of the membrane. The competition between prothrombin and pyrularia thionin is not influenced by added Ca++. This indicates that membrane PS interacts in a specific and Ca++-independent manner with at least one site on prothrombin, as proposed earlier (Tendian and Lentz, 1990). The competition between thionin and prothrombin was also demonstrated for the release of radiolabeled chromate from loaded P388 cells. The competition observed with the P388 cells shows that the competition is not a unique phenomenon with erythrocytes, but occurs with other cell membranes.

The effect of 17beta-estradiol on production of cytokines in cultures of peripheral blood

Estrogen's action on bone may be mediated by cytokines produced by monocytes. We have reported a decreased ratio of interleukin-1beta (IL-1beta) to interleukin-1 receptor antagonist (IL-1ra) produced by whole blood cultures in vivo in women taking hormone replacement therapy (HRT). Also, one study has shown an effect of estradiol on tumor necrosis factor-alpha (TNF-alpha) secretion by separated monocytes in vitro. The aim of this study was to evaluate the effect of estrogen in vitro on the secretion of cytokines using whole blood cultures. Subjects consisted of 12 healthy postmenopausal women, ages 57-69 years, 4-20 years since menopause. Cytokines IL-1beta, interleukin-1alpha (IL-1alpha), IL-1ra, interleukin-6 (IL-6), TNF-alpha, and granulocyte macrophage-colony stimulating factor (GM-CSF) were measured in unstimulated and in stimulated (500 ng/mL lipopolysaccharide [LPS]) whole blood cultures treated with 17beta-estradiol (E(2)) at concentrations of 10(-12)--10(-6) mol/L. We found significant decreases in the spontaneous secretion of IL-6, TNF-alpha, IL-1ra, IL-1beta, and ratio of IL-1beta/IL-1ra compared with control, at physiological concentrations of E(2). The action of E(2) was blocked by the use of the antiestrogen ICI 182780 in coculture. A decrease in cytokine secretion was not observed when the inactive form of estrogen, 17alpha-estradiol, was used in place of 17beta-estradiol. GM-CSF and IL-1alpha were not detectable in unstimulated cultures. Cytokine levels measured in stimulated cultures were not attenuated by treatment with E(2). We conclude that E(2) inhibits the spontaneous secretion of cytokines measured in whole blood cultures at physiological concentrations, and that the powerful stimulatory effect of LPS prevents any significant inhibition by E(2) in stimulated cultures.

Possible explanation of the disparity between the in vitro and in vivo measurements of Rubisco activity: a study in loblolly pine grown in elevated pCO2

Rubisco activity can be measured using gas exchange (in vivo) or using in vitro methods. Commonly in vitro methods yield activities that are less than those obtained in vivo. Rubisco activity was measured both in vivo and in vitro using a spectrophotometric technique in mature Pinus taeda L. (loblolly pine) trees grown using free-air CO2 enrichment in elevated (56 Pa) and current (36 Pa) pCO2. In addition, for studies where both in vivo and in vitro values of Rubisco activity were reported net CO2 uptake rate (A) was modelled based on the in vivo and in vitro values of Rubisco activity reported in the literature. Both the modelling exercise and the experimental data showed that the in vitro values of Rubisco activity were insufficient to account for the observed values of A. A trichloroacetic acid (TCA) precipitation of the protein from samples taken in parallel with those used for activity analysis was co-electrophoresed with the extract used for determining in vitro Rubisco activity. There was significantly more Rubisco present in the TCA precipitated samples, suggesting that the underestimation of Rubisco activity in vitro was attributable to an insufficient extraction of Rubisco protein prior to activity analysis. Correction of in vitro values to account for the under-represented Rubisco yielded mechanistically valid values for Rubisco activity. However, despite the low absolute values for Rubisco activity determined in vitro, the trends reported with CO2 treatment concurred with, and were of equal magnitude to, those observed in Rubisco activity measured in vivo.

Improving self-management skills: a whole systems approach

This article outlines the rationale behind an approach developed at the National Primary Care Research and Development Centre (NPCRDC) to improve patients' abilities to self-manage their conditions with the support of services provided by the NHS. The approach is systematic and requires involvement of patients in the development of information, changing access arrangements to health services and promoting a patient-centred approach to care. A programme of research and development is currently being undertaken at The University of Manchester by researchers based at NPCRDC to investigate the effectiveness of this approach. The evidence base for the strategy under investigation is discussed and proposals are made for the role of nurses as facilitators for the self-management agenda in the NHS.

Clinical relevance of Flt1 and Tie1 angiogenesis receptors expression in B-cell chronic lymphocytic leukemia (CLL)

Angiogenesis, a complex process tightly controlled by several molecules including vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) along with their receptors, plays a major role in the growth and metastasis of solid tumors. The expression and production of VEGF and bFGF have been documented in numerous solid tumors and hematopoietic neoplasms. Having recently shown increased expression of cellular VEGF in the leukemic cells of patients with chronic lymphocytic leukemia (CLL) we decided to investigate the expression of angiogenic receptors Flt1 and Tie1. Levels of Tie1 and Flt1 proteins were measured in leukemic cells from 231 patients with B-cell CLL using Western blot analysis and solid-phase radioimmunoassay (RIA). A strong correlation was found between Flt1 and Tie1 levels and white blood cell count (WBC) and absolute lymphocyte counts. Levels of Flt1 but not Tie1 correlated with levels of cellular VEGF. Interestingly, Tie1 correlated well with Rai stage (P=0.04). Flt1 and Tie1 did not correlate with survival, although when we evaluated the patients with early disease (Rai stage 0-II), higher levels of Tie1 but not of Flt1 correlated with worse survival. These data suggest that Tie1 plays a role in the early stages of B-cell CLL and as the disease progresses, the tumor cells become independent from the effects of Tie1. Further studies are now needed to dissect the mechanisms responsible for this phenomenon.