Recent outbreaks of infectious syphilis, United Kingdom, January 2012 to April 2014

Six outbreaks of infectious syphilis in the United Kingdom, ongoing since 2012, have been investigated among men who have sex with men (MSM) and heterosexual men and women aged under 25 years. Interventions included case finding and raising awareness among healthcare professionals and the public. Targeting at-risk populations was complicated as many sexual encounters involved anonymous partners. Outbreaks among MSM were influenced by the use of geospatial real-time networking applications that allow users to locate other MSM within close proximity.

A self-completed nutrition screening tool for community-dwelling older adults with high reliability: a comparison study

OBJECTIVES

Malnutrition is common in community-dwelling older adults and is associated with poor outcomes including hospitalization and mortality. Recently, a 6-question short form mini nutritional assessment (SF-MNA) was validated for rapid nutrition screening. Ideally, nutrition screening could be performed by individuals or their caregivers prior to or during an outpatient clinical visit, thus allowing for the ongoing monitoring of nutritional status among older adults.

DESIGN

We compared the SF-MNA administered by a healthcare professional (HCP) to a 6-item self-administered screening tool (Self-MNA) in 463 community dwelling older adults who gave informed consent. The population was 60% women with a mean age of 76.8±6.8 years. The HCP was blinded to the results of the Self-MNA questionnaire.

RESULTS

Using the SF-MNA, 27% of subjects were malnourished, 38% were at risk, and 35% had normal nutrition status. The agreement between the Self-MNA and the SF-MNA was 99% (Self-MNA sensitivity 99%, specificity 98%, false negative rate 1%, false positive rate 2%) for identifying Malnourished subjects and 83% (sensitivity 89%, specificity 77%, false negative rate 11%, false positive rate 23%) for identifying At Risk of Malnutrition compared to the MNA-SF administered by a HCP.

CONCLUSION

We found that the Self-MNA demonstrates sufficient inter-rater reliability for use in nutrition screening among community-dwelling older adults. Further validation studies and the possible impact of language translation should be pursued.

Why has oral health promotion and prevention failed children requiring general anaesthesia for dental extractions?

OBJECTIVES

Many children in the UK still require dental treatment under general anaesthesia (DGA). Why oral health promotion and prevention, in this cohort of children, has failed is poorly understood. By questioning the parents/carers of children undergoing DGA this study aimed to establish: 1 previous exposure to oral health education and promotion activities; 2 beliefs and behaviours about dental caries and prevention; and 3 what parents perceive useful in preventing dental caries.

BASIC RESEARCH DESIGN

A cross-sectional questionnaire based study.

CLINICAL SETTING

Dental general anaesthetic centres in Wales, UK.

PARTICIPANTS

207 consecutively attending parents of children aged < 10 years requiring a DGA.

RESULTS

In total, 150 (76%) parents/carers claimed to have received previous oral health advice and 103 (52%) had received toothbrushing instruction from a dentist. Only 18 (9%) reported the application of topical fluoride. Sixty seven (34%) believed "tooth decay runs in families" and 53 (27%) it was simply bad luck that their child had dental decay. The majority (89%) believed that information leaflets on oral health would be useful and 133 (67%) would find information on a website helpful.

CONCLUSIONS

This study suggests that there is a significant scope for increasing the exposure of high risk children to fluoride. A sense of fatalism and erroneous beliefs were evident amongst some parents/carers of children needing DGA. These issues need to be addressed in the future design of oral health promotion/prevention activities.

Dynamics Of MoS2 Photoablation

Speed distributions were determined for the ions ejected from MoS2 by excimer laser ablation. It was found that the majority of ionic species were atomic and were ablated with speeds in excess of 6 km/s. The speed distributions were found to be non-Maxwellian and were best described by a supersonic expansion model. The differences in ArF and KrF excimer laser ablation are discussed.

Effectiveness of seasonal 2010/11 and pandemic influenza A(H1N1)2009 vaccines in preventing influenza infection in the United Kingdom: mid-season analysis 2010/11

This study provides mid-season estimates of the effectiveness of 2010/11 trivalent influenza vaccine and previous vaccination with monovalent influenza A(H1N1)2009 vaccine in preventing confirmed influenza A(H1N1)2009 infection in the United Kingdom in the 2010/11 season. The adjusted vaccine effectiveness was 34% (95% CI: -10 - 60%) if vaccinated only with monovalent vaccine in the 2009/10 season; 46% (95% CI: 7 - 69%) if vaccinated only with trivalent influenza vaccine in the 2010/11 season and 63% (95% CI: 37 - 78%) if vaccinated in both seasons.

Two waves of pandemic influenza A(H1N1) 2009 in Wales--the possible impact of media coverage on consultation rates, April-December 2009

In the United Kingdom, the influenza A(H1N1) 2009 pandemic had a distinct two-wave pattern of general practice consultations for influenza-like illness (ILI). We describe the epidemiology of the influenza pandemic in Wales between April and December 2009 using integrated data from a number of independent sources: GP surveillance, community virology surveillance, hospital admissions and deaths, and media enquiries monitoring. The first wave peaked in late July at 100 consultations per 100,000 general practice population and attracted intensive media coverage. The positivity rate for the A(H1N1)2009 influenza did not exceed 25% and only 44 hospitalisations and one death were recorded. By contrast, the second wave peaked in late October and although characterised by lower ILI consultation rates (65 consultations per 100,000 general practice population) and low profile media activity, was associated with much higher positivity rates for pandemic influenza A(H1N1)2009 (60%) and substantially more hospital admissions (n=379) and deaths (n=26). The large number of ILI-related consultations during the first wave in Wales probably reflected the intensive media activity rather than influenza virus circulating in the community. Data from community surveillance schemes may therefore have considerably overestimated the true incidence of influenza. This has implications for the future interpretation of ILI surveillance data and their use in policy making, and underlines the importance of using integrated epidemiological, virological and hospital surveillance data to monitor influenza activity.

Two waves of pandemic influenza A(H1N1)2009 in Wales – the possible impact of media coverage on consultation rates, April – December 2009

In the United Kingdom, the influenza A(H1N1)2009 pandemic had a distinct two-wave pattern of general practice consultations for influenza-like illness (ILI). We describe the epidemiology of the influenza pandemic in Wales between April and December 2009 using integrated data from a number of independent sources: GP surveillance, community virology surveillance, hospital admissions and deaths, and media enquiries monitoring. The first wave peaked in late July at 100 consultations per 100,000 general practice population and attracted intensive media coverage. The positivity rate for the A(H1N1)2009 influenza did not exceed 25% and only 44 hospitalisations and one death were recorded. By contrast, the second wave peaked in late October and although characterised by lower ILI consultation rates (65 consultations per 100,000 general practice population) and low profile media activity, was associated with much higher positivity rates for pandemic influenza A(H1N1)2009 (60%) and substantially more hospital admissions (n=379) and deaths (n=26). The large number of ILI-related consultations during the first wave in Wales probably reflected the intensive media activity rather than influenza virus circulating in the community. Data from community surveillance schemes may therefore have considerably overestimated the true incidence of influenza. This has implications for the future interpretation of ILI surveillance data and their use in policy making, and underlines the importance of using integrated epidemiological, virological and hospital surveillance data to monitor influenza activity.

Acquisition of Key-Pecking via Autoshaping as a Function of Prior Experience: "Learned Laziness"?

A group of pigeons that had previously received noncontingent food delivery acquired the key-peck response (in autoshape training) more slowly than did a naive control group; key-peck acquisition was most rapid for a group given operant treadle-press training in the initial phase.

An assessment of the role of handling cues in "spontaneous recovery" after extinction

Three experiments examined the assertion that presession handling cues that accompany training with reinforcement might account for spontaneous recovery when they reoccur following extinction. In Experiment 1, after extensive training on a variable-interval schedule, key pecking in pigeons was extinguished following either normal or distinctively different handling and transportational cues. Those cues resulted in enhanced spontaneous recovery 24 hr later when normal cues were reinstated. In Experiment 2, however, subjects tested following the normal handling cues showed no more spontaneous recovery than did subjects that spent the entire extinction-test interval in the experimental chambers and thus were tested without handling cues altogether. In Experiment 3, a group whose test for recovery began 10 min after being placed in the chambers yielded as much spontaneous recovery as did a group tested normally. Furthermore, a group for which extinction began at mid-session and for which handling therefore could not be a discriminative cue for extinction showed no more spontaneous recovery than did the other two groups. Handling cues thus contributed to spontaneous recovery only after explicit discrimination training, as provided in Experiment 1.

Context specificity of operant discrimination performance in pigeons

In an experiment designed to investigate odors as potential retrieval cues in pigeons' memory (i.e., as conditional stimuli), 8 pigeons first learned to peck a red keylight (S+, reinforced) and not a blue one (S-, extinguished) in the presence of either a eucalyptus oil or isoamyl acetate odor. They were repeatedly switched between two chambers with the same odor to habituate any reaction to the switching that would be required for eventual testing for conditional control by the odors. Next, the birds learned the reversal (blue S+, red S-) in the presence of the alternative odor in one of these chambers. When the birds were then switched to the alternative chamber for additional training, although the odor was still appropriate to the reversal problem, behavior appropriate to the original training condition recurred. Testing indicated that reversal performance was specific to the one chamber in which it had been trained.

Rules, praise, and ignoring: elements of elementary classroom control

An attempt was made to vary systematically the behavior of two elementary school teachers to determine the effects on classroom behavior of Rules, Ignoring Inappropriate Behaviors, and showing Approval for Appropriate Behavior. Behaviors of two children in one class and one child in the other class were recorded by observers, as were samples of the teachers' behavior. Following baseline recordings, Rules, Ignoring, and Approval conditions were introduced one at a time. In one class a reversal of conditions was carried out. The main conclusions were that: (a) Rules alone exerted little effect on classroom behavior, (b) Ignoring Inappropriate Behavior and showing Approval for Appropriate Behavior (in combination) were very effective in achieving better classroom behavior, and (c) showing Approval for Appropriate Behaviors is probably the key to effective classroom management.

Production and elimination of disruptive classroom behavior by systematically varying teacher's behavior

The effects of teacher behaviors on the classroom behaviors of children were investigated by systematically varying approving (praise, smiles, contacts, etc.) and disapproving (verbal reprimands, physical restraint, etc.) classes of teacher behavior. Measures were taken on both teacher and child behaviors. Each day a sample of 10 children was observed. The subject pool was a class of 28 well-behaved children in a middle-primary public school class. The results demonstrated that approving teacher responses served a positive reinforcing function in maintaining appropriate classroom behaviors. Disruptive behaviors increased each time approving teacher behavior was withdrawn. When the teacher's disapproving behaviors were tripled, increases appeared most markedly in the gross motor and noise-making categories of disruptive behavior. The findings emphasize again the important role of the teacher in producing, maintaining, and eliminating disruptive as well as pro-social classroom behavior.

Factors affecting conditional discrimination learning by pigeons

In Experiment 1 (within subjects) and Experiment 2 (between subjects) it was shown that the sequential training of pigeons on a color discrimination and then on its reversal, each in a different floor-tilt/texture context, failed to produce conditional control of discriminative performance by those contexts. Daily alternation between the two problems (with correlated contexts) was successful, however. In each of these experiments conditional control was better reflected in generalization test performance in extinction than during sessions of training with reinforcement.

Relative and absolute density of reinforcement as factors influencing the peak shift

Four groups of six pigeons each were given nondifferential training on multiple variable-interval variable-interval reinforcement schedules and then were switched to differential training involving a multiple schedule in which reinforcement density was reduced in one of the two components. The multiple schedules used in the four groups had mean interreinforcement intervals of 1 min and 1 min in the two components changed to 1 min, 5 min; 2.5 min, 2.5 min changed to 2.5 min, 5 min; 12 sec, 12 sec changed to 12 sec, 24 sec; and 12 sec, 12 sec changed to 12 sec, 60 sec. In subsequently administered wavelength generalization tests, some peak shifts were observed in each condition and occurred occasionally in the absence of behavioral contrast or rate reduction in the less-reinforced component. The best predictor of peak shift was a high proportion of total responses emitted during the more-reinforced component at the end of differential training.

Does conditional discrimination learning by pigeons necessarily involve hierarchical relationships?

Four experiments demonstrate that when putative conditional and discriminative cues are presented simultaneously in the single reversal procedure, it is not possible to ascribe a uniquely conditional or uniquely discriminative function to either of the cues. In Experiment 1, pigeons were trained to respond to a blue key and not to a red key while the houselight was on; then in a different session they learned the reversal of this discrimination with the houselight off (single reversal). Separate groups were tested for color generalization with houselight conditions alternating in blocks of trials or for houselight intensity generalization with blue and red key colors alternating in blocks of trials. Both test procedures revealed a conditional relationship between houselight and key color conditions. Experiment 2 produced the same result following training in which the key colors were held constant across training sessions while the houselight and no houselight conditions varied within sessions. In Experiment 3, separate groups were trained with the two procedures but were tested with randomly ordered combinations of key colors and houselight intensities. The two groups yielded indistinguishable bidimensional generalization gradients with peaks at both previously reinforced stimulus combinations. In Experiment 4 the subjects were switched from one of these training procedures to the other with no decrement in their discriminative performance. We conclude that for successive discriminations between conditional- and discriminative-stimulus combinations, the notion of a hierarchical relation between conditional and discriminative stimuli must be extended to include a symmetrical relationship or the notion should be abandoned altogether.

Context specificity of operant discriminative performance in pigeons: II. Necessary and sufficient conditions

Six experiments were performed to explore the necessary and sufficient conditions for producing context specificity of discriminative operant performance in pigeons. In Experiment 1, pigeons learned a successive discrimination (red S+/blue S-) in two chambers that had a particular odor present and between which they were frequently switched. The birds subsequently learned the reversal (blue S+/ red S-) in one of these chambers with a different odor present. When switched to the alternative chamber, although the odor and the reinforcement contingency were still appropriate to the reversal, performance appropriate to the original discrimination recurred in subjects for which the houselights were on during training and testing but not for those for which the houselights were off. This indicated the importance of visual contextual cues in producing context specificity. Experiment 2 showed that the frequent switching between boxes in initial training was of no consequence, presumably because the apparatus cues were highly salient to the subjects. Experiment 3 showed significantly less context specificity when odor cues were omitted. Experiment 4 showed that simply using a different reinforced stimulus in each phase of training was ineffective in producing context specificity. Experiment 5 showed that the generalization test procedure used in Experiment 4 was sensitive to context specificity when discrimination-reversal training was used with different odors in the two training phases. Experiment 6 replicated the results of Experiment 4, but then showed that when different odors accompanied the two training phases, context specificity was obtained with the single-stimulus paradigm. Thus in both single-stimulus and discrimination-reversal paradigms, redundant odor cues potentiated learning about apparatus cues.

Stimulus generalization as a function of the delay between training and testing procedures: a reevaluation

Three groups of 12 pigeons each were trained to discriminate between lights of 550 mmu (S(D)), correlated with 1-min variable-interval reinforcement and 570 mmu (S(Delta)), correlated with extinction. Group A was tested for wavelength generalization in extinction 1 min after meeting the discrimination criterion; Group B was tested 24 hr later; Group C was tested 24 hr later after a 3-min (reinforced) warm-up with the S(D). The post-discrimination gradient of Group B was significantly flatter and showed significantly greater area shift than that of Groups A and C. The gradient of Group C was similar to that of Group A, indicating that the warm-up eliminated the effect of the delay period.

Reinforcement duration and the peak shift in post-discrimination gradients

Pigeons were trained to key-peck for food, first with single-stimulus training and then with successive discrimination (multiple schedule) training. In the multiple schedule, two different wavelengths were each correlated with equally frequent variable-interval reinforcement but different durations (6 sec vs. 2 sec) of access to grain. For some birds, the different durations of feeding cycle were cued by different intensities of the food hopper light. For some of these "cued" birds, single-stimulus training had been carried out with 6-sec feedings and when multiple-schedule training was introduced, the novel stimulus was correlated with 2-sec feedings. For the others, 2-sec feedings were originally used, and the novel stimulus was then present during the 6-sec reinforcement duration. The cueing procedure enhanced discrimination performance, and was necessary for the consistent production of a peak shift. In addition, the condition in which original training had been carried out with 6-sec feedings, and thus reinforcement duration was reduced in the presence of the novel stimulus, led to the best performance.

Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status

OBJECTIVE

To validate a revision of the Mini Nutritional Assessment short-form (MNA(R)-SF) against the full MNA, a standard tool for nutritional evaluation.

METHODS

A literature search identified studies that used the MNA for nutritional screening in geriatric patients. The contacted authors submitted original datasets that were merged into a single database. Various combinations of the questions on the current MNA-SF were tested using this database through combination analysis and ROC based derivation of classification thresholds.

RESULTS

Twenty-seven datasets (n=6257 participants) were initially processed from which twelve were used in the current analysis on a sample of 2032 study participants (mean age 82.3y) with complete information on all MNA items. The original MNA-SF was a combination of six questions from the full MNA. A revised MNA-SF included calf circumference (CC) substituted for BMI performed equally well. A revised three-category scoring classification for this revised MNA-SF, using BMI and/or CC, had good sensitivity compared to the full MNA.

CONCLUSION

The newly revised MNA-SF is a valid nutritional screening tool applicable to geriatric health care professionals with the option of using CC when BMI cannot be calculated. This revised MNA-SF increases the applicability of this rapid screening tool in clinical practice through the inclusion of a "malnourished" category.

Systemic inflammatory markers in older persons: the effect of oral nutritional supplementation with prebiotics

OBJECTIVE

To evaluate the effect of oral nutritional supplementation with and without oligosaccharides on gut bacteriology, in particular the bifidogenic flora, and on immunology and inflammatory parameters in older persons at risk of malnutrition.

DESIGN

Prospective, randomized, double-blind, controlled study.

SETTING

Division of Geriatric Medicine, St. Louis University, Missouri, United States.

PARTICIPANTS

Seventy-four community dwelling elderly and/or nursing home subjects (age superior 70 y; 84 +/- 7 years) either undernourished or at risk of undernutrition.

INTERVENTION

Daily liquid supplements, with (1.3 g/250 ml) and without oligosaccharides (OS) for 12 weeks.

MEASUREMENTS

Nutritional evaluation, serum immunoglobulins, lymphocyte subsets, various cytokines and the endotoxin soluble receptor CD14 (sCD14) in serum, and cytokines specific mRNA in peripheral blood mononuclear cells at baseline and 12 weeks, and fecal bacteriologicy.

RESULTS

Specific mRNA extracted from blood leucocytes showed a different level of pro-inflammatory gene activation: TNF-alpha mRNA and IL-6 mRNA diminished in the OS group after 12 weeks, while no changes were detected in the control group (P=0.05 and P=0.04 respectively). Serum levels of sCD14, a product shed by activated macrophages, decreased only in the OS group without reaching statistical significance (P=0.08). No significant differences were detected in the fecal gut flora or in the nutritional parameters.

CONCLUSIONS

This study shows that the administration of supplements in older persons at risk of malnutrition may benefit from the addition of prebiotics that can improve the low noise inflammatory process frequently observed in this population.

Domestic and travel-related foodborne gastrointestinal illness in a population health survey

Routine surveillance data underestimate incidence of foodborne gastrointestinal (FGI) illness and provide little information on illness related to travel. We analysed data from the Welsh Health Survey to estimate population incidence, and to examine risk factors for FGI and factors associated with consulting a doctor. Reported frequency of any FGI in the 3 months before interview was 20.0% [95% confidence interval (CI) 19.5-20.4; equivalent to 0.8 episodes per person-year], and for travel-related FGI was 1.6% (95% CI 1.5-1.8). In the final model, sex, age group, marital status, self-reported health, long-term illness, smoking and alcohol consumption were all independent predictors of FGI. People who consulted a doctor were likely to be older, in poorer health, taking regular medication, or to report mental illness. FGI is common but risk factors for illness and consultation differ and impressions of the epidemiology of the disease based on surveillance data are therefore distorted.

Psychosocial effects of acne

This article discusses the psychological effect of acne vulgaris. It is shown that acne has significant effect on self-image and impacts quality of life. The impact of acne may be equivalent to that of asthma or epilepsy. Anxiety and depression and a reduction in social functioning are a consequence of this condition. Effective treatment results in improvement of quality-of-life measurement. Most of the data is gathered from case control studies. Further work, particularly prospective longitudinal cohort studies, needs to be performed to validate the impact of acne on quality of life. Acne severity grading should incorporate life quality scores to better establish the true impact of this condition on our patients in order to optimize therapy.

A prospective, randomized clinical study of adjunctive peripheral parenteral nutrition in adult subacute care patients

BACKGROUND

A number of frail, older, undernourished patients cannot maintain adequate oral intake to meet protein-calorie needs after an illness, even when high-density nutritional supplements are added. Tolerance to enteral nutrition by gastric tube is poor in this group of patients. Peripheral parenteral nutrition is an effective method of administering nutritional support to patients with mild to moderate nutritional deficiencies who are unable to receive enteral nutrition or for whom enteral nutrition alone cannot meet energy needs. However, no data exists for the use of peripheral parenteral nutrition longer than two weeks and overall there are remarkably few studies on the efficacy of peripheral parenteral nutrition.

METHODS

A Phase 4, single center, prospective, randomized, parallel group design clinical trial was conducted to evaluate long-term safety of peripheral parenteral nutrition in post-acute patients receiving inadequate enteral nutrition. Nutritional status was measured by the Mini-Nutritional Assessment and functional status by the Functional Inventory Measure. Subjects received a mean duration for peripheral parenteral nutrition of 15.8 +/- 6.7 days (range 8-23).

RESULTS

The peripheral parenteral nutrition group demonstrated several trends towards improvement in prealbumin, CD4 cell count, and functional status compared to the untreated control group. Two patients in the peripheral parenteral nutrition group developed low-grade phlebitis; however, this did not result in discontinuing intravenous therapy. No other adverse events occurred. This study demonstrates that peripheral parenteral nutrition is feasible and safe in postacute care.

CONCLUSIONS

We conclude that peripheral parenteral nutrition can be safely administered in post-acute settings with a low rate of complications.

Tuberculosis education in an endemic setting: application of participatory methods to video development in The Gambia

OBJECTIVE

To produce an educational video for tuberculosis (TB) awareness in The Gambia using participatory methods and integrated formative evaluation.

METHODS

A steering group was formed of key people working in TB research, health education, the health service and the media. They developed a script and commissioned local production of the video in three local languages and English. A formative participatory evaluation of the project was conducted using document review, attendance at rehearsals and semi-structured interviews. A pilot version of the video was evaluated through focus groups in Banjul and remote villages. Data were analysed using a general inductive approach.

RESULTS

Five major themes emerged from evaluation of the project participatory process: collaboration, knowledge sharing, networking, ownership and a common desire to sustain the project goals for video dissemination. The video was well received and described as informative, entertaining and professional. Audiences were able to identify the key messages, prevailing attitudes about TB were challenged, and many participants expressed a desire to act on their new knowledge.

CONCLUSION

A participatory approach to the development of a video in The Gambia proved to be empowering to local participants and led to the production of a resource well received by Gambian people.

The relationship of functional status, nutritional assessment, and severity of illness to in-hospital mortality

BACKGROUND

Prediction of in-hospital mortality may direct hospital resources towards those patients most at risk. A number of single domain risk instruments have been developed, indicating that functional status, nutritional assessment, and severity of illness individually predict in-hospital mortality. The interaction among these predictors is less well described.

OBJECTIVE

To determine the relationship of functional status, nutritional assessment, and severity of illness to in-hospital mortality.

DESIGN, SETTING, SUBJECTS

Cohort study of 1712 consecutive admissions over a one year period to an Internal Medical Service at a tertiary university teaching hospital.

MAIN OUTCOME MEASURES

Death during hospital admission.

RESULTS

Dependency in activities of daily living (OR = 3.37, 95% CI 1.78 to 6.37, p = 0.0002) and body mass index less than 20 (OR = 2.38, 95% CI 1.20 to 4.74, p = 0.01) predicted in-hospital mortality after adjusting for nutritional risk assessment, and severity of illness score.

CONCLUSIONS

Impairment in functional status and low body mass index produce the best predictors of inhospital mortality, after adjusting for nutritional risk and severity of illness score. Among these factors, functional impairment may be amenable to correction.

Age-related changes in wound healing

Evidence for age-related effects on wound healing have been derived for the most part from empirical observations without adjustment for confounders other than age. Age-related changes in the structure and function of the skin do occur. Some of these changes result from chronic solar radiation exposure rather than chronological age per se. The tensile strength of wounds, accumulation of wound healing factors and rate of wound closure have all been examined in relation to chronological aging. However, the clinical impact of these changes in acute wound healing appears to be small. Poor healing in chronic wounds is more often related to comorbid conditions rather than age alone. Since the majority of these chronic wounds occur in elderly populations, this has contributed to the conclusion that aging itself may influence healing. Progress in understanding the role that growth factors play in wound healing and the ability to synthesise adequate quantities of these factors for clinical use has led to clinical trials evaluating their use in wound healing. The results of these studies, with the possible exception of those in diabetic wounds, have been disappointing. Insight into the wound healing process indicates that growth factors interact during wound healing in a sequential and orderly process. Improved wound healing may require different clinical designs or the use of these factors in a precisely timed sequential administration.

Common medical terminology comes of age, Part Two: Current code and terminology sets--strengths and weaknesses

A number of clinical coding and vocabulary schemes are in use in healthcare enterprises today. Most of them are weak in light of the qualities that characterize adequate controlled medical terminologies, as outlined in Part One of this review. Here we look at the major code and terminology sets with a critical eye, as well as suggest practical steps to enable health industry information system purchasers and users to move forward with their effort to use common terminology to improve the quality, service, and knowledge in their enterprise.

Common medical terminology comes of age, Part One: Standard language improves healthcare quality

It has become abundantly clear that standards of recording clinical terms in human-readable, computer-processable format are indispensable. Controlled medical terminology is the missing link in health information standards (in fact, medical terminology can be viewed as the mother of all standards); its absence interferes with the business of healthcare and impedes the core processes of healing and maintaining health. Medicine has lacked the controlled common medical vocabulary that would enable universal sharing of data at the point of care and ensure reliable information for determining health intervention effectiveness. Simple clinical and code content alone has proven insufficient for healthcare enterprises to successfully manage the terminology problem; the "lexical runtime engine," formerly called a vocabulary server (VOSER), which manages the vocabulary ontology and serves up the relevant vocabulary to users of applications in the clinical environment, has recently become a reality.

[3H]-SB-269970 radiolabels 5-HT7 receptors in rodent, pig and primate brain tissues

The selective 5-HT7 receptor antagonist radioligand, [3H]-SB-269970, has been reported to radiolabel the human cloned 5-HT7(a) receptor and 5-HT7 receptors in guinea pig cortex (thomas et al, 2000). Saturation analysis of [3H]-SB-269970 binding to mouse forebrain, rat cortex, pig cortex, marmoset cortex and human thalamus membranes was consistent with labelling a homogenous population of binding sites in each tissue. K(D) values for [3H]-SB-269970 binding in these tissues ranged from 0.9 to 2.3 nM, being similar to those reported for the human cloned and guinea pig cortex 5-HT7 receptors (1.3 and 1.7 nM, respectively). Bmax values for [3H]-SB-269970 binding to the mouse, rat, pig, marmoset and human brain membranes were 20, 30, 31, 14 and 68 fmoles x mg x protein(-1), respectively. For each species the profile of inhibition of [3H]-SB-269970 binding, using a number of 5-HT7 receptor agonists and antagonists, correlated well with that reported for the human cloned 5-HT7(a) receptor (correlation coefficients were 0.95, 0.94, 0.92, 0.95, 0.97 versus the mouse, rat, pig, marmoset and human tissues, respectively). In conclusion, [3H]-SB-269970 has been shown to radiolabel 5-HT7 receptors in rodent, pig and primate brain and represents a valuable tool with which to further characterise the distribution and function of 5-HT7 receptors in native tissues and elucidate their potential role in disease states.

An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH)

BACKGROUND

Currently, there is no instrument that provides an accurate and simple method of monitoring pressure ulcer healing in clinical practice. This article reports the two studies that were conducted to assess the validity of the Pressure Ulcer Scale for Healing (PUSH) as a tool to monitor healing of stage II-IV pressure ulcers.

METHODS

Subjects in both studies (N = 103 and N = 269) were elderly (mean Study 1, 75 years, mean Study 2, 80 years), and the majority were women (Study 1, 51%, Study 2, 70%). Study data were extracted from patients' permanent records.

RESULTS

Principal components analysis confirmed that the PUSH tool accounted for 58% to 74% of the wound healing variance over a 10-week period in Study 1 and 40% to 57% of the wound healing variance over a 12-week period in Study 2. In addition, multiple regression analysis, used to measure the sensitivity of the model to total healing, showed PUSH accounted for 39% of the variance in 6 weeks and 31% of the variance over 12 weeks (p <.001; Studies 1 and 2, respectively).

CONCLUSIONS

Data from these two studies confirmed that the PUSH tool, with the components of length times width, exudate amount, and tissue type, is a valid and sensitive measure of pressure ulcer healing. It is a practical approach that provides clinically valid data regarding pressure ulcer healing. Further testing is needed to confirm these findings.

Novel (4-piperazin-1-ylquinolin-6-yl) arylsulfonamides with high affinity and selectivity for the 5-HT(6) receptor

The discovery of (4-piperazin-1-ylquinolin-6-yl) arylsulfonamides and their binding affinities for a selection of 5-HT and dopamine subreceptors is described. Many compounds show high affinity (pK(i)>8) for the 5-HT(6) receptor and >100-fold selectivity against a range of other receptors. Structure-activity relationships of these compounds are discussed.

Are all pressure ulcers avoidable?

A quality of care debate centers on whether pressure ulcers result from factors largely dependent on caregivers, or whether pressure ulcers result from factors associated with patient morbidity. A reduction in incidence, defined as the development of a new pressure ulcer, is the focus of prevention strategies. Yet epidemiological data demonstrates a stability in the incidence of pressure ulcers despite drastic improvements in understanding of pressure ulcers, increased regulatory oversight, and improvements in technologies available for prevention of pressure ulcers. The explanation for this stable incidence of pressure ulcers includes a failure of known effective preventive treatment to be applied or the failure of prevention strategies to be effective in spite of being applied. No intervention strategy has been reported that consistently and reproducibly reduces the incidence of pressure ulcers to zero. The published data on prevention of pressure ulcers do not support an assumption that all pressure ulcers are preventable. An effective prevention strategy demonstrated to eliminate pressure ulcers across healthcare settings is lacking.

Evidence of persisting serum antibodies to Escherichia coli O157 lipopolysaccharide and Verocytotoxin in members of rural communities in England

The techniques of enzyme-linked immunosorbent assay (ELISA) and immunoblotting were used to examine a total of 1667 sera, from apparently healthy members of rural communities in England, for antibodies to the lipopolysaccharide (LPS) of Escherichia coli O157 and Verocytotoxins (VT). Twenty-nine sera from 22 individuals were shown to have antibodies specific for E. coli O157 LPS. Some of these lived on livestock farms and had occupational contact with cattle, suggesting that personnel working with farm animals may produce serum antibodies to the O157 LPS antigens. Fifteen people had IgG class antibodies to O157 LPS, suggesting long-term exposure to E. coli O157 and five people had serum antibodies on more than one occasion showing evidence of persistent antibodies to O157 LPS. Thirteen sera from 12 of 22 individuals also contained antibodies to VT1, VT2 or both toxins. Ten sera contained antibodies to VT1 and VT2, three sera contained antibodies to VT2 only.

Prevention and treatment of pressure ulcers: what works? what doesn't?

Although no gold standard for preventing or treating pressure ulcers has been established, data from clinical trials indicate specific efforts are worthwhile. Preventive strategies include recognizing risk, decreasing the effects of pressure, assessing nutritional status, avoiding excessive bed rest, and preserving the integrity of the skin. Treatment principles include assessing the severity of the wound; reducing pressure, friction, and shear forces; optimizing wound care; removing necrotic debris; managing bacterial contamination; and correcting nutritional deficits.

Issues and dilemmas in the prevention and treatment of pressure ulcers: a review

Considerable dogma and rhetoric, rather than evidence-based results, have accompanied recommendations for the prevention and treatment of pressure ulcers. Therapy for pressure ulcers is generally empiric, based on anecdotal experience, or borrowed from the treatment of patients with acute wounds. The treatment of pressure ulcers is problematic because of multiple comorbidities of patients, the chronic duration of pressure ulcers, and often by the physician's relative unfamiliarity with treatment options. Issues and dilemmas in the prevention of pressure ulcers center around risk assessment, means of pressure relief, and nutritional support. Similar issues in the treatment of pressure ulcers include implementing pressure relief, nutritional support, local wound care, the best method of debridement, diagnosing infection, the use of topical growth factors, and surgical treatment. The accumulating data for the prevention and management of pressure ulcers permits an outline of clinical strategies.

Assessing ethnicity in New Zealand health research

AIMS

To investigate the patterns and criteria reported for categorisation of ethnicity in a sample of health research reports which made comparisons between Maori and non-Maori.

METHODS

A total of 98 research reports, which made comparisons between Maori and non-Maori samples, were selected from the New Zealand Medical Journal over five 12-month periods and one 24-month period between 1980 and 1996.

RESULTS

Only 19% of the 98 articles reported any information about the criteria used for categorising ethnicity. Only three articles mentioned how people of dual or multiple ethnicity were categorised. Although the term 'race' was commonly used in the 1980s, the terms 'ethnicity' and 'ethnic group' were more widely used later to describe ethnicity.

CONCLUSIONS

Much of the New Zealand research comparing Maori and non-Maori samples is likely to have unacknowledged error. Most articles did not meet minimum expected standards for reporting procedures for categorising ethnicity. There seemed to be little awareness of the major changes which have taken place in the New Zealand Census question concerning ethnicity between 1981 and 1996. Some suggestions were made for effective practice when assessing and reporting ethnicity in New Zealand research.

Improving outcome of pressure ulcers with nutritional interventions: a review of the evidence

Pressure ulcers and malnutrition frequently co-exist in frail patients. Nutritional parameters have been correlated with development and with healing in chronic pressure ulcers, leading to suggestions that improving nutritional status can prevent or treat pressure ulcers. Despite a strong association, a causal relationship of poor nutritional status to development of pressure ulcers has not been established. Support for a causal relationship would include evidence that nutritional interventions improve general nutritional status, acute wound healing, or chronic wound healing. The data suggesting that nutritional intervention can improve clinical outcome are limited. No study has demonstrated that improvement in nutritional status can prevent pressure ulcers. There is at least suggestive evidence that improvement in nutritional status can improve outcome in pressure ulcer healing.

Nutritional management in long-term care: development of a clinical guideline. Council for Nutritional Strategies in Long-Term Care

BACKGROUND

Involuntary weight loss resulting from malnutrition is a major problem among residents in long-term care facilities. Although body weight is easily measured, the evaluation of unintended weight loss in long-term care facilities is difficult.

METHODS

The Council for Nutritional Clinical Strategies in Long-Term Care, an expert panel of interdisciplinary thought leaders representing academia and the medical community, derived a structured approach aimed at improving management of malnutrition in long-term care settings, using literature review and consensus development. The Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care is based on a best-evidence approach to the management of nutritional problems in long-term care.

RESULTS

The Clinical Guide is divided into two parts, one designed for nursing staff, dietary staff, and dietitians, and a second directed to physicians, pharmacists, and dietitians.

CONCLUSIONS

A structured approach to the management of unintended weight loss or malnutrition in long-term care is intended to ensure a comprehensive resident evaluation. While the Clinical Guide is presented in a linear fashion, many of the considerations can be done simultaneously and the order varied dependent on the individual resident's needs. Further research to validate the effectiveness of using the algorithm in long-term care settings will be required.

Wound management in postacute care

Decreasing hospital length of stay has dictated that postacute and long-term care facilities bear the brunt of treating acute and chronic wounds. Two types of chronic wounds are discussed: (1) pressure ulcers and (2) diabetic ulcers. The differential diagnosis of these ulcers is imperative because the management of both types of wound differs substantially. Wound therapy includes relieving pain, correcting nutritional deficiencies, maintaining an optimal wound environment, shielding the wound from further damage, removing necrotic debris, promoting granulation tissue formation, protecting against bacterial contamination, choosing an appropriate dressing, and surgical treatment. The application of these principles is discussed, and the differences among wound types are highlighted.

A simple test of association for contingency tables with multiple column responses

Loughin and Scherer (1998, Biometrics 54, 630-637) investigated tests of association in two-way tables when one of the categorical variables allows for multiple-category responses from individual respondents. Standard chi-squared tests are invalid in this case, and they developed a bootstrap test procedure that provides good control of test levels under the null hypothesis. This procedure and some others that have been proposed are computationally involved and are based on techniques that are relatively unfamiliar to many practitioners. In this paper, the methods introduced by Rao and Scott (1981, Journal of the American Statistical Association 76, 221-230) for analyzing complex survey data are used to develop a simple test based on a corrected chi-squared statistic.

Characterization of SB-269970-A, a selective 5-HT(7) receptor antagonist

The novel 5-HT(7) receptor antagonist, SB-269970-A, potently displaced [(3)H]-5-CT from human 5-HT(7(a)) (pK(i) 8.9+/-0.1) and 5-HT(7) receptors in guinea-pig cortex (pK(i) 8.3+/-0.2). 5-CT stimulated adenylyl cyclase activity in 5-HT(7(a))/HEK293 membranes (pEC(50) 7.5+/-0.1) and SB-269970-A (0.03 - 1 microM) inhibited the 5-CT concentration-response with no significant alteration in the maximal response. The pA(2) (8.5+/-0.2) for SB-269970-A agreed well with the pK(i) determined from [(3)H]-5-CT binding studies. 5-CT-stimulated adenylyl cyclase activity in guinea-pig hippocampal membranes (pEC(50) of 8.4+/-0.2) was inhibited by SB-269970-A (0.3 microM) with a pK(B) (8.3+/-0.1) in good agreement with its antagonist potency at the human cloned 5-HT(7(a)) receptor and its binding affinity at guinea-pig cortical membranes. 5-HT(7) receptor mRNA was highly expressed in human hypothalamus, amygdala, thalamus, hippocampus and testis. SB-269970-A was CNS penetrant (steady-state brain : blood ratio of ca. 0.83 : 1 in rats) but was rapidly cleared from the blood (CLb=ca. 140 ml min(-1) kg(-1)). Following a single dose (3 mg kg(-1)) SB-269970 was detectable in rat brain at 30 (87 nM) and 60 min (58 nM). In guinea-pigs, brain levels averaged 31 and 51 nM respectively at 30 and 60 min after dosing, although the compound was undetectable in one of the three animals tested. 5-CT (0.3 mg kg(-1) i.p.) induced hypothermia in guinea-pigs was blocked by SB-269970-A (ED(50) 2.96 mg kg(-1) i.p.) and the non-selective 5-HT(7) receptor antagonist metergoline (0.3 - 3 mg kg(-1) s.c.), suggesting a role for 5-HT(7) receptor stimulation in 5-CT induced hypothermia in guinea-pigs. SB-269970-A (30 mg kg(-1)) administered at the start of the sleep period, significantly reduced time spent in Paradoxical Sleep (PS) during the first 3 h of EEG recording in conscious rats.