Cranioplasty: A Multidisciplinary Approach

Decompressive craniectomy (DC) is an operation where a large section of the skull is removed to accommodate brain swelling. Patients who survive will usually require subsequent reconstruction of the skull using either their own bone or an artificial prosthesis, known as cranioplasty. Cranioplasty restores skull integrity but can also improve neurological function. Standard care following DC consists of the performance of cranioplasty several months later as historically, there was a concern that earlier cranioplasty may increase the risk of infection. However, recent systematic reviews have challenged this and have demonstrated that an early cranioplasty (within three months after DC) may enhance neurological recovery. However, patients are often transferred to a rehabilitation unit following their acute index admission and before their cranioplasty. A better understanding of the pathophysiological effects of cranioplasty and the relationship of timing and complications would enable more focused patient tailored rehabilitation programs, thus maximizing the benefit following cranioplasty. This may maximise recovery potential, possibly resulting in improved functional and cognitive gains, enhancement of quality of life and potentially reducing longer-term care needs. This narrative review aims to update multi-disciplinary team regarding cranioplasty, including its history, pathophysiological consequences on recovery, complications, and important clinical considerations both in the acute and rehabilitation settings.

Atomoxetine in the treatment of children and adolescents with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled, dose-response study

OBJECTIVE

Atomoxetine is an investigational, nonstimulant pharmacotherapy being studied as potential treatment for attention-deficit/hyperactivity disorder (ADHD). It is thought to act via blockade of the presynaptic norepinephrine transporter in the brain. We assessed the efficacy of 3 doses of atomoxetine compared with placebo in children and adolescents with ADHD.

METHODS

A total of 297 children and adolescents who were 8 to 18 years of age and had ADHD as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, were randomized to placebo or atomoxetine dosed on a weight-adjusted basis at 0.5 mg/kg/day, 1.2 mg/kg/day, or 1.8 mg/kg/day for an 8-week period. ADHD symptoms, affective symptoms, and social and family functioning were assessed using parent and investigator rating scales.

RESULTS

Approximately 71% of children enrolled were male, approximately 67% met criteria for mixed subtype (both inattentive and hyperactive/impulsive symptoms), and the only common psychiatric comorbidity was oppositional defiant disorder (approximately 38% of the sample). At baseline, symptom severity was rated as moderate to severe for most children. At endpoint, atomoxetine 1.2 mg/kg/day and 1.8 mg/kg/day were consistently associated with superior outcomes in ADHD symptoms compared with placebo and were not different from each other. The dose of 0.5 mg/kg/day was associated with intermediate efficacy between placebo and the 2 higher doses, suggesting a graded dose-response. Social and family functioning also were improved in the atomoxetine groups compared with placebo with statistically significant improvements in measures of children's ability to meet psychosocial role expectations and parental impact. Discontinuations as a result of adverse events were <5% for all groups.

CONCLUSION

Among children and adolescents aged 8 to 18, atomoxetine was superior to placebo in reducing ADHD symptoms and in improving social and family functioning symptoms. Atomoxetine was associated with a graded dose-response, and 1.2 mg/kg/day seems to be as effective as 1.8 mg/kg/day and is likely to be the appropriate initial target dose for most patients. Treatment with atomoxetine was safe and well tolerated.

Grief and older people: the making or breaking of emotional bonds following partner loss in later life

The aim of this ethnographic study was to explore retrospectively the grief experiences of 12 older people whose partners had recently died in hospital, following a period of terminal illness. The rationale was based upon developing an understanding of the grief experiences of newly bereaved older people. In doing so, it is important to consider that grief is not only shaped by culture and social context but also by the nature of the relationship between the mourner and the deceased. For most of this century, the dominant conceptualization relating to grief and the social experience of bereavement has been based on the psychoanalytical school of thought. This process is said to involve the mourner passing through a number of stages or phases and forms the basis of the 'grief work hypothesis'. Using in-depth ethnographic interviews, the mourner's reactions to and perceptions of the loss were explored. Tape-recorded interview data were analysed using the inductive process of both content analysis and discourse evaluation. The findings from this study shed light on an area of conjugal bereavement that has received little attention in the past and challenges traditional models of grief. The indications are that in the first year of bereavement, the bereaved retain and modify the emotional relationship with their deceased partners, through a range of symbolic behaviours. The discussion raises issues concerning the need to consider the extent to which contemporary conceptualizations of grief explain the reactions of older people whose grief experiences are shaped by their social situation. The study also highlights important issues concerning the need to understand the complexity of grief experiences and bereavement support for older people which has a number of implications for nurses in both hospital and community settings.

Implementing clinical supervision

To discover whether clinical supervision would be a useful tool, nurses must discuss their aims and expectations and, through workshops, create a system that reflects their needs. A co-ordinator well-versed in the literature could lead this project.

Effect of exercise on postprandial insulin responses in Mexican American and non-Hispanic women

Postprandial insulin responses (integrated area under the curve) to an oral glucose load after a period of aerobic exercise and no exercise (control) were compared in sedentary normoglycemic Mexican American and non-Hispanic women pair-matched (n = 9) on total body fat mass (21.8 +/- 3.5 kg). The age (27.4 +/- 3.0 years), body mass index (BMI) (23.6 +/- 1.4 kg/m2), waist to hip ratio (WHR) (0.85 +/- .02), waist circumference (83.5 +/- 4.5 cm), lean mass (36.2 +/- 1.5 kg), and maximal O2 consumption ([VO2 max] 32.9 +/- 1.6 mL x kg(-1) x min(-1)) were similar, although the centrality index (subscapular/triceps skinfolds) was significantly greater in Mexican Americans (0.88 +/- 0.06 v 0.70 +/- 0.05, P < .01). Exercise (treadmill walking for 50 minutes at 70% VO2 max) and control trials were performed 4 weeks apart and 5 to 12 days after the onset of menstruation. A 75-g oral glucose load was administered 15 hours after the completion of each trial, with the subjects 12 hours postprandial. Blood samples were drawn prior to glucose ingestion (fasting, 0 minutes) and at minutes 15, 30, 60, 90, 120, and 150 postingestion. The postprandial insulin response was calculated using a trapezoidal method. In Mexican Americans, significant (P < .02) reductions in the postprandial insulin response (exercise v control, 6.5 +/- 1.0 v 8.5 +/- 1.4 pmol/L x min x 10(4)) and fasting insulin (exercise v control, 77.4 +/- 7.0 v 88.5 +/- 10.3 pmol/L) occurred after exercise compared with the control condition. In non-Hispanics, neither the postprandial insulin response (exercise v control, 7.2 +/- 1.0 v 6.2 +/- 0.9 pmol/L x min x 10(4)) nor fasting insulin (exercise v control, 77.0 +/- 8.2 v 82.9 +/- 8.9 pmol/L) were significantly different between trials. The postprandial insulin response in the control trial was significantly correlated with the change in the insulin response (control minus exercise) in the 18 women (r = .56, P = .01). No trial or group differences were found for postprandial glucose and C-peptide responses. Mexican American women have a high risk of developing type 2 diabetes, and aerobic exercise may be valuable in the prevention or delay of onset of diabetes by reducing peripheral insulin resistance.

Scheduled intermittent hospitalization for psychiatric patients

OBJECTIVE

The effect of scheduled intermittent hospitalization on the hospital utilization, community adjustment, and self-esteem of persons with serious and persistent mental illness was examined in an experimental study.

METHODS

Fifty-seven male veterans, aged 65 or younger, with a primary axis I psychiatric diagnosis who were frequent utilizers of inpatient care over the previous two years were randomly assigned to two groups. Patients in the experimental group were prescheduled for four hospital admissions, each lasting nine to 11 days, per year for two years. Patients in the control group had traditional access to hospital care. Psychiatric bed days, community adjustment, and self-esteem were assessed during and after the intervention.

RESULTS

No differences between the groups on demographic or clinical variables were detected at study entry. The experimental group showed improvement in self-esteem, affect, and complaints of physical symptoms at one year. No statistically significant differences between groups were found in hospital utilization, financial management, substance abuse, or psychological well-being at one year.

CONCLUSIONS

Scheduled intermittent hospitalization may be an appropriate and promising alternative to traditional care for revolving-door patients. This intervention could maintain patients at a higher level of wellness than traditional care and reduce the recurrence of the crises that precipitate hospitalization.

Effects of nifedipine, a calcium channel antagonist, on cognitive function in schizophrenic patients with tardive dyskinesia

We examined whether nifedipine, a calcium channel antagonist, added to a stable regimen of neuroleptic medication would affect cognition in patients with chronic schizophrenia or schizoaffective disorder who had tardive dyskinesia. Fifteen patients with tardive dyskinesia were treated with nifedipine (60 mg daily) or matching placebo for 4 weeks and then were crossed over from nifedipine to placebo or from placebo to nifedipine for another 4 weeks. At the end of each 4-week phase of the study, the patients performed a rotary pursuit test of procedural learning and a dementia scale assessing general cognitive abilities. Nifedipine improved performance in the rotary pursuit test and conceptual abilities in the dementia scale compared with placebo, but only for patients who first were exposed to the tests during the placebo condition. These results provide preliminary evidence that calcium channel antagonists might enhance learning and memory in schizophrenic patients with tardive dyskinesia.

Preattentive and attentive eye movements during visual scanning of a cocaine cue: correlation with intensity of cocaine cravings

The visual scanning of 19 recently abstinent crack cocaine-dependent men was assessed while they viewed a picture of a cocaine cue and a picture of a neutral cue. Cocaine craving scores were inversely correlated with the number of preattentive fixations and saccades and were positively correlated with the number of attentive fixations.

The euthanasia debate

Euthanasia is an important issue that should be high on the nurse's moral agenda. The UK legal position is confused about themes central to euthanasia. Analysis can help explore and clarify core issues in the euthanasia debate.

D-cycloserine adjuvant therapy to molindone in the treatment of schizophrenia

This preliminary investigation examined the therapeutic efficacy of two doses of oral D-cycloserine (5 and 15 mg p.o. b.i.d.) administered as an adjuvant to molindone (150 mg p.o. q.d.) in the treatment of schizophrenia. D-Cycloserine is an agonist at the N-methyl-D-aspartate (NMDA) subclass of glutamate receptor complex. An NMDA agonist intervention was studied because of the schizophreniform psychosis precipitated by phencyclidine (PCP), which is a noncompetitive antagonist at the NMDA glutamate receptor. The PCP model of schizophrenia is regarded as the most comprehensive pharmacological model of this disorder. In this preliminary, placebo-controlled, double-blind, parallel-group study, the measures of treatment efficacy were the Brief Psychiatric Rating Scale, Schedule for the Assessment of Negative Symptoms, and Clinical Global Impression Scale. The final scores for each item of the outcome measures employed were based on the consensus of at least two trained raters who were present during each rating interview. In the 13 subjects evaluated, although the D-cycloserine was well tolerated, neither dose seemed to possess adjuvant therapeutic efficacy. However, since another recent report of nine patients with schizophrenia treated for 2 weeks with a slightly higher dose of D-cycloserine (50 mg/day) described significant clinical and neuropsychological improvement, further study of the adjuvant potential of slightly higher doses of D-cycloserine seems warranted. Additionally, there might be a therapeutic window for D-cycloserine dosing, as daily doses of 250 mg have been associated with symptom worsening.

An open-label study of the therapeutic efficacy of high-dose famotidine adjuvant pharmacotherapy in schizophrenia: preliminary evidence for treatment efficacy

Histaminergic projections innervate brain areas implicated in the pathophysiology of schizophrenia. In a previous open-label study, there was the suggestion that famotidine, and H2 histamine-receptor antagonist, possessed adjuvant therapeutic properties when added to the stable neuroleptic medications regimens of 10 treatment-refractory patients. In that study, the maximal dosage of famotidine was limited to 40 mg/day, the recommended maximal dosage for the treatment of peptic ulcer disease. In this study, we examined 18 patients fulfilling DSM-III-R criteria for schizophrenia and schizoaffective disorder who had famotidine (100 mg/day) added to their stable neuroleptic medication regimen. Patients were rated on baseline, weekly thereafter, and 1 week after famotidine discontinuation, by using the Brief Psychiatric Rating Scale (BPRS), Schedule for the Assessment of Negative Symptoms (SANS), and the Clinical Global Impression (CGI). On all of these outcome measures, statistically significant improvements suggestive of a beneficial adjunctive effect of famotidine were found. Famotidine (100 mg/day) was well tolerated by the study subjects. There was a wide range of famotidine blood levels achieved at the end of 3 weeks of famotidine adjunctive treatment, but these blood levels did not correlate with BPRS or SANS score changes. However, the patients with the greatest improvement in BPRS scores (and without concomitant deterioration in SAND scores) had some of the higher famotidine levels found in the study. Double-blind studies further assessing the potential adjunctive benefit of famotidine in the treatment of schizophrenia are indicated.

Smooth pursuit eye movements in the evaluation of famotidine adjunctive therapy of schizophrenia: a preliminary report

Smooth pursuit eye movements (SPEM) are often abnormal in schizophrenic patients and have been proposed as a trait marker of the disorder. We explored the use of SPEM as an outcome measure in an open-label clinical trial of famotidine, an H-2 antagonist, in patients with schizophrenia; famotidine has been proposed as an adjunctive medication, particularly for negative symptoms. Prior studies using SPEM as an outcome measure have not found a significant effect with "typical" neuroleptic medication, and one study found greater SPEM dysfunction with clozapine treatment. In this study, 19 schizophrenic subjects were stabilized for at least 1 week on conventional neuroleptic medications and then administered oral famotidine, 100 mg daily, for an additional 3 weeks. SPEM and clinical measures were assessed. Whereas Brief Psychiatric Rating Scale (BPRS) and Schedule for Assessment of Negative Symptoms (SANS) scores decreased significantly with famotidine administration, there was no significant change in SPEM performance over the course of the study. Two subjects (11%) doubled their signal/noise ratio and maintained this increase after famotidine discontinuation, whereas three subjects (17%) approximately halved this ratio and returned to baseline after famotidine discontinuation. SPEM changes were not found to correlate significantly with changes in BPRS or SANS scores. These findings suggest that SPEM dysfunction reflects a "trait" rather than clinical "state" in schizophrenia, and changes in SPEM performance might not be expected always to parallel changes in clinical ratings.

Ethics in the intensive care unit: a need for research

Intensive care units are challenging and technologically advanced environments. Dealing with situations that have an ethical dimension is an intrinsic part of working in such a milieu. When a moral dilemma emerges, it can cause anxiety and unease for all staff involved with it. Theoretical and abstract papers reveal that having to confront situations of ethical difficulty is a contributory factor to levels of poor morale and burnout among critical care staff. Despite this, there is a surprising dearth of published nursing research in the UK that investigates how staff deal with ethical issues in intensive care units. The purpose of this paper is to explore and discuss the development of a research framework designed to explore how staff deal with moral dilemmas in a British intensive care unit.

Cloning and expression of a gene encoding an integrin-like protein in Candida albicans

The existence of integrin-like proteins in Candida albicans has been postulated because monoclonal antibodies to the leukocyte integrins alpha M and alpha X bind to blastospores and germ tubes, recognize a candidal surface protein of approximately 185 kDa, and inhibit candidal adhesion to human epithelium. The gene alpha INT1 was isolated from a library of C. albicans genomic DNA by screening with a cDNA probe from the transmembrane domain of human alpha M. The predicted polypeptide (alpha Int1p) of 188 kDa contains several motifs common to alpha M and alpha X: a putative I domain, two EF-hand divalent cation-binding sites, a transmembrane domain, and a cytoplasmic tail with a single tyrosine residue. An internal RGD tripeptide is also present. Binding of anti-peptide antibodies raised to potential extracellular domains of alpha Int1p confirms surface localization in C. albicans blastopores. By Southern blotting, alpha INT1 is unique to C. albicans. Expression of alpha INT1 under control of a galactose-inducible promoter led to the production of germ tubes in haploid Saccharomyces cerevisiae and in the corresponding ste12 mutant. Germ tubes were not observed in haploid yeast transformed with vector alone, in transformants expressing a galactose-inducible gene from Chlamydomonas, or in transformants grown in the presence of glucose or raffinose. Transformants producing alpha Int1p bound an anti-alpha M monoclonal antibody and exhibited enhanced aggregation. Studies of alpha Int1p reveal novel roles for primitive integrin-like proteins in adhesion and in STE12-independent morphogenesis.

A measure of pupillary oscillation as a marker of cocaine-induced paranoia

Cocaine-induced paranoia (CIP) remains an important drug-induced model of idiopathic paranoia for which no psychophysiologic marker has yet emerged. Measures of pupillary oscillation were able to significantly distinguish a group of abstinent crack cocaine abusers endorsing past CIP (n = 32) from another group of crack addicts who denied past CIP (n = 29).

Effect of intensity and energy expenditure on postexercise insulin responses in women

The purposes of the study were to compare insulin responses after rest and exercise of two different intensities and equal total energy expenditure and to examine these responses in normoglycemic women. Twenty-four untrained women (age 23.4 +/- 0.9 yr) completed three randomly assigned treatments over the course of a 3- to 4-wk period: rest, 40% maximal oxygen consumption x 87 min (Low), and 70% maximal oxygen consumption x 50 min (High). Total energy expenditure was 1,821 +/- 61 and 1,692 +/- 59 kJ, heart rate was 119 +/- 2 and 163 +/- 2 beats/min, and oxygen consumption was 17.1 and 27.2 ml.kg-1.min-1 for Low and High, respectively. Fifteen to 17 h posttreatment and 12 h postprandial, each subject drank a 75-g glucose solution (oral glucose tolerance test). Blood samples were drawn before and at 30, 60, 90, 120, and 150 min after ingestion and were analyzed for glucose and insulin. Glucose areas and responses at the same time points across treatments were similar. Area under the insulin curve was significantly lower (P < 0.05) after High (51,864 +/- 3,780 pM x min) compared with rest (61,009 +/- 4,425 pM x min), but Low (59,191 +/- 5,307 pM x min) was not different from either rest or High. The insulin level at the 120-min time point was significantly (P < 0.01) lower after High (290.8 pM) compared with rest (391.7 pM). On the basis of these results, exercise-related changes in insulin responses are more dependent on exercise intensity than on energy expenditure in untrained women.

Famotidine adjunctive pharmacotherapy of schizophrenia: a case report

Recent reports suggest some utility for famotidine, a histamine type 2 (H2) antagonist, in the treatment of schizophrenia. The current report describes a treatment-resistant patient with chronic undifferentiated schizophrenia whose most dramatic symptomatic improvements were temporarily related to the open-label addition of famotidine (40-100 mg/day) to conventional neuroleptic treatment (molindone 150-200 mg/day) over the course of approximately 10 months. During one 2-week interval, his symptoms were controlled with famotidine (40 mg/day) alone. The case suggests that some adjuvant efficacy exists for famotidine in at least some patients with schizophrenia. Placebo-controlled trials are needed to more fully evaluate the utility of famotidine in the treatment of schizophrenia.

Presynaptic actions of morphine: blockade of cholecystokinin-induced noradrenaline release in the rat supraoptic nucleus

1. This study aimed to establish the site at which morphine acts to inhibit oxytocin release in response to peripheral administration of cholecystokinin (CCK). 2. Conscious rats were given morphine or vehicle followed by CCK or vehicle (I.V.). Fos immunoreactivity was apparent 90 min after CCK injection in the supraoptic nucleus of vehicle- but not morphine-pretreated animals. 3. In the dorsomedial (C2/A2) and the ventrolateral (C1/A1) regions of the brainstem, about half of the cells immunoreactive for tyrosine hydroxylase (TH) expressed Fos-like protein after CCK injection. In the C2/A2 region, 20% of the Fos-positive cells also showed TH immunoreactivity, whereas in the C1/A1 region 68% did so. Morphine treatment did not significantly change the number of cells expressing Fos immunoreactivity, or the percentage of TH-positive cells expressing Fos-like protein. 4. Amine release was measured in the supraoptic nucleus of urethane-anaesthetized rats using a microdialysis probe. An I.V. injection of CCK increased the concentrations in the dialysate of noradrenaline and serotonin, but not of either adrenaline or dopamine. Pretreatment with morphine (I.V.) blocked the effects of CCK in a naloxone-reversible manner. 5. Inclusion of morphine in the dialysate also blocked the increase in noradrenaline and serotonin in response to CCK in a naloxone-reversible manner. 6. These observations indicate that morphine acts near or within the supraoptic nucleus to block CCK-evoked noradrenaline release presynaptically. This presynaptic action of morphine may be a cause of the blockade of oxytocin release after CCK.

Validation of near-infrared spectroscopy in humans

Near-infrared (NIR) spectroscopy is a noninvasive technique that uses the differential absorption properties of hemoglobin to evaluate skeletal muscle oxygenation. Oxygenated and deoxygenated hemoglobin absorb light equally at 800 nm, whereas at 760 nm absorption is primarily from deoxygenated hemoglobin. Therefore, monitoring these two wavelengths provides an index of deoxygenation. To investigate whether venous oxygen saturation and absorption between 760 and 800 nm (760-800 nm absorption) are correlated, both were measured during forearm exercise. Significant correlations were observed in all subjects (r = 0.92 +/- 0.07; P < 0.05). The contribution of skin flow to the changes in 760-800 nm absorption was investigated by simultaneous measurement of skin flow by laser flow Doppler and NIR recordings during hot water immersion. Changes in skin flow but not 760-800 nm absorption were noted. Intra-arterial infusions of nitroprusside and norepinephrine were performed to study the effect of alteration of muscle perfusion on 760-800 nm absorption. Limb flow was measured with venous plethysmography. Percent oxygenation increased with nitroprusside and decreased with norepinephrine. Finally, the contribution of myoglobin to the 760-800 nm absorption was assessed by using 1H-magnetic resonance spectroscopy. At peak exercise, percent NIR deoxygenation during exercise was 80 +/- 7%, but only one subject exhibited a small deoxygenated myoglobin signal. In conclusion, 760-800 nm absorption is 1) closely correlated with venous oxygen saturation, 2) minimally affected by skin blood flow, 3) altered by changes in limb perfusion, and 4) primarily derived from deoxygenated hemoglobin and not myoglobin.

An advocate for whom--doctor or patient? How far can a nurse be a patient's advocate?

1. Nursing has always placed a great deal of emphasis on safeguarding patients' interests. 2. The role of advocate is presented as a key means by which nurses can represent the patient's 'best interests'. 3. Healthcare is so laden down by issues of power and politics that it raises doubts about whether nurses are actually in a position to act as the patient's advocate.

A freedom to choose. The ethics of informed consent

1. It is difficult to know how much information should be given to patients to help them give an informed consent. 2. Informed consent provides an avenue for the expression of the ethical themes of autonomy, respect for persons and truth. 3. Informed consent acknowledges patients' intrinsic right to decide what happens to their bodies.

Simultaneous in vivo measurements of HbO2 saturation and PCr kinetics after exercise in normal humans

Simultaneous measurements of phosphocreatine (PCr) and oxyhemoglobin (HbO2) saturation were made during recovery from exercise in calf muscles of five male subjects. PCr was measured using magnetic resonance spectroscopy in a 2.0-T 78-cm-bore magnet with a 9-cm-diam surface coil. Relative HbO2 saturation was measured as the difference in absorption of 750- and 850-nm light with use of near-infrared spectroscopy. The light source and detectors were 3 cm apart. Exercise consisted of isokinetic plantar flexion in a supine position. Two 5-min submaximal protocols were performed with PCr depletion to 60% of resting values and with pH values of > 7.0. Then two 1-min protocols of rapid plantar flexion were performed to deplete PCr values to 5-20% of resting values with pH values of < 6.8. Areas of PCr peaks (every 8 s) and HbO2 saturation (every 1 s) were fit to a monoexponential function, and a time constant was calculated. The PCr time constant was larger after maximal exercise (68.3 +/- 10.5 s) than after submaximal exercise (36.0 +/- 6.5 s), which is consistent with the effects of low pH on PCr recovery. HbO2 resaturation approximated submaximal PCr recovery and was not different between maximal (29.4 +/- 5.5 s) and submaximal (27.6 +/- 6.0 s) exercise. We conclude that magnetic resonance spectroscopy measurements of PCr recovery and near-infrared spectroscopy measurements of recovery of HbO2 saturation provide similar information as long as muscle pH remains near 7.0.

In vivo magnetic resonance spectroscopy measurement of deoxymyoglobin during exercise in patients with heart failure. Demonstration of abnormal muscle metabolism despite adequate oxygenation

BACKGROUND

Skeletal muscle metabolic abnormalities have been described in patients with heart failure that are independent of total limb perfusion, histochemical changes, and muscle mass. However, these skeletal muscle metabolic abnormalities may result from tissue hypoxia caused by maldistribution of flow. Myoglobin is an O2 binding protein that can indirectly assess tissue hypoxia.

METHODS AND RESULTS

In vivo measurement of deoxymyoglobin was performed by use of proton (1H) magnetic resonance spectroscopy in 16 heart failure (HF) (left ventricular ejection fraction = 20 +/- 6%; VO2 = 14.5 +/- 5.1 mL/kg per minute) and 7 healthy (Nl) subjects. Simultaneous phosphorus (31P) magnetic resonance spectroscopy and near-infrared spectroscopy also were obtained to examine muscle metabolism and oxygenation. Supine calf plantarflexion was performed every 4 seconds. Incremental steady-state work was performed. A second exercise protocol studied rapid incremental (RAMP) exercise with plantarflexion every 2 seconds. Arterial occlusion at end exercise provided physiological calibration for myoglobin and hemoglobin signals. With steady-state exercise, the work slope, ie, inorganic phosphorus to phosphocreatine ratios versus work, was significantly greater in patients with heart failure (Nl: 0.18 +/- 0.08; HF: 0.40 +/- 0.32 W-1; P < .05). Intracellular pH was reduced significantly at end exercise in patients but not healthy subjects. Despite these metabolic abnormalities, muscle oxygenation derived from 760- to 850-nm absorption was comparable in both groups throughout exercise. The relation of inorganic phosphorus/phosphocreatine (P1/PCr) ratio and muscle oxygenation was shifted upward in patients with heart failure such that at the same muscle oxygenation, Pi/PCr ratio in these patients was increased. No deoxymyoglobin signals were observed at rest. At maximal exercise, 4 of the healthy subjects and 3 of the patients exhibited deoxymyoglobin (P = NS). With RAMP exercise, the work slope was again significantly greater in patients with heart failure (Nl: 0.21 +/- 0.10; HF: 0.57 +/- 0.32 W-1; P < .05). Intracellular pH again was significantly decreased at end exercise in patients but not healthy subjects. Five of the healthy subjects and 3 of the heart failure patients had deoxymyoglobin signal (P = NS). With arterial occlusion, deoxymyoglobin was seen in all subjects.

CONCLUSION

Abnormal skeletal muscle metabolism in patients with heart failure usually occurs in the absence of myoglobin deoxygenation, suggesting that the abnormalities are not a result of cellular hypoxia during exercise with minimal cardiovascular stress.

Gaze discrimination in patients with schizophrenia: preliminary report

The authors administered a gaze discrimination task to 24 patients with chronic schizophrenia and 25 subjects with no psychiatric history. Each subject was shown slides and asked, "Is the person in the slide looking directly at you?" Patients with schizophrenia were more likely than comparison subjects to perceive the person in the slide as looking at them when the person was looking away. Because there is evidence that gaze discrimination performance involves the superior temporal sulcus region of the brain and this region has been implicated in theories about the pathogenesis of schizophrenia, further study of the gaze discrimination task seems indicated.

Tools which aid the decision-making process. Addressing moral dilemmas in nursing practice

Clinical practice can give rise to varying situations whereby conflicting interests pose nurses with difficult ethical dilemmas. This article outlines two principal theories of moral analysis, and shows how they can be used as a basis for decision-making.

Building bridges: teaching ward-based ethics

Ethics has traditionally been taught in the 'ivory towers' of academia. Recent developments and reforms in nurse education have given ethics a prominent position in most curricula. However, the vast majority of ethics teaching continues to take place in academic departments. This approach fuels the practitioner's views that nursing is a pragmatic activity whilst ethics is a cognitive endeavour; such perspectives entrench ethics firmly in the traditional gap between theory and practice. The focus of this paper presents an argument that the teaching of ethics must be versed in clinical reality if bridges are ever to be built and the theory-practice gap crossed.

Understanding ethics in nursing practice

Ethics has traditionally been viewed as an abstract subject confined to the ivory towers of academia. This article challenges that view and describes how ethics can offer nurses a framework for analysing difficult situations at the interface of practice.

Noradrenaline, dopamine and serotonin release in the paraventricular and supraoptic nuclei of the rat in response to intravenous cholecystokinin injections

Abstract Microdialysis sampling was used to measure noradrenaline, dopamine and serotonin release in the supraoptic and paraventricular nuclei of urethane-anaesthetized rats following intravenous injection of 20mug/kg cholecystokinin. This dose of cholecystokinin stimulates oxytocin release from the posterior pituitary, while slightly inhibiting vasopressin release. Dialysis probes were placed in the paraventricular nucleus, and into dorsal or ventral regions of the supraoptic nucleus. Samples were collected at 10-min intervals in each animal before, during and after two injections of cholecystokinin, and following a control injection of 0.9% NaCI. The injections of cholecystokinin stimulated significant increases in the concentrations of noradrenaline, dopamine and serotonin in the paraventricular nucleus and of noradrenaline and serotonin in the dorsal supraoptic nucleus region. Conversely, in the ventral supraoptic nucleus region a significant reduction in noradrenaline release was observed, but dopamine and serotonin concentrations were not significantly affected. The control injections did not alter noradrenaline, dopamine or serotonin release.

Striatal grafts in rats with unilateral neostriatal lesions--II. In vivo monitoring of GABA release in globus pallidus and substantia nigra

GABA release was recorded in vivo by push-pull perfusion from the globus pallidus and substantia nigra of control rats, rats with unilateral ibotenic acid lesions of the neostriatum, and rats with embryonic striatal tissue grafts implanted in the lesioned striatum. The lesions reduced baseline levels of GABA release to 5% of control levels in the globus pallidus and to 13% of control levels in the substantia nigra pars reticulata. GABA release was substantially restored in both the globus pallidus and substantia nigra of the grafted rats, to 34 and 60%, respectively. Peripheral injection of the dopaminergic stimulant methamphetamine induced a short (lasting approximately 20 min) 4-5 fold increase in GABA release in the intact globus pallidus and a longer (lasting longer than 80 min) increase in the substantia nigra. The stimulatory effect of methamphetamine on GABA release was completely abolished in both sites by the strial lesions, suggesting that the effect was mediated via a direct or indirect dopaminergic action on striatal output neurons. The grafts reinstated methamphetamine-induced stimulation of GABA release in striatal output targets to a level (as a proportion of baseline) that was similar to that seen in the control rats. The results support the view that activation of the dopaminergic inputs to the striatum is functionally excitatory on the major striatal output projections to the globus pallidus and substantia nigra pars reticulata. The results also support the hypothesis that striatal grafts have the capacity to become functionally incorporated by reciprocal graft-host connections into the neural circuitry of the host brain.