Multi-species outbreak of SARS-CoV-2 Delta variant in a zoological institution, with the detection in two new families of carnivores

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a worldwide distribution in humans and many other mammalian species. In late September 2021, 12 animals maintained by the Chicago Zoological Society's Brookfield Zoo were observed with variable clinical signs. The Delta variant of SARS-CoV-2 was detected in faeces and nasal swabs by qRT-PCR, including the first detection in animals from the families Procyonidae and Viverridae. Test positivity rate was 12.5% for 35 animals tested. All animals had been vaccinated with at least one dose of a recombinant vaccine designed for animals and all recovered with variable supportive treatment. Sequence analysis showed that six zoo animal strains were closely correlated with 18 human SARS-CoV-2 strains, suggestive of potential human-to-animal transmission events. This report documents the expanding host range of COVID-19 during the ongoing pandemic.

Observational Study of Metformin and Risk of Mortality in Patients Hospitalized with Covid-19

Background Type 2 diabetes (T2DM) and obesity are significant risks for mortality in Covid19. Metformin has been hypothesized as a treatment for COVID19. Metformin has sex specific immunomodulatory effects which may elucidate treatment mechanisms in COVID-19. In this study we sought to identify whether metformin reduced mortality from Covid19 and if sex specific interactions exist. Methods De-identified claims data from UnitedHealth were used to identify persons with at least 6 months continuous coverage who were hospitalized with Covid-19. Persons in the metformin group had at least 90 days of metformin claims in the 12 months before hospitalization. Unadjusted and multivariate models were conducted to assess risk of mortality based on metformin as a home medication in individuals with T2DM and obesity, controlling for pre-morbid conditions, medications, demographics, and state. Heterogeneity of effect was assessed by sex. Results 6,256 persons were included; 52.8% female; mean age 75 years. Metformin was associated with decreased mortality in women by logistic regression, OR 0.792 (0.640, 0.979); mixed effects OR 0.780 (0.631, 0.965); Cox proportional-hazards: HR 0.785 (0.650, 0.951); and propensity matching, OR of 0.759 (0.601, 0.960). TNF-alpha inhibitors were associated with decreased mortality in the 38 persons taking them, by propensity matching, OR 0.19 (0.0378, 0.983). Conclusions Metformin was significantly associated with reduced mortality in women with obesity or T2DM in observational analyses of claims data from individuals hospitalized with Covid-19. This sex-specific finding is consistent with metformin reducing TNF-alpha in females over males, and suggests that metformin conveys protection in Covid-19 through TNF-alpha effects. Prospective studies are needed to understand mechanism and causality.

Cardiac disease is linked to adiposity in male gorillas (Gorilla gorilla gorilla)

Cardiac disease is a major cause of morbidity and mortality for adult gorillas. Previous research indicates a sex-based difference with predominantly males demonstrating evidence of left ventricular hypertrophy. To evaluate these findings, we analyzed serum markers with cardiac measures in a large sample of gorillas. The study sample included 44 male and 25 female gorillas housed at American Association of Zoo and Aquariums (AZA)-accredited zoos. Serum samples were collected from fasted gorillas during routine veterinary health exams and analyzed to measure leptin, adiponectin, IGF-1, insulin, ferritin, glucose, triglycerides, and cholesterol. Cardiac ultrasonography via transthoracic echocardiogram was performed simultaneously. Three echocardiographic parameters were chosen to assess cardiac disease according to parameters established for captive lowland gorillas: left ventricular internal diameter, inter-ventricular septum thickness, and left ventricular posterior wall thickness. Our data revealed that high leptin, low adiponectin, and lowered cholesterol were significantly and positively correlated with measures of heart thickness and age in males but not in females. Lowered cholesterol in this population would be categorized as elevated in humans. High leptin and low adiponectin are indicative of increased adiposity and suggests a potential parallel with human obesity and cardiovascular disease in males. Interestingly, while females exhibited increased adiposity with age, they did not progress to cardiac disease.

Feasibility of Implementing Patient Priorities Care for Older Adults with Multiple Chronic Conditions

Older adults with multiple chronic conditions (MCCs) receive care that is fragmented and burdensome, lacks evidence, and most importantly is not focused on what matters most to them. An implementation feasibility study of Patient Priorities Care (PPC), a new approach to care that is based on health outcome goals and healthcare preferences, was conducted. This study took place at 1 primary care and 1 cardiology practice in Connecticut and involved 9 primary care providers (PCPs), 5 cardiologists, and 119 older adults with MCCs. PPC was implemented using methods based on a practice change framework and continuous plan-do-study-act (PDSA) cycles. Core elements included leadership support, clinical champions, priorities facilitators, training, electronic health record (EHR) support, workflow development and continuous modification, and collaborative learning. PPC processes for clinic workflow and decision-making were developed, and clinicians were trained. After 10 months, 119 older adults enrolled and had priorities identified; 92 (77%) returned to their PCP after priorities identification. In 56 (46%) of these visits, clinicians documented patient priorities discussions. Workflow challenges identified and solved included patient enrollment lags, EHR documentation of priorities discussions, and interprofessional communication. Time for clinicians to provide PPC remains a challenge, as does decision-making, including clinicians' perceptions that they are already doing so; clinicians' concerns about guidelines, metrics, and unrealistic priorities; and differences between PCPs and patients and between PCPs and cardiologists about treatment decisions. PDSA cycles and continuing collaborative learning with national experts and peers are taking place to address workflow and clinical decision-making challenges. Translating disease-based to priorities-aligned decision-making appears challenging but feasible to implement in a clinical setting.

Implementation of the Safewards model in public mental health facilities: A qualitative evaluation of staff perceptions

BACKGROUND

The Safewards model is gaining increasing acceptance in the mental health field in Australia and overseas. One of the most important goals of inpatient psychiatric services is to provide a safe and therapeutic environment for both patients and staff. However, this goal can be difficult to achieve if staff-patient interaction is not conducive to preventing violence and aggression.

OBJECTIVE

The purpose of this study was to explore nursing staff perceptions of the factors impacting on their capacity to establish Safewards in acute adult inpatient wards.

DESIGN

This study was guided by a phenomenological approach to develop a rich understanding of staff perceptions using semi-structured interviews.

SETTING AND SAMPLE

The setting was three acute mental health wards attached to general hospitals; one in a large provincial hospital and two in metropolitan hospitals in south-east Queensland. Interview participants were a purposive sample of fifteen registered nurses across each of the three wards.

METHOD

Semi-structured interviews were conducted at 12 months post-implementation of Safewards. The study was underpinned by Michie's integrative framework of behaviour change that helped identify target areas in order to enhance successful implementation of this model.

RESULTS

Content analysis of interview transcripts highlighted a range of factors including failure to address the difficulties encountered by some staff in engaging with Safewards interventions, lack of support from management, poor use of nurse educator time, the 'language' of Safewards, high acuity on the study wards, and staff and patient turnover.

CONCLUSION

This study highlights some difficulties with implementing Safewards and maintaining fidelity of the Safewards interventions in busy acute inpatient wards. Although these findings are from a qualitative study consisting of only 15 staff, our results indicate that efforts to implement Safewards need to address challenges faced by staff in engaging with the interventions, ensure buy-in from management, ensure adequate training and support during implementation and review training materials to ensure they fit with the local (i.e. Australian) context. Safewards provides an opportunity for a change in attitudes and development of a more therapeutic ward environment.

Mental health nurses' views about antipsychotic medication side effects

WHAT IS KNOWN ON THE SUBJECT?: The only previous quantitative study that examined nurses' use of assessment tools to identify antipsychotic medication side effects found that about 25% of mental health nurses were using assessment tools. No previous studies have examined factors that influence the manner in which mental health nurses assess antipsychotic medication side effects. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: One-third of the respondents were not aware of any antipsychotic medication side-effect assessment tool, and only one-quarter were currently using an assessment tool. 'Service responsibility' was significantly associated with ongoing use of antipsychotic medication assessment tools, indicating that respondents with more positive attitudes to their service were more likely to continue using antipsychotic medication assessment tools. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The low level of awareness and use of antipsychotic medication side-effect assessment tools indicates that nursing educational institutions should incorporate more detail about these tools in course content, and emphasize in particular the benefits that result from the use of these tools in clinical practice. Service processes contributed significantly to the use of antipsychotic medication assessment tools, which indicates that managers need to foster workplace cultures that promote routine use of these tools.

ABSTRACT

Introduction Limited evidence suggests that only a minority of mental health nurses regularly use standardized assessment tools to assess antipsychotic medication side effects, but the factors that contribute to the non-routine use of these tools remain unknown. Aim To examine Australian mental health nurses' awareness of, and attitudes towards, side-effect assessment tools, and also identify factors the influence the use of these tools. Methods A cross-sectional survey was undertaken through distributing an online questionnaire via email to members of the Australian College of Mental Health Nurses. Completed questionnaires were received from 171 respondents. Linear regression was used to examine the relationship between the 'service responsibility' and 'personal confidence' scale scores, and awareness, previous use and ongoing use of antipsychotic medication assessment tools. Results Only one-quarter of the respondents (26.5%) were currently using an assessment tool. 'Service responsibility' was significantly associated with ongoing use of antipsychotic medication assessment tools (Β = 3.26; 95% CI 0.83-5.69). 'Personal confidence' did not influence the ongoing use of assessment tools (Β = -0.05; 95% CI -1.06-1.50). Implications for clinical practice Stakeholders can incorporate 'service responsibility' processes to foster increased use of assessment tools, which may enhance the identification antipsychotic medication side effects and improve the quality of care for service users.

Functional Analysis of the Cooled Rat Testis

Direct cooling of the testis results in the depletion of most germ cells in vivo. Germ cell-depleted testes are now commonly used to investigate spermatogenic regeneration and can serve as recipients for germ cell transplantation. The present study explored the effects of cooling rat testes on the depletion of endogenous germ cells, spermatogenic regeneration, and Sertoli cell function. Adult rat testes were cooled with iced Ringer's solution for 60 minutes, which results in the initiation of apoptotic germ cell loss within 8 hours. Pachytene spermatocytes at stages XII-I were the cells most sensitive to cooling. In 46%-67% of seminiferous tubule cross-sections, only Sertoli cells remained in the cooled testes 3-10 weeks after treatment. Germ cell loss was accompanied by a significant decrease in circulating inhibin B and an increase in follicle-stimulating hormone concentrations, which indicated a change in Sertoli cell function. Quantitative analysis of mRNA expression associated with apoptotic signals showed no significant uniform changes among the cooled testes, although some individuals had a distinct up-regulation of FAS mRNA at 24 hours. Attempts to use the cooled testes as recipient testes for mouse-to-rat germ cell transplantation were undertaken, but none of the mouse germ cells transplanted into the testes 15-34 days after cooling appeared to have undergone spermatogenesis 64-92 days after transplantation. These data suggest that modifications to Sertoli cell function resulting from testicular cooling create an environment that is unable to support spermatogenesis by donor germ cells.

Dehiscence of the posterior and superior semicircular canal presenting in pregnancy

OBJECTIVE

We present an interesting case of superior and posterior semicircular canal dehiscence in pregnancy.

METHOD

We present a case report and a review of the world literature concerning semicircular canal dehiscence.

CASE REPORT

A 34-year-old woman presented with sound and pressure induced vertigo at 22 weeks gestation. A thinly sliced computed tomography (CT) scan of the petrous temporal bones viewed with coronal reconstructions was performed post-partum. This showed the presence of both left superior canal and posterior canal dehiscence.

CONCLUSION

To our knowledge this is the first reported case of semicircular canal dehiscence in pregnancy. The diagnosis of semicircular canal dehiscence should be suspected in pregnant patients with sound induced vertigo.

The Mental Health Nurse Incentive Program: reactions of general practitioners and their patients

Objective. To evaluate reactions of general practitioners (GPs) and their patients to the Mental Health Nurse Incentive Program (MHNIP). Method. A descriptive, exploratory approach was employed using discussion groups with 25 GPs and individual interviews with 19 patients receiving treatment through the MHNIP. All discussion groups and interviews were audio taped, transcribed and analysed using thematic content analysis. Results. There was overwhelming support for the MHNIP across GP and patient groups. Patients noted that the treatment provided through the program was convenient, holistic and non-stigmatising. GPs valued the collaborative working arrangements with mental health nurses (MHNs) and highlighted the ability of these nurses to provide a wide range of interventions for patients with complex mental health problems. Conclusions. The collaborative working arrangement between GPs and MHNs promoted through the MHNIP was perceived to have significantly enhanced primary care services for those with mental health problems. What is known about the topic? The introduction of MHNs into GP practices under the MHNIP, a new primary care initiative, represents a major reform in the provision of primary care services for those with mental health problems. What does this paper add? This paper reports on the reactions of GPs and patients to the introduction of the MHNIP. What are the implications for practitioners? The collaborative model promoted through the program enables family doctors to play a greater role in the management of mental health conditions within the primary care setting. MHNs working with the program need considerable experience and skill in dealing with a broad range of mental health problems. In general, GPs require a better understanding of the overall program.

Successful outcome of cochlear implantation in a patient with superficial siderosis

OBJECTIVE

To present the management of a rare case of progressive bilateral sensorineural hearing loss in a patient with superficial siderosis secondary to a cavernoma.

METHOD

A case report and a review of the literature concerning superficial siderosis.

RESULTS

The patient benefited significantly from a cochlear implantation.

CONCLUSIONS

Careful assessment and adequate counselling is necessary to determine the best approach to hearing rehabilitation in patients with superficial siderosis of the central nervous system. Cochlear implantation in patients with superficial siderosis is controversial due to the retrocochlear origin of the hearing loss and, although the case presented had a successful outcome, the results might deteriorate with time.

An unusually small dimer interface is observed in all available crystal structures of cytosolic sulfotransferases

Cytosolic sulfotransferases catalyze the sulfonation of hormones, metabolites, and xenobiotics. Many of these proteins have been shown to form homodimers and heterodimers. An unusually small dimer interface was previously identified by Petrotchenko et al. (FEBS Lett 2001;490:39-43) by cross-linking, protease digestion, and mass spectrometry and verified by site-directed mutagenesis. Analysis of the crystal packing interfaces in all 28 available crystal structures consisting of 17 crystal forms shows that this interface occurs in all of them. With a small number of exceptions, the publicly available databases of biological assemblies contain either monomers or incorrect dimers. Even crystal structures of mouse SULT1E1, which is a monomer in solution, contain the common dimeric interface, although distorted and missing two important salt bridges.

Prolactin levels in Western Lowland gorillas

Hyperprolactinemia is known to cause menstrual irregularity and infertility in humans. However, little is known about the role of prolactin in menstruation and fertility in Western Lowland gorillas. To create a database of prolactin values in gorillas, we have performed immunoassays on serum specimens dating back to 1983 from nine female gorillas at the Brookfield Zoo. We matched these samples with documented behavioral data to correlate menstrual timing. In addition, we ran other reproductive hormones both to aid in determining the phase of the menstrual cycle and to evaluate the effect of the prolactin on suppression of these hormones during the premenarchal and postpartum phases. We found that values for luteinizing hormone, follicle-stimulating hormone, estradiol and progesterone cycle in very similar patterns to humans. Based on the 59 available samples, prolactin was found to be higher in gorillas than in humans in nearly every phase of the menstrual cycle (range 49.9-93.7 ng/mL) and such levels do not appear to alter the reproductive axis as it does in humans. Thus, prolactin may have a different impact on fertility in gorillas than it does in humans.

Introduction of routine outcome measures: staff reactions and issues for consideration

The aim of this study was to explore clinician reactions to (i) the introduction of routine outcome measures and (ii) the utility of outcomes data in clinical practice. Focus group discussions (n = 34) were conducted with mental health staff (n = 324) at approximately 8 months post implementation of routine outcome measures. A semi-structured interview schedule was used to collect data on two key issues; reactions to the introduction of outcome measures and factors influencing the utility of outcomes data in clinical practice. Data from the discussion groups were analysed using content analysis to isolate emerging themes. While the majority of participants endorsed the collection and utilization of outcomes data, many raised questions about the merits of the initiative. Ambivalence, competing work demands, lack of support from senior medical staff, questionable evidence to support the use of outcome measures, and fear of how outcomes data might be used emerged as key issues. At 8 months post implementation a significant number of clinical staff remained ambivalent about the benefits of outcome measurement and had not engaged in the process. The shift to a service model driven by outcomes and case-mix data will take time and resources to achieve. Implications for nursing staff are discussed.

Aggressive behaviour in the high-secure forensic setting: the perceptions of patients

Twenty-seven patients undergoing treatment in a high-secure forensic facility participated in focus group interviews to elicit their perceptions of (1) the factors leading to aggressive behaviour; and (2) strategies to reduce the risk of such behaviour. The focus group interviews were audiotaped, transcribed and analysed using content analysis. The participants identified that a combination of patient, staff and environmental factors contributed to violence in the study wards. The cause of aggressive behaviour centred around five major themes: the environment; empty days; staff interactions; medication issues; and patient-centred factors. Potential strategies identified by patients to reduce aggressive behaviour included: early intervention; the provision of meaningful activities to reduce boredom; separation of acutely disturbed patients; improved staff attitudes; implementation of effective justice procedures; and a patient advocate to mediate during times of conflict. Findings suggested that social and organizational factors need to be addressed to change the punitive subculture inherent in forensic psychiatric facilities, and to ensure a balance between security and effective therapy.

Benzo[a]pyrene diol epoxide forms covalent adducts with deoxycytidylic acid by alkylation at both exocyclic amino N(4) and ring imino N-3 positions

The carcinogen 7r,8t-dihydroxy-9t,10t-epoxy-7,8,9,10-tetrahydrobenzo[a]pyrene (anti-BPDE) alkylates DNA at dGuo, dAdo, and dCyd. dCyd adducts, formed in small amounts, elute near the more abundant dGuo adducts. We isolated the dCyd adducts formed with dCMP. Each BPDE enantiomer forms three major adducts with dCMP, two cis and one trans. The trans adduct and one of the cis adducts form by alkylation at exocyclic N(4), while the second cis adduct is a dUrd adduct formed by alkylation at ring N-3 followed by deamination. Epoxide ring-opening geometries were assigned on the basis of halide and temperature effects on adduct yield, the sign of the major CD band, and benzo ring proton NMR coupling constants. One of each set of cis adducts is fluorescent (FL), and the other is nonfluorescent (NF). The trans and FL cis adducts have fluorescence quantum yields 40-50% of that of the BPDE hydrolysis product. The long wavelength UV maxima of the FL and NF cis adducts are red-shifted 1 and 3 nm relative to the trans adduct. (1)H NMR deuterium exchange experiments indicate that in the trans and FL cis adducts N(4)-H is coupled to C10-H. Adduct formation experiments with methyl-protected Cyd derivatives show that NF cis adducts result from alkylation at N-3. MS results, pK(a) measurements, and dUrd alkylation experiments indicate that the N-3 dCyd adducts spontaneously deaminate to dUrd adducts. NMR coupling constants show that in the NF cis adduct the C7 and C8 substituents are quasi equatorial and the C9 substituent is quasi axial, unlike in other cis BPDE adducts. (1)H NOESY spectra of the (-)-BPDE NF cis adduct reveal that it exists in two conformers. Molecular modeling shows that the conformers result from two low-energy conformations of very similar energies with the pyrimidine in opposite orientations, separated by significant barriers to rotation of the uracil moiety.

Cerebrospinal fluid glucose levels and sensorineural hearing loss in bacterial meningitis

BACKGROUND

Low cerebrospinal fluid (CSF) glucose levels have been associated with sensorineural hearing loss (SNHL) in bacterial meningitis but systematic investigations are lacking.

PATIENTS AND METHODS

A retrospective case control study was conducted comparing CSF glucose levels in 47 cases with and 145 controls without SNHL following bacterial meningitis.

RESULTS

The mean CSF glucose level (standard deviation [SD]) was 1.3 mmol/l (1.2) in cases and 2.5 mmol/l (1.6) in controls (p < 0.001). The difference between the groups was significant for Streptococcus pneumoniae and Haemophilus influenzae but not for Neisseria meningitidis infection. It was independent of the delay of treatment if this was greater than 12 h. This delay was significantly longer in cases compared to controls.

CONCLUSION

In bacterial meningitis other than that caused by N. meningitidis and independent of the duration of symptoms prior to diagnosis, CSF glucose levels were significantly lower in patients developing a SNHL compared to controls.

Monitoring consumer satisfaction with inpatient service delivery: the Inpatient Evaluation of Service Questionnaire

OBJECTIVE

To report on the development, testing and psychometric properties of a brief consumer satisfaction measure for use with psychiatric inpatients.

METHOD

Focus group discussions with inpatients were used to develop a pool of items related to satisfaction with hospital stay. A second cohort of 72 inpatients was invited to rate the 51 items that emerged for importance in contributing to satisfaction. Mean importance scores highlighted 20 items that were subsequently framed into neutrally worded statements. A draft questionnaire comprising these statements was introduced, on a trial basis, in a range of inpatient facilities.

RESULTS

Factor analysis of 356 completed questionnaires yielded three factors comprising a staff-patient alliance; doctor/treatment issues; and an environmental component. Psychometric properties include good response variability and high internal consistency.

CONCLUSIONS

The Inpatient Evaluation of Service Questionnaire addresses many of the shortcomings of existing satisfaction measures. It was developed through extensive consumer involvement, it is simply worded, easy to score and appears to perform well with acute and rehabilitation inpatients.

The impact of relocation on elderly patients with mental illness

Twenty-three elderly patients with long-term mental illness were relocated from a large tertiary mental health facility to two extended care units (ECUs) in their district of origin. The patients were assessed on measures of functioning, aggression and agitation at 6 weeks pre-relocation, and again at 6 weeks and 6 months post-relocation. The impact of relocation on the group proved to be less dramatic than findings reported in the literature. The adverse affects of relocation were likely to have been offset by the preparation and planning undertaken prior to relocation, and the support provided to staff and patients in the period following relocation. The findings have implications for nursing staff involved in the relocation of people with mental illness between wards within a hospital or from one hospital to another.

Support for condom availability and needle exchange programs among Massachusetts adults, 1997

This study was conducted to determine whether demographic factors, variables related to HIV risk status, or personal attitudes predicted public support for condom availability programs in high schools and needle exchange programs. Data for these analyses were collected from the 1997 Massachusetts Behavioral Risk Factor Surveillance System (BRFSS) among adults aged 18-64. Overall, 79% of Massachusetts adults aged 18-64 supported condom availability programs, and 60% supported needle exchange programs. Younger age was the strongest demographic predictor of support for condom availability, and higher socioeconomic status was the strongest predictor of support for needle exchange programs. Support for both programs was weakly associated with personal HIV risk status but strongly associated with positive attitudes toward teaching about HIV in schools and advising sexually active teens to use condoms. Our data suggest that there is broad-based public support for implementation of condom availability and needle exchange programs as tools for HIV prevention.

Immobilization of cesium-137 and uranium in contaminated sediments using soil amendments

Batch and dynamic leaching methods were used to evaluate the effectiveness of hydroxyapatite (HA), illite, and zeolite, alone and in combination, as soil additives for reducing the migration of cesium-137 (137Cs+) and uranium (U) from contaminated sediments. Amendment treatments ranging from 0 to 50 g kg(-1) were added to the sediment and equilibrated in 0.001 M CaCl2. After equilibration, the treatment supernatants were analyzed for 137Cs+, U, PO4, and other metals. The residual sediments were then extracted overnight using one of the following: 1.0 M NH4Cl, 0.5 M CaCl2, or the Toxicity Characteristic Leaching Procedure (TCLP) extractant. Cesium was strongly sorbed to the contaminated sediments, presumably due to interlayer fixation within native illitic clays. In fact, 137Cs+ was below detection limits in the initial equilibration solutions, the CaCl2 extract, and the TCLP solution, regardless of amendment. Extractants selective for interlayer cations (1.0 M NH4Cl) were necessary to extract measurable levels of 137Cs+. Addition of illitic clays further reduced Cs+ extractability, even when subjected to the aggressive extractants. Zeolite, however, was ineffective in reducing Cs+ mobility when subjected to the aggressive extractants. Hydroxyapatite was less effective than illite at reducing NH4+-extractable Cs+. Hydroxyapatite, and mixtures of HA with illite or zeolite, were highly effective in reducing U extractability in both batch and leaching tests. Uranium immobilization by HA was rapid with similar final U concentrations observed for equilibration times ranging from 1 h to 30 d. The current results demonstrate the effectiveness of soil amendments in reducing the mobility of U and Cs+, which makes in-place immobilization an effective remediation alternative.

Trans- and cis-DNA adduct concentration in epidermis from mouse and rat skin treated ex vivo with benzo[a]pyrene diol epoxide and its corresponding chlorohydrin

Benzo[a]pyrene diol epoxide, a metabolite of benzo[a]pyrene (BaP), and chlorohydrin, the reaction product of chloride and the epoxide, form in vitro the same trans- and cis-stereoisomeric DNA adducts, but in different proportions. In this study, we asked whether the DNA adduct concentration can be kept the same by applying the appropriate dose of (+/-)-7r,8t-dihydroxy-9t,10t-epoxy-7,8,9,10-tetrahydrobenzo[a]pyrene (anti-BPDE)and (+/-)-7r,8t,9t-trihydroxy-10c-chloro-7,8,9,10-tetrahydrobenzo[a]pyrene (trans-BPDCH) to rodent skin and whether the DNA adducts formed differ only in their trans- and cis-stereoisomerism. Skin from C57Bl6 mice, spontaneous hypertension rats (SHR) and Sprague-Dawley (SD) rats was treated ex vivo immediately after the death of the animals with anti-BPDE and its corresponding bay region chlorohydrin trans-BPDCH and the epidermis was analyzed for DNA adducts 1h after the application. We found that adduct formation at the exocyclic amino groups of deoxyguanosine and deoxyadenosine in epidermal DNA followed a linear dose-response within 6--100 nmol/cm(2) with both chemicals. In order to achieve the same adduct concentration in mouse, spontaneous hypertension rat (SHR), and Sprague-Dawley (SD) rat skin, respectively, a 37-, 23- and 10-fold lower dose of anti-BPDE than of trans-BPDCH had to be applied. The order of 2'-deoxyguanosine (dGuo) adduct concentration with anti-BPDE was similar to what has been reported, but the order with trans-BPDCH was (+)-cis-BPDE-N(2)-dGuo adduct>(+)-trans-BPDE-N(2)-dGuo=(-)-trans-BPDE-N(2)-dGuo>(-)-cis-BPDE-N(2)-dGuo in mouse skin. Irrespective of species or strain, a significantly higher proportion of cis-adducts was obtained after treatment with trans-BPDCH than after treatment with anti-BPDE. Therefore, DNA adduct concentration can be kept the same by applying the appropriate dose of anti-BPDE and trans-BPDCH to rodent skin and the DNA adducts formed differ only in their trans- and cis-stereoisomerism.

Inhibins, activins and follistatin: actions on the testis

While the early studies of the inhibins, activins and follistatins concentrated on their role as endocrine regulators of FSH secretion, recent data has emphasized the local actions of the activins and follistatin. Inhibin, through its capacity to suppress FSH secretion can modulate numerous processes within the testis. However, to date, evidence to support a local role for inhibin is limited. In contrast, activin and its binding protein follistatin are produced by a large number of cell-types within the testis raising the possibility of a range of paracrine and autocrine actions. These include the modulation of androgen production, influence on the proliferation of Sertoli cells and germ cells as well as the capacity to influence the structural and functional features of mitochondria within germ cells. Some of these actions are carefully controlled in a temporal relationship during the development of testicular function in the rat in which there is no separation in time between birth and the onset of spermatogenesis. Given the range of actions of activin in different cell-types, recognition of systems that are designed to modulate its actions are crucial in enhancing our understanding of how these many roles can be compartmentalized.

Developmental regulation of the bcl-2 family during spermatogenesis: insights into the sterility of bcl-w-/- male mice

Expression of bcl-w, a close relative of bcl-2 is essential for male fertility in mice. Although the initial wave of spermatogenesis in bcl-w -/- mice proceeds normally until 3-4 weeks of age, adults fail to produce sperm. To clarify why bcl-w is essential for adult but not juvenile spermatogenesis, we investigated the expression pattern of eight bcl-2 family members. We found that both the level and pattern of expression varied in different cell types during juvenile and adult spermatogenesis. Anti-apoptotic genes bcl-w, bcl-2 and bcl-xL were all expressed in spermatogonia during juvenile spermatogenesis, but only bcl-w was detected in spermatogonia of adult mice. A similar shift was evident in Sertoli cells. This developmental regulation may co-ordinate physiological germ cell apoptosis in wild type mice and account for the time of onset for pathological germ cell apoptosis in bcl-w -/- animals.

The use of the Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSERS) in clinical practice

Forty-four mental health clients completed the Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSERS)--a self-rating scale to assess the prevalence and intensity of neuroleptic side-effects. In the month prior to the study, 50% of the clients surveyed had experienced more than half of the side-effects outlined on the 41-item scale. A prevalence profile allowed us to rank the frequency of individual side-effects across the sample. Some side-effects such as 'difficulty concentrating', 'difficulty remembering', 'tiredness' and 'restlessness' were experienced by most of the clients in the study while 'unusual skin marks', 'difficulty passing water', 'rashes' were experienced by a few. A prevalence profile may be a useful guide in developing strategies for managing side-effects more effectively in small groups of clients. In addition, the use of the LUNSERS in clinical practice would enable case managers to establish baseline measures for individual clients and evaluate changes in medication and other non-medical strategies for reducing unwanted side-effects. The identification and assessment of antipsychotic side-effects is an important area for client and professional carer education.

Enhancing case managers' skills in the assessment and management of antipsychotic medication side-effects

OBJECTIVE

Our goal was to reduce the prevalence of antipsychotic medication side-effects by providing a short-term training program on the assessment and management of side-effects to case managers.

METHOD

Forty-four patients in receipt of community-based mental health services were allocated to comparison (n = 20) and intervention (n = 24) groups based on the health service district in which they resided. While case managers working with the intervention group attended a short-term training program to improve their assessment and management of neuroleptic side-effects, case managers providing services to the comparison group received no additional training. Side-effects were assessed pre- and postintervention using the Liverpool University Neuroleptic Side-effect Rating Scale (LUNSERS).

RESULTS

A reduction in the overall prevalence of side-effects in both groups was observed, however, only those patients in the intervention group reported a statistically significant reduction in mean side-effect scores between the pre- and postmeasures (Wilcoxon Matched Pairs Signed-ranks Test, z = -2.8411, two-tailed, p < 0.01). In addition, qualitative data collected during the second survey revealed that patients in the intervention group had acquired some positive management strategies for dealing with unwanted side-effects. The strategies were elicited from eight different patients distributed across six of the 12 case managers who took part in the training program.

CONCLUSIONS

Training cases managers in the assessment and management of side-effects may help to reduce their impact on the lives of people prescribed neuroleptic medication.

Cloning and characterization of a 72-kDa inositol-polyphosphate 5-phosphatase localized to the Golgi network

The inositol-polyphosphate 5-phosphatase enzyme family removes the 5-position phosphate from both inositol phosphate and phosphoinositide signaling molecules. We have cloned and characterized a novel 5-phosphatase, which demonstrates a restricted substrate specificity and tissue expression. The 3.9-kb cDNA predicts for a 72-kDa protein with an N-terminal proline rich domain, a central 5-phosphatase domain, and a C-terminal CAAX motif. The 3. 9-kilobase mRNA showed a restricted expression but was abundant in testis and brain. Antibodies against the sequence detected a 72-kDa protein in the testis in the detergent-insoluble fraction. Indirect immunofluorescence of the Tera-1 cell line using anti-peptide antibodies to the 72-kDa 5-phosphatase demonstrated that the enzyme is predominantly located to the Golgi. Expression of green fluorescent protein-tagged 72-kDa 5-phosphatase in COS-7 cells revealed that the enzyme localized predominantly to the Golgi, mediated by the N-terminal proline-rich domain, but not the C-terminal CAAX motif. In vitro, the protein inserted into microsomal membranes on the cytoplasmic face of the membrane. Immunoprecipitated recombinant 72-kDa 5-phosphatase hydrolyzed phosphatidylinositol 3,4,5-trisphosphate and phosphatidylinositol 3, 5-bisphosphate, forming phosphatidylinositol 3,4-bisphosphate and phosphatidylinositol 3-phosphate, respectively. We propose that the novel 5-phosphatase hydrolyzes phosphatidylinositol 3,4, 5-trisphosphate and phosphatidylinositol 3,5-bisphosphate on the cytoplasmic Golgi membrane and thereby may regulate Golgi-vesicular trafficking.

Regulation of germ cell and Sertoli cell development by activin, follistatin, and FSH

We have demonstrated a role for activin A, follistatin, and FSH in male germ cell differentiation at the time when spermatogonial stem cells and committed spermatogonia first appear in the developing testis. Testis fragments from 3-day-old rats were cultured for 1 or 3 days with various combinations of these factors, incubated with bromodeoxyuridine (BrdU) to label proliferating cells, and then processed for stereological analysis and detection of BrdU incorporation. Gonocyte numbers were significantly elevated in cultures treated with activin, while the combination of FSH and the activin antagonist, follistatin, increased the proportion of spermatogonia in the germ cell population after 3 days. All fragment groups treated with FSH contained a significantly higher proportion of proliferating Sertoli cells, while activin and follistatin each reduced Sertoli cell division. In situ hybridization and immunohistochemistry on normal rat testes demonstrated that gonocytes, but not spermatogonia, contain the activin beta(A) subunit mRNA and protein. In contrast, gonocytes first expressed follistatin mRNA and protein at 3 days after birth, concordant with the transition of gonocytes to spermatogonia. Collectively, these data demonstrate that germ cells have the potential to regulate their own maturation through production of endogenous activin A and follistatin. Sertoli cells were observed to produce the activin/inhibin beta(A) subunit, the inhibin alpha subunit, and follistatin, demonstrating that these cells have the potential to regulate germ cell maturation as well as their own development. These findings indicate that local regulation of activin bioactivity may underpin the coordinated development of germ cells and somatic cells at the onset of spermatogenesis.

The roles of inhibin and related peptides in gonadal function

Inhibin A and B are dimeric proteins capable of suppressing FSH both in vitro and in vivo. The principal form in the male is inhibin B which is produced in the testis and circulates to inhibit pituitary FSH secretion. Activin A, B and AB are dimeric proteins that share the same beta subunits with the inhibins but, in contrast, stimulate FSH secretion. Although activin A circulates, castration does not lead to a decrease in serum concentrations, indicating that the testis is not the major source of activin A. In the circulation, the activins are bound to a structurally unrelated binding protein, follistatin, that neutralizes the biological actions of these proteins. The subunits of the inhibins/activins as well as follistatin are also produced locally within the pituitary and their levels can be modulated by testosterone and gonadotrophin releasing hormone as well as by autocrine mechanisms. Consequently, the output of FSH is dependent of the balance between local processes and the circulating feedback exerted by testosterone and inhibin. There is increasing data to support the local gonadal production of not only inhibin but also activin and follistatin by both germ cells and somatic cells such as the Sertoli cells. Evidence is accumulating to support the concept that these proteins exert local regulatory mechanisms in the testis.

Development and validation of clinical indicators for mental health nursing practice

A national study was undertaken in Australia to develop and validate a set of clinical indicators for mental health nursing. Using survey and action research procedures, the indicators were developed in two stages. During stage one, focus group interviews involving 39 nurses were conducted at national conferences in Australia and New Zealand in order to provide a pool of indicator statements. A Delphi survey of an Australian sample of mental health nurses (n = 33) was then conducted to refine the indicators. In stage two, the refined indicators were tested and validated in selected clinical settings. A total of 1751 mental health nurses employed at 14 sites were involved in the second stage of the study. The resulting data were used to establish the set of national indicators that the Australian and New Zealand College of Mental Health Nurses will use in practice accreditation and benchmarking.

Patients' perceptions of seclusion: a qualitative investigation

Twelve patients receiving acute in-patient psychiatric care in Queensland, Australia, participated in semi-structured interviews to elicit their perceptions of seclusion. All respondents had experienced time in seclusion within the 7 days prior to interview. Interviews were audiotaped, transcribed and analysed using content analysis. Five major themes emerged: use of seclusion, emotional impact, sensory deprivation, maintaining control and staff-patient interaction. The prevailing negativity towards seclusion underscores the need for ongoing critical review of its use. In particular, the relationship between patient responses to seclusion and the circumstances in which seclusion takes place requires greater consideration. Interventions such as providing information to patients about seclusion, increased interaction with patients during seclusion, attention to privacy and effective debriefing following seclusion may help to reduce the emotional impact of the practice.

Application of morphometric techniques to postnatal rat testes in organ culture: insights into testis growth

The extent of Sertoli cell proliferation during fetal and neonatal development determines the final adult testis size and potential for sperm output. To gain further knowledge of the factors that regulate Sertoli cell proliferation, the present study used a new approach to analyse changes in morphology and proliferation in the postnatal testis by combining organ culture with morphometric analysis. Fragments of rat testes from days 0 to 10 postpartum were cultured in contact with DMEM for 6 h or 72 h and fixed. The effects of ovine follicle-stimulating hormone (FSH) and activin were studied in an additional 72-h organ culture experiment using day 9 testes. Bromodeoxyuridine (BrdU) was added for the last 6 h of culture to mark proliferating cells. Two-microm sections of the fragments were analysed for morphological changes of the seminiferous cords, and the proportion of BrdU-labelled Sertoli and germ cells was determined. Assessment of 6-h samples revealed growth characteristics consistent with those observed in vivo during days 1-10 of postnatal development. From day 2 onwards, the volume fraction of seminiferous cords began to increase, while significant growth in cross-sectional area of the cords occurred only after day 6. In these culture conditions, germ cell proliferation and testicular architecture was consistent with that expected for the age of the tissue at time of explant. The proportion of dividing Sertoli cells declined from 15-20% at days 0-4 postpartum to below % at day 10 postpartum in the 6-h culture, and it was low or abolished in the 3-day culture at all time points. Activin and FSH together, but not singly, stimulated Sertoli cell proliferation in the 72-h culture. This paper presents a new approach to analysis of in vitro testis development. The combination of fragment culture and stereological analysis permits rigorous and detailed assessment of developmental changes in the postnatal testis.

Factors influencing nurse-patient interaction in the acute psychiatric setting: an exploratory investigation

Nurse-patient interaction in acute psychiatric in-patient facilities has been the subject of much discussion in the literature and remains a contentious issue. How and why nurses interact with patients in the acute care setting requires definition within the current dynamic environment of mental health service provision. Factors which impact on the manner in which nurses care for patients also require investigation. This article presents the findings of a collaborative research study that investigates factors that influence nurse-patient interaction in the acute psychiatric setting. Ten nurses on the study ward were given opportunity, through semi-structured interviews, to outline and describe the factors perceived to influence nurse-patient interaction. Factors identified as influencing interaction included the ward environment, something always comes up, nurses' attributes, patient factors, instrumental support and focus of nursing. Issues which emerged from the study provide managers and clinical nurses with an opportunity for generating new possibilities for nurse-patient interaction. However, these issues must be addressed in a sensitive way that takes into account the complex and dynamic nature of acute care settings.

Absconding behaviour: an exploratory investigation in an acute inpatient unit

OBJECTIVE

The aim of this study is to identify patient and environmental characteristics associated with absconding behaviour, and to gain an understanding of the behaviour from the patients' perspective.

METHOD

A prospective analysis of 77 consecutive incidents of absent-without-leave (AWOL) behaviour (n = 51 patients) was undertaken to develop a profile of patient and environmental characteristics associated with absconding behaviour. In addition, semi-structured interviews were carried out with a subsample of 14 patients within 24 h of returning to hospital from being AWOL.

RESULTS

Those who absconded were male (58%), under 40 years of age (74%), admitted involuntarily (78%), and had a diagnosis of schizophrenia (42%). One-third of all AWOL incidents resulted from repeated absconding by the same individuals. The first 7 days post admission was a high-risk period for absconding behaviour. Issues raised in the interviews with patients identified a number of situational and environmental factors which are likely to increase the risk of absconding.

CONCLUSIONS

Situational and environmental factors are more likely than patient characteristics to be predictive of absconding behaviour.

Mutations in a gene encoding a new oxygen-regulated photoreceptor protein cause dominant retinitis pigmentosa

The autosomal dominant retinitis pigmentosa (RP) locus, designated RP1, has been mapped through linkage studies to a 4-cM interval at 8q11-13. Here we describe a new photoreceptor-specific gene that maps in this interval and whose expression is modulated by retinal oxygen levels in vivo. This gene consists of at least 4 exons that encode a predicted protein of 2,156 amino acids. A nonsense mutation at codon 677 of this gene is present in approximately 3% of cases of dominant RP in North America. We also detected two deletion mutations that cause frameshifts and introduce premature termination codons in three other families with dominant RP. Our data suggest that mutations in this gene cause dominant RP, and that the encoded protein has an important but unknown role in photoreceptor biology.

Ultrasonographic monitoring of artificially stimulated ejaculation in three rhinoceros species (Ceratotherium simum, Diceros bicornis, Rhinoceros unicornus)

Manual massage of the penis and rectal electroejaculation methods have been minimally effective for collecting semen from the rhinoceros. These two methods for stimulating ejaculation were evaluated by rectal ultrasonography. One individual each of three rhinoceros species (Ceratotherium simum simum, Rhinoceros unicornis and Diceros bicornis) was stimulated by manual massage of the penis and two black rhinoceroses (Diceros bicornis) were electroejaculated. On ultrasonography, neither manual massage nor rectal electroejaculation affected the accessory glands. The pelvic urethra remained empty during manual massage of unconditioned animals; however, this area was filled before commencement of massage of conditioned animals. The pelvic urethra also filled during electroejaculation. Semen accumulated in the pelvic urethra during pauses between electrical stimulations and was moved distally into the penile urethra by rectal and penile massage. The volumes of seminal fluid recovered from electroejaculation in this study exceeded previously reported attempts. This study demonstrated the potential of transrectal imaging for improving the recovery of semen by these methods.

Boarding house life for people with mental illness: an exploratory study

The present study explored residents' perceptions of life in boarding houses within the Central Sydney Area Health Service. A purposeful sample of 14 people with a mental illness participated in semistructured interviews. The transcribed interviews were analysed for lifestyle issues to increase understanding of the factors that impact on quality of life from the consumers' perspective. It was encouraging to find that basic needs were being met, but it would appear that there is considerable room for improvement in quality of life for this vulnerable group of people. The findings of the present study should prove valuable for policy makers and health professionals who provide services to people with mental illness resident in boarding houses.

Apoptosis regulator bcl-w is essential for spermatogenesis but appears otherwise redundant

Proteins of the Bcl-2 family are important regulators of apoptosis in many tissues of the embryo and adult. The recently isolated bcl-w gene encodes a pro-survival member of the Bcl-2 family, which is widely expressed. To explore its physiological role, we have inactivated the bcl-w gene in the mouse by homologous recombination. Mice that lack Bcl-w were viable, healthy, and normal in appearance. Most tissues exhibited typical histology, and hematopoiesis was unaffected, presumably due to redundant function with other pro-survival family members. Although female reproductive function was normal, the males were infertile. The testes developed normally, and the initial, prepubertal wave of spermatogenesis was largely unaffected. The seminiferous tubules of adult males, however, were disorganized, contained numerous apoptotic cells, and produced no mature sperm. Both Sertoli cells and germ cells of all types were reduced in number, the most mature germ cells being the most severely depleted. The bcl-w-/- mouse provides a unique model of failed spermatogenesis in the adult that may be relevant to some cases of human male sterility.

Weight changes during clozapine treatment

OBJECTIVE

The aim of this study was to assess the prevalence and magnitude of weight changes pre- and post-clozapine and to explore the ability of demographic and clinical factors to predict weight gain at 12 months post-clozapine.

METHOD

Weight changes in a sample of 51 patients were assessed at 3 months pre-clozapine, at baseline, and at 3 and 12 months post-clozapine. In addition, demographic data and information concerning changes in appetite and activity level at 3 months was gathered and used to predict weight gain at 12 months.

RESULTS

Seventy percent of patients gained an average of 7.5 kg (10.6% increase in baseline body weight) over the 12-month period. Although post-clozapine weight gain for the total group was significant at 12 months, weight gain for the female subsample (n = 16) did not reach significance at either the 3 or 12 month assessments. The only factors associated with marked weight gain (> 15% increase) at 12 months were increased food intake early in treatment and having gained weight at 3 months.

CONCLUSION

Clozapine treatment was found to be associated with significant weight gain in patients prescribed clozapine, especially male patients. Considering the long-term health risks associated with excess weight gain, health professionals can play an important role in educating clients about the potential for weight gain with clozapine treatment.

Synthesis and characterization of bay region halohydrins derived from Benzo[a]pyrene diol epoxide and their role as intermediates in halide-catalyzed cis adduct formation

The bay region epoxide of benzo[a]pyrene (anti-BPDE) alkylates DNA to form adducts with >98% trans stereochemistry. Halide ions catalyze this reaction; however, this pathway is characterized by the formation of adducts with altered cis stereochemistry. Bay region halohydrins are possible intermediates in these reactions, but are too unstable to be isolated from aqueous solutions. However, we successfully synthesized halohydrins in tetrahydrofuran (THF) by treatment of anti-BPDE with the corresponding lithium halide salt in the presence of acetic acid. Absorbance and CD spectroscopy clearly indicated the formation of chloro-, bromo-, and iodohydrins. The structure and stereochemistry of the chlorohydrin was established by NMR. Chloride addition is exclusively at the benzylic position of the epoxide, and the stereochemistry of the C-9 and -10 positions is trans. The long-wavelength absorbance band in the chloro-, bromo-, and iodohydrin is red-shifted 7, 13, and 22 nm, respectively, relative to the hydrolysis product of anti-BPDE. The ellipticity of the same absorbance band in CD spectra of enantiomerically pure halohydrins is opposite in sign compared to that of the corresponding anti-BPDE enantiomer. The relative stability of these derivatives is chlorohydrin > bromohydrin > iodohydrin. The chloro- and bromohydrins were isolated, but the iodohydrin decomposed during this manipulation. The addition of 500 mM chloride decreased the hydrolysis rate of the chlorohydrin 4-fold in 50% THF/buffer. Direct evidence for the transient formation of the iodohydrin in aqueous buffer/acetone mixtures was obtained by absorbance spectroscopy. At 1 M chloride, bromide, and iodide, alkylation of deoxyadenosine by anti-BPDE in aqueous buffer yields 85, 91, and 92% cis adducts, respectively. In the absence of halide, alkylation of deoxyadenosine in buffer by anti-BPDE, the chlorohydrin, and the bromohydrin yields 32, 65, and 83% cis adducts, respectively.

Arrests and incarceration of injection drug users for syringe possession in Massachusetts: implications for HIV prevention

Multiperson use of syringes is a major risk behavior responsible for the spread of HIV-1 among injection drug users (IDUs). In Massachusetts, two laws regulate syringes: one is a prescription law prohibiting possession or purchase of syringes without a prescription, and the other makes it illegal to possess drug paraphernalia, including syringes. In 1993, Massachusetts amended the prescription law to permit the establishment of syringe exchange programs in two cities. Enrolled participants are allowed to possess syringes anywhere in the state, and about 5% of the estimated 40,000 IDUs in Massachusetts are program participants. To understand how HIV prevention efforts with active IDUs may be constrained by the enforcement of laws criminalizing possession of syringes after the amendment in the law, we reviewed data from multiple sources to assess the number of arrests for syringe possession in 10 large cities in Massachusetts to evaluate incarceration rates and lengths of sentences for those convicted of syringe possession and to estimate costs of incarceration for those convicted of syringe possession. At least 824 persons were arrested for syringe possession in 1995. In examining the data on convictions, we found that 417 persons were convicted in 1994 of syringe possession in the absence of other serious charges, and of these, 41.0% were sentenced to incarceration. The average sentence imposed was 5 months (range, 3 days-2 years). Assuming that those convicted serve about two thirds of their sentences, the cost of incarceration was estimated at $1,140,183 excluding costs for arrest, pretrial detention, prosecution, or other costs of enforcement. Costs for incarcerating persons convicted of both syringe and drug possession were not included; the total cost of incarceration of persons convicted of possession of a syringe, with or without other major charges, is probably considerably higher. Had these funds been allocated to pay for drug treatment, 1629 admissions to drug detoxification programs could have been purchased. Retaining drug paraphernalia and syringe prescription laws in Massachusetts may contribute to HIV transmission. These findings support the recommendation of the American Medical Association to modify drug paraphernalia laws so that IDUs can purchase and possess syringes without a prescription.

Neuroleptic malignant syndrome: an assessment of registered psychiatric nurses' knowledge

Neuroleptic Malignant Syndrome (NMS) is a potentially fatal complication of neuroleptic use and is frequently underdiagnosed by medical and nursing staff. The current project was undertaken to assess the knowledge registered psychiatric nurses (RPN) have of the signs, symptoms and interventions to be initiated in cases of NMS. A total of 126 RPN employed in a large tertiary inpatient facility and community mental health centre responded to a self-completed questionnaire. The results indicate that while the RPN in the study's sample demonstrated adequate knowledge of NMS, there was evidence to suggest that these RPN may actually lack confidence in their ability to identify and initiate appropriate interventions in suspected cases of NMS. Although RPN employed in the rehabilitation and psychogeriatric areas of the hospital had more years of experience in the mental health field, their overall knowledge of NMS was significantly lower than that of RPN employed in other clinical settings (F = 3.35; d.f. = 5119; P = 0.007). The findings underscore the importance of ongoing education for RPN employed within clinical mental health settings.