Longitudinal Impacts of Precision Greenness on Alzheimer's Disease

BACKGROUND

The potential for greenness as a novel protective factor for Alzheimer's disease (AD) requires further exploration.

OBJECTIVES

This study assesses prospectively and longitudinally the association between precision greenness - greenness measured at the micro-environmental level, defined as the Census block - and AD incidence.

DESIGN

Older adults living in consistently high greenness Census blocks across 2011 and 2016 were compared to those living in consistently low greenness blocks on AD incidence during 2012-2016.

SETTING

Miami-Dade County, Florida, USA.

PARTICIPANTS

230,738 U.S. Medicare beneficiaries.

MEASUREMENTS

U.S. Centers for Medicare and Medicaid Services Chronic Condition Algorithm for AD based on ICD-9 codes, Normalized Difference Vegetation Index, age, sex, race/ethnicity, neighborhood income, and walkability.

RESULTS

Older adults living in the consistently high greenness tertile, compared to those in the consistently low greenness tertile, had 16% lower odds of AD incidence (OR=0.84, 95% CI: 0.76-0.94, p=0.0014), adjusting for age, sex, race/ethnicity, and neighborhood income. Age, neighborhood income and walkability moderated greenness' relationship to odds of AD incidence, such that younger ages (65-74), lower-income, and non-car dependent neighborhoods may benefit most from high greenness.

CONCLUSIONS

High greenness, compared to low greenness, is associated with lower 5-year AD incidence. Residents who are younger and/or who reside in lower-income, walkable neighborhoods may benefit the most from high greenness. These findings suggest that consistently high greenness at the Census block-level, may be associated with reduced odds of AD incidence at a population level.

National adoption of neoadjuvant chemotherapy: paradigm shift in the treatment of pancreatic cancer

BACKGROUND

The historical standard of care in treating operable pancreatic cancer via upfront surgery has been challenged recently using a neoadjuvant approach. The aim of the study is to examine the national practice patterns in the management of pancreatic cancer with an emphasis on the trends of neoadjuvant systemic therapy use.

METHODS

This is a cross-sectional time-series study using the National Cancer Database from 2006 to 2019. Patients who underwent resection for stage I-II pancreatic adenocarcinoma were selected.

RESULTS

Overall, 25% of patients had neoadjuvant chemotherapy, 49% had surgery followed by adjuvant chemotherapy and 26% had surgery alone. The rate of neoadjuvant chemotherapy has increased from 11% in 2006 to 43% in 2019. There was a decrease in the rate of surgery followed by chemotherapy from 48% to 38%, and a decrease in the rate of surgery alone from 41% to 19%. The rate of radiation therapy use has decreased over time, as has the resection rate, while median overall survival has steadily improved over the years.

CONCLUSIONS

In 2019, the rate of using neoadjuvant systemic therapy overtook the rate of surgery first followed by adjuvant systemic therapy, marking a pragmatic national shift in the clinical management of pancreatic cancer.

Multisystem inflammatory syndrome in children during the first two years of the COVID-19 pandemic in Luxembourg

Objective

Estimate the incidence of multisystem inflammatory syndrome (MIS-C) in children (0-15 years), the role of SARS-CoV-2 variants during the first two years of COVID-19 pandemic in Luxembourg; and describe the demographic, biological and clinical characteristics of the patients.

Method

Observational retrospective cohort study. Cases between March 2020 and February 2022 were ascertained from the national registry of MIS-C cases by a retrospective review of medical records. Reported SARS-CoV-2 infections were obtained from the national COVID-19 surveillance system. We calculated monthly MIS-C incidence, the ratio between MIS-C and SARS-CoV-2 infections and associated rate ratios by the periods corresponding to the circulation of different variants.

Results

18 children were diagnosed with MIS-C among 35,200 reported infections. The incidence rate of MIS-C was 7.2 [95% confidence interval (CI) 4.5-11.4] per 1,000,000 person-months. A higher incidence of MIS-C was observed between September and December 2021, corresponding to the circulation of the Delta variant than during the first year of the pandemic (RR 3.6, 95% CI, 1.1-12.3). The lowest rate of MIS-C per infection was observed during the Omicron (RR 0.17, 95% CI, 0.03-0.82). Median age at diagnosis was 6.5 years. Previously healthy children made up 88% of MIS-C cases, none were vaccinated against SARS-CoV-2. 33% required intensive care. All patients recovered fully.

Conclusions

MIS-C incidence and MIS-C risk per infection changed significantly over time during the first two years of COVID-19 pandemic. Monitoring of MIS-C incidence in future SARS-CoV-2 waves will be essential to guide public health interventions and vaccination policies for children.

Reasonable requests: echocardiography referral forms as a measure of coherent clinical communication

BACKGROUND

Well performed clinical communication is a cornerstone of collaborative care in medicine but may be confounded by inconsistent intentions of the messenger and biased interpretation by the recipient. A comparison of the findings of electronic echocardiography reports with clinician-completed standardised request forms provided an opportunity to assess communication quality.

AIM

The study aimed to determine clinician aptitude to complete written echocardiography referral forms by assessing the completeness, appropriateness, accuracy, and coherency of the reported clinical findings, conclusions and requests made on the referral forms. The study explored factors that may influence the quality of communication through this referral medium.

METHODS

A retrospective cohort study was conducted on patients who underwent trans-thoracic echocardiography imaging at Cecilia Makiwane Hospital in East London over 26 months. Paper echocardiography request forms that recorded the requesting clinician's findings on examination, the provisional clinical diagnosis, and the specific echocardiographic information sought, were compared with the actual findings on echocardiography.

RESULTS

Of 613 request forms reviewed, 97 cases were excluded due to illegibility or because they lacked analysable information or requester details, leaving 516 forms suitable for study. No pathology was found on echocardiography in 31%. Of the murmurs expected from the echocardiography findings, only half were recorded on the request form (sensitivity and positive predictive value both 52%.). Only 35% of request forms that mentioned a mitral systolic murmur gave a working diagnosis of mitral regurgitation and only 38% of request forms that mentioned an aortic systolic murmur considered aortic stenosis. Clinically suspected cardiomyopathy (CMO) had a PPV of 43% and echocardiographic CMO was missed clinically in 41%. Apex beat displacement reported clinically was not associated with echocardiographic LV dilatation in 65% of cases. One-third (34%) of forms reporting murmurs did not request valve function assessment and 17% considering cardiomyopathy did not request left ventricular function assessment.

CONCLUSION

Echocardiography request forms highlight vulnerabilities in clinical communication. Specifically, important clinical features were missing and more concerningly, included when unlikely to be present. There was a lack of concordance between recorded clinical findings and postulated diagnoses. Clinicians sometimes appeared unclear about the value or appropriateness of the requested assistance. Greater emphasis on teaching examination and communication skills may foster safer and more efficient use of scarce resources.

Dysregulation of miR-21-associated miRNA regulatory networks by chronic ethanol consumption impairs liver regeneration

Impaired liver regeneration has been considered as a hallmark of progression of alcohol-associated liver disease. Our previous studies demonstrated that in vivo inhibition of the microRNA (miRNA) miR21 can restore regenerative capacity of the liver in chronic ethanol-fed animals. The present study focuses on the role of microRNA regulatory networks that are likely to mediate the miR-21 action. Rats were chronically fed an ethanol-enriched diet along with pair-fed control animals and treated with AM21 (anti-miR-21), a locked nucleic acid antisense to miR-21. Partial hepatectomy (PHx) was performed and miRNA expression profiling over the course of liver regeneration was assessed. Our results showed dynamic expression changes in several miRNAs after PHx, notably with altered miRNA expression profiles between ethanol and control groups. We found that in vivo inhibition of miR-21 led to correlated differential expression of miR-340-5p and anticorrelated expression of miR-365, let-7a, miR-1224, and miR-146a across all sample groups after PHx. Gene set enrichment analysis identified a miRNA signature significantly associated with hepatic stellate cell activation within whole liver tissue data. We hypothesized that at least part of the PHx-induced miRNA network changes responsive to miR-21 inhibition is localized to hepatic stellate cells. We validated this hypothesis using AM21 and TGF-β treatments in LX-2 human hepatic stellate cells in culture and measured expression levels of select miRNAs by quantitative RT-PCR. Based on the in vivo and in vitro results, we propose a hepatic stellate cell miRNA regulatory network as contributing to the restoration of liver regenerative capacity by miR-21 inhibition.

Longitudinal impacts of greenness on cardiovascular disease conditions

Introduction

Environmental determinants of health, such as greenness, play an increasing role in our understanding of cardiovascular disease, and can inform how to address geographic cardiovascular disparities. This study assesses the impact of greenness and changes in greenness on cardiovascular disease.

Purpose

The purpose of this study is to investigate the impact of greenness and changes in greenness on cardiovascular disease diagnoses.

Methods

The sample for this prospective, longitudinal study was comprised of 243,558 U.S. Medicare beneficiaries 65 years or older, residing on the same Census Block from 2011 through 2016, and who had a Miami-Dade residential 9-digit zip code. Analyses examined the impact of greenness, measured by mean block-level Normalized Difference Vegetation index (NDVI) from satellite imagery to incidence of new cardiovascular conditions including: acute myocardial infarction, atrial fibrillation, heart failure, ischemic heart disease, hypertension, and stroke/ transient ischemic attack. Zero-inflated poisson regression was used to model the odds of developing any new cardiovascular disease and number of new cardiovascular conditions based on block level greenness while adjusting for individual age, gender, race/ethnicity, number of baseline cardiovascular conditions, and neighborhood characteristics including income and walkability.

Results

Living in a higher greenness Census Block was associated with lower odds of having at least one new cardiovascular condition and having a small number of new conditions, adjusting for individual and neighborhood level characteristics. When compared to individuals living in the lowest tertile of greenness throughout the study, those individuals living in the highest tertile of greenness throughout the study had a 16% lower odds of having any new cardiovascular conditions (OR=0.84, 95% CI: 0.79–0.90, p<0.001) and among individuals developing at least one new cardiovascular disease, 4% fewer new cardiovascular conditions (OR=0.96, 95% CI: 0.92–0.99, p<0.05). When compared to individuals living in the lowest tertile of greenness throughout the study, those individuals living in areas that increased their greenness from the lowest tertile to the highest tertile of greenness had a 15% lower odds of having any new cardiovascular conditions (OR=0.85, 95% CI: 0.75–0.97, p<0.001) and among individuals developing at least one new cardiovascular disease, 9% fewer new cardiovascular conditions (OR=0.91, 95% CI: 0.83–0.99, p<0.05).

Conclusions

High greenness is associated with lower rates of cardiovascular conditions over time, both when greenness increases and when a Census Block maintains high greenness. It is remarkable that these effects appear in five years, a relatively short amount of time for a positive environmental impact; and that even for those who began in the lowest greenness tertile, an increase to the high greenness tertile had a significant effect.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Robert Wood Johnson Evidence for Action Grant

Integrated Multiomics Reveals Glucose Use Reprogramming and Identifies a Novel Hexokinase in Alcoholic Hepatitis

BACKGROUND & AIMS

We recently showed that alcoholic hepatitis (AH) is characterized by dedifferentiation of hepatocytes and loss of mature functions. Glucose metabolism is tightly regulated in healthy hepatocytes. We hypothesize that AH may lead to metabolic reprogramming of the liver, including dysregulation of glucose metabolism.

METHODS

We performed integrated metabolomic and transcriptomic analyses of liver tissue from patients with AH or alcoholic cirrhosis or normal liver tissue from hepatic resection. Focused analyses of chromatin immunoprecipitation coupled to DNA sequencing was performed. Functional in vitro studies were performed in primary rat and human hepatocytes and HepG2 cells.

RESULTS

Patients with AH exhibited specific changes in the levels of intermediates of glycolysis/gluconeogenesis, the tricarboxylic acid cycle, and monosaccharide and disaccharide metabolism. Integrated analysis of the transcriptome and metabolome showed the used of alternate energetic pathways, metabolite sinks and bottlenecks, and dysregulated glucose storage in patients with AH. Among genes involved in glucose metabolism, hexokinase domain containing 1 (HKDC1) was identified as the most up-regulated kinase in patients with AH. Histone active promoter and enhancer markers were increased in the HKDC1 genomic region. High HKDC1 levels were associated with the development of acute kidney injury and decreased survival. Increased HKDC1 activity contributed to the accumulation of glucose-6-P and glycogen in primary rat hepatocytes.

CONCLUSIONS

Altered metabolite levels and messenger RNA expression of metabolic enzymes suggest the existence of extensive reprogramming of glucose metabolism in AH. Increased HKDC1 expression may contribute to dysregulated glucose metabolism and represents a novel biomarker and therapeutic target for AH.

Hepatic lipocalin 2 promotes liver fibrosis and portal hypertension

Advanced fibrosis and portal hypertension influence short-term mortality. Lipocalin 2 (LCN2) regulates infection response and increases in liver injury. We explored the role of intrahepatic LCN2 in human alcoholic hepatitis (AH) with advanced fibrosis and portal hypertension and in experimental mouse fibrosis. We found hepatic LCN2 expression and serum LCN2 level markedly increased and correlated with disease severity and portal hypertension in patients with AH. In control human livers, LCN2 expressed exclusively in mononuclear cells, while its expression was markedly induced in AH livers, not only in mononuclear cells but also notably in hepatocytes. Lcn2-/- mice were protected from liver fibrosis caused by either ethanol or CCl4 exposure. Microarray analysis revealed downregulation of matrisome, cell cycle and immune related gene sets in Lcn2-/- mice exposed to CCl4, along with decrease in Timp1 and Edn1 expression. Hepatic expression of COL1A1, TIMP1 and key EDN1 system components were elevated in AH patients and correlated with hepatic LCN2 expression. In vitro, recombinant LCN2 induced COL1A1 expression. Overexpression of LCN2 increased HIF1A that in turn mediated EDN1 upregulation. LCN2 contributes to liver fibrosis and portal hypertension in AH and could represent a new therapeutic target.

In Vivo Zonal Variation and Liver Cell-Type Specific NF-κB Localization after Chronic Adaptation to Ethanol and following Partial Hepatectomy

NF-κB is a major inflammatory response mediator in the liver, playing a key role in the pathogenesis of alcoholic liver injury. We investigated zonal as well as liver cell type-specific distribution of NF-κB activation across the liver acinus following adaptation to chronic ethanol intake and 70% partial hepatectomy (PHx). We employed immunofluorescence staining, digital image analysis and statistical distributional analysis to quantify subcellular localization of NF-κB in hepatocytes and hepatic stellate cells (HSCs). We detected significant spatial heterogeneity of NF-κB expression and cellular localization between cytoplasm and nucleus across liver tissue. Our main aims involved investigating the zonal bias in NF-κB localization and determining to what extent chronic ethanol intake affects this zonal bias with in hepatocytes at baseline and post-PHx. Hepatocytes in the periportal area showed higher NF-κB expression than in the pericentral region in the carbohydrate-fed controls, but not in the ethanol group. However, the distribution of NF-κB nuclear localization in hepatocytes was shifted towards higher levels in pericentral region than in periportal area, across all treatment conditions. Chronic ethanol intake shifted the NF-κB distribution towards higher nuclear fraction in hepatocytes as compared to the pair-fed control group. Ethanol also stimulated higher NF-κB expression in a subpopulation of HSCs. In the control group, PHx elicited a shift towards higher NF-κB nuclear fraction in hepatocytes. However, this distribution remained unchanged in the ethanol group post-PHx. HSCs showed a lower NF-κB expression following PHx in both ethanol and control groups. We conclude that adaptation to chronic ethanol intake attenuates the liver zonal variation in NF-κB expression and limits the PHx-induced NF-κB activation in hepatocytes, but does not alter the NF-κB expression changes in HSCs in response to PHx. Our findings provide new insights as to how ethanol treatment may affect cell-type specific processes regulated by NF-κB activation in liver cells.

The many faces of hydatid disease

No abstact

A review of internal medicine re-admissions in a peri-urban South African hospital

OBJECTIVE

To measure the re-admission rate and the number of preventable re-admissions in a secondary-level South African hospital, and to identify factors predictive of re-admission.

METHOD

The admission register for the medical wards at Cecilia Makiwane Hospital (CMH) was used to identify re-admitted patients, whose folders were then reviewed. A comparison group of patients who were not re-admitted was randomly generated from the same register.

RESULTS

The re-admission rate for the 7 months ending October 2006 was 8.5% (262/3 083). Patients who were more likely to be re-admitted had chronic respiratory disease (odds ratio (OR) 4.2, 95% confidence interval (CI) 1.2 - 14.6), HIV infection (OR 5.0, CI 2.1 - 12.0), were older than 50 years (OR 5.2, CI 2.5 - 10.9), had a first admission of more than 8 days (OR 3.2, CI 1.5 - 6.6) or a booked medical outpatients followup (OR 5.1, CI 2.6 - 10.3). Age distribution of re-admissions was bimodal, with HIV-positive individuals (27.4% overall) accounting for 50% of all admissions younger than 50 years, but only 9.1% of those 50 years or older. In individuals older than 50 years, 42.1% of admissions were due to chronic cardiorespiratory illnesses. Half of re-admissions were judged to be potentially preventable, mainly through improved patient education.

CONCLUSION

One in 12 general medical patients was readmitted. Chronic diseases and inadequate patient education and discharge planning accounted for the largest group of re-admissions in older patients. Re-admission of HIV/AIDS patients has generated a second peak in younger individuals, and the impact of the antiretroviral roll-out on admission rates warrants further scrutiny.

Activation of estrogen signaling pathways collaborates with loss of Brca1 to promote development of ERalpha-negative and ERalpha-positive mammary preneoplasia and cancer

BRCA1 can regulate estrogen receptor-alpha (ERalpha) activity. This study tested the hypotheses that Brca1 loss in mammary epithelium alters the estrogenic growth response and that exposure to increased estrogen or ERalpha collaborates with Brca1 deficiency to accelerate preneoplasia and cancer development. Longer ductal extension was found in mammary glands of Brca1(f/f;MMTV-Cre) mice during puberty as compared to wild-type mice. Terminal end bud differentiation was impaired in Brca1 mutant mice with preservation of prolactin-induced alveolar differentiation. Exogenous estrogen stimulated an abnormal sustained increase in mammary epithelial cell proliferation and the appearance of ERalpha-negative preneoplasia in postpubertal Brca1 mutant mice. Carcinogenesis was investigated using Brca1(f/f;MMTV-Cre) mice hemizygous for p53. Exogenous estrogen increased the percentage of mice with multiple hyperplastic alveolar nodules. Targeted conditional ERalpha overexpression in mammary epithelial cells of mice that were Brca1 mutant and hemizygous for p53 increased the percentage of mice exhibiting multiple hyperplastic nodules, invasive mammary cancers and cancer multiplicity. Significantly more than half of the preneoplasia and cancers were ERalpha negative even as their initiation was promoted by ERalpha overexpression.

Women's health in prison must be improved

The challenges encompassing the care and control of prisoners have stretched the minds and intellect of many from areas as diverse as politicians, professionals, lay people and academics. Providing good quality health care is an ongoing struggle for any multidisciplinary team in prison health care. The complexity of the relationship between professionals and the patient is amplified because of the unique environment and the prison culture.

Sodium arsenite enhances AP-1 and NFkappaB DNA binding and induces stress protein expression in precision-cut rat lung slices

Arsenic is a known human carcinogen. These studies were designed to examine the impact of low arsenite concentrations on immediate early gene expression in precision-cut rat lung slices. Precision-cut lung slices are a versatile in-vitro system for toxicity studies, as they preserve the architecture and cellular heterogeneity of the lung. Since 0.1-100 microM arsenite did not compromise slice viability at 4 hours, effects of arsenite on the expression of c-jun/AP-1, NFkappaB, HSP 32, HSP 72, HSP 60, and HSP 90 were studied, using these concentrations of arsenite at 4 h. Nuclear c-jun was increased by 10 and 100 microM arsenite, while NFkappaB was not affected. Gel-shift assays indicated that 10 microM arsenite resulted in an enhanced DNA-binding activity of both AP-1 and NFkappaB. Confocal microscopic analysis of AP-1 indicated nuclear localization of this transcription factor, mainly in type-II epithelial cells and alveolar macrophages. Nuclear localization of NFkappaB was lower than that observed for AP-1, while most of the NFkappaB was localized to cytoplasm of type-II epithelial cells and alveolar macrophages. HSP 32 was increased by 1.0 and 10 microM arsenite, while HSP 72 was increased by only 100 microM arsenite. HSP 60 and HSP 90 were not changed by arsenite. These studies indicate that noncytotoxic concentrations of arsenite are capable of affecting signal transduction pathways and gene expression in the lung.

Prison health care: is it a crisis waiting to break?

Anew report from the British Medical Association on prison health care, entitled Prison Medicine: A Crisis Waiting to Break, is an excellent exposition of the difficulties and challenges facing doctors and other healthcare staff as they carry out their duties when working in prisons (British Medical Association, 2001).

The prison healthcare service: a workforce committed to change

This article discusses the changes that are needed in the prison healthcare service, outlining the move to a multidisciplinary team approach, away from the outdated, medically dominated service which prevails today. This article supports the partnership arrangements put forward in 'The Future Organization of Prison Health Care' (Department of Health (DoH), 1999) and suggests how this can be achieved locally, calling on nurses working in the prison environment to be proactive and forge links with colleagues in local NHS services. The need for clinical governance to be firmly established and regular reports to be submitted to prison governors on the quality and provision of services is highlighted.

Prison health care: work environment and the nursing role

This article, the first in a new series on prison nursing, gives an overview of the world of prison nursing and the environmental factors that make it so different from other types of nursing. It welcomes the recommendation in the report 'Patient or Prisoner: A New Strategy for Health Care in Prisons' (HM Chief Inspector of Prisons for England and Wales, 1996) that the NHS should be responsible for providing health care for prisoners and the recent publication of the report of the Joint Prison Service/NHS Executive Working Group 'Future Organization of Prison health Care' (Department of Health, 1999), which endorses a formal partnership between the NHS and prison service. The article highlights the benefits that this will have for prison nurses who often feel professionally isolated. The role of the nurse working in the prison healthcare environment is outlined. The work of prison nurses differs from the role of nurses working in other healthcare situations as it is controlled by environmental factors associated with regimes, security and the prison culture. However, changes are taking place and a closer link with local services is envisaged. These changes are an excellent opportunity for nurses and nursing to establish a clear role in prisons and to develop further healthcare standards in the prison service.

Prison nursing: working at the cutting edge

At present there is a shortfall of skilled nursing staff within the NHS. This shortage also affects the prison healthcare service (Home Office, 1998a,b). Recruitment in this area is often made more difficult by a lack of understanding of the prison healthcare service and, in particular, the role of nurses practising within it.

Ah receptor-independent induction of CYP1A2 gene expression in genetically inbred mice

Acenaphthylene is a tricyclic aromatic hydrocarbon which induces hepatic methoxyresorufin O-demethylase (MROD) activity and CYP1A2 mRNA levels in 2 week-old male B6C3F1 mice. In the present study, this induction response was further investigated in genetically-inbred mice which differ in their aryl-hydrocarbon (Ah)-responsiveness. Acenapthylene (300 mg/kg) induced a 5- to 23-fold induction of MROD activity in Ah-nonresponsive (DBA and SJL) and responsive (C3H, C57/BL6, A/J, CBA and B6C3F1) mice. The highest induction response was observed in the DBA strain in which there was a 23- and 15-fold increase in activity in males and females, respectively. Acenaphthylene also caused a 2-fold increase in CYP1A2 mRNA and immunoreactive protein levels in 2 week-old DBA mice; however, this induction response was not observed in 6 week-old animals. For example, MROD activity in 6 week-old DBA mice was induced <2-fold by acenaphthylene, mainly as a consequence of increased basal CYP1A2 expression and MROD activity which, at the age of 6 weeks, approached levels induced by acenaphthylene in the 2 week-old mice. This was also observed by immunohistochemical staining with CYP1A2 antibodies of 2 and 6 week-old hepatic tissue from treated and control mice which also showed that CYP1A2 induction was dependent on the age of the animals.

Exploring the NHS executive document Signposts for Success

The recent document 'Signposts for Success' (Department of Health (DoH), 1988a) offers an extensive blueprint for the strategic development of services for people with a learning disability in the next decade. This article discusses the key issues raised and some of the controversial aspects that have to be addressed.

Equity and access to health care for women with learning disabilities

The increased expectation for women with learning disabilities to become more autonomous and independent is generally a positive and dynamic force. However, care must be taken to ensure that, within this environment, women with learning disabilities are not isolated or lack support as this increases their vulnerability. These issues exist for all women within our society, but women with learning disabilities are more vulnerable because of their lack of voice both individually and politically. Within this new culture of independence and rights for women with learning disabilities, nurses must ensure that they address their own accountability and responsibility.

New deal for people with learning difficulties

It is not often that service users, carers, and people involved with learning difficulties services can get excited, and it is certainly unusual to get news such as the Health Secretary's announcement of new guidance and advice for the NHS on how best to improve health care for people with learning difficulties (Department of Health (DoH), 1997).

Future directions for learning disability nursing

Over the past decade learning disability nurses have had to make many changes in the way they practice. Changes in attitude towards the way in which people with learning disabilities are cared for has meant that nurses have had to adjust their practice to address different expectations in the way these services are delivered. Nursing now provides opportunities for people with learning disabilities to express themselves and become involved in decision-making that affects their lives. For nurses this is a totally new way of working with this client group. Learning disability nurses have risen to the challenge that has resulted from moving into community care and forming links with primary healthcare teams.

Learning disability nursing and primary healthcare

This article addresses the issues surrounding the role of learning disability nurses and their relationship with primary healthcare colleagues. It highlights opportunities in general practice for the learning disability nurse who has become a key player in shaping services for this client group as services swing towards primary healthcare. The NHS Executive document NHS Priorities and Planning Guidance 1997-98 is explored and the opportunities that this gives the community learning disability nurse are discussed. The article stresses the need for learning disability nurses to obtain quality research-based evidence on effective caring interventions. The importance of clinical audit and outcome measurements from interventions are highlighted. Finally, the importance of good communication and being able to respond to this client group's needs is emphasized.

Should the NHS take over prison services?

The central aim of the green discussion paper by the Inspector of Prisons (Home Office, 1996) was:

‘To consider health-care arrangements in prison service establishments in England and Wales with a view to ensuring that prisoners are given access to the same quality and range of health-care services as the general public received from the National Health Service’.

Residential care for people with learning disabilities

The report Residential Provision for People with Learning Disabilities (Emerson et al, 1996) is the first phase in the Government's independent evaluation of the different types of residential care for people with learning disabilities. A study into the costs of village communities has also been undertaken (Goushaw, 1996).

Health of the Nation for people with learning disabilities

This article explores issues related to the health of people with learning disabilities, with particular reference to the Department of Health (1995a) document The Health of the Nation: A Strategy for People with Learning Disabilities. This publication has stimulated care staff across all agencies to take a fresh look at this client group and their health needs in the five key areas: coronary heart disease and stroke; cancers; HIV/AIDS and sexual health; accidents; and mental health.

Setting the agenda for learning disability nursing

The positive leadership from the Department of Health's Chief Nursing Officer (CNO), Yvonne Moores, in terms of her initiative for learning disability nursing has done much to stimulate nurses across the nation, and to encourage debate not only among nurses but also across all the professionals working together for our client group.