A survey of the UK maxillofacial laboratory service: Profiles of staff and work

We sent questionnaires to 98 maxillofacial laboratories in the United Kingdom and asked about the composition of their staff, the kind of work that they do, and their activities in relation to the treatment of disfigured patients who require facial and body prostheses. We received 59 replies about 193 laboratory staff, most of whom had 10 or more years experience and held basic and advanced qualifications in dental technology. Most laboratories did all sorts of work including maxillofacial, orthodontic, dental prosthetic and crown and bridge work. Only five confined themselves to maxillofacial work. One hundred and eighteen staff (61%) had contact with 4,259 disfigured patients who required prostheses. Fifty-three laboratory managers (89%) thought that maxillofacial prosthetists and technologists gave psychological support to these patients, but only 12 laboratories (21%) had staff with formal training in counselling.

Strengthening the parent-child relationship: a review of family interventions and their use in medical settings

The quality of family functioning is important for both psychological well-being and physical health. This review describes family interventions that aim to improve the strength of the parent-child relationship and considers ways in which these approaches can be applied to physical health care. This review first describes the development of family therapy in dealing with children's behavioural and emotional difficulties. As shown in psychotherapeutic settings, parenting skills can affect children's emotional well-being and ability to control their own conduct. Intervention strategies that focus on developing the ability of parents to provide a benign and nurturing parenting style are considered. The review then considers how the principles of family therapy can be applied to settings where physical health is the central issue. In medical settings, families are not only affected by medical interventions but they can also serve to facilitate or hinder clinical effectiveness. Illustrations of how these interventions can be applied in medical settings are provided. Although a practising clinician will need training in using family therapy techniques, it may be possible to recruit a family therapist to help in particular cases.

Enhanced susceptibility to pulmonary infection with Burkholderia cepacia in Cftr(-/-) mice

Progressive pulmonary infection is the dominant clinical feature of cystic fibrosis (CF), but the molecular basis for this susceptibility remains incompletely understood. To study this problem, we developed a model of chronic pneumonia by repeated instillation of a clinical isolate of Burkholderia cepacia (genomovar III, ET12 strain), an opportunistic gram-negative bacterium, from a case of CF into the lungs of Cftr (m1unc-/-) (Cftr(-/-)) and congenic Cftr(+/+) controls. Nine days after the last instillation, the CF transmembrane regulator knockout mice showed persistence of viable bacteria with chronic severe bronchopneumonia while wild-type mice remained healthy. The histopathological changes in the lungs of the susceptible Cftr(-/-) mice were characterized by infiltration of a mixed inflammatory-cell population into the peribronchiolar and perivascular spaces, Clara cell hyperplasia, mucus hypersecretion in airways, and exudation into alveolar airspaces by a mixed population of macrophages and neutrophils. An increased proportion of neutrophils was observed in bronchoalveolar lavage fluid from the Cftr(-/-) mice, which, despite an increased bacterial load, demonstrated minimal evidence of activation. Alveolar macrophages from Cftr(-/-) mice also demonstrated suboptimal activation. These observations suggest that the pulmonary host defenses are compromised in lungs from animals with CF, as manifested by increased susceptibility to bacterial infection and lung injury. This murine model of chronic pneumonia thus reflects, in part, the situation in human patients and may help elucidate the mechanisms leading to defective host defense in CF.

Adjusting to disfigurement: processes involved in dealing with being visibly different

This paper reviews current psychological understandings of the process of adjustment to acquired and congenital disfiguring conditions, such as burns, dermatological diseases, and cleft palate. It is primarily aimed at researchers and clinicians interested in understanding and ameliorating the psychosocial impact of such disfigurements. The literature was accessed using psychological, medical, and nursing databases. The research indicates that the experience of disfigurement is multifaceted, involving individual and societal factors. The adjustment process involves the way that disfigured people interpret their disfigurement, their self, and their encounters with others. These interpretations are likely to be influenced by the interaction between various underlying cognitive self-schemas and the social context. Efficacious interventions provide disfigured people with practical strategies to deal with social encounters and/or tackle underlying cognitive processes. However, many of the studies examined were methodologically limited or uninformed by psychological theory. Future research is needed to gain a better appreciation of the experience of living with a disfigurement and to inform the development of effective clinical interventions. In particular, there is a need for studies using longitudinal and qualitative methologies, as this would foster greater understanding of the psychological and emotional processes involved in adjusting to disfiguring conditions.

Social anxiety and disfigurement: the moderating effects of fear of negative evaluation and past experience

OBJECTIVES

To examine the relevance of social anxiety and past experience to the social and psychological consequences of disfigurement.

METHOD

One hundred and forty-one patients on the psoriasis register at a dermatology clinic responded to a postal survey which was designed to examine the effects of psoriasis on quality of life as it was related to clinical severity, level of social anxiety and patients' previous experiences of acceptance or rejection.

RESULTS

Psoriasis was most relevant for quality of life for those patients whose condition was visible on their face and hands and who reported a high fear of negative evaluation. Current quality of life, fear of negative evaluation and HAD anxiety scores were only tentatively related to the nature of previous experiences.

CONCLUSIONS

Although direction of causality cannot be ascertained from these results, they suggest that interventions designed to reduce social anxiety could be used to help people who are having difficulty in adjusting to disfiguring medical conditions.

Biological control of clubroot on cauliflower with Trichoderma and Streptomyces spp

The effectiveness of Trichoderma and Streptomyces spp in suppressing clubroot of brassicas which is caused by Plasmodiophora brassicae was tested on cauliflower seedlings in glasshouse and field crops The glasshouse experiment showed that of fifteen isolates of Trichoderma spp and one Streptomyces sp tested six of these reduced (P

Responses by four Local Research Ethics Committees to submitted proposals

BACKGROUND

There is relatively little research concerning the processes whereby Local Research Ethics Committees discharge their responsibilities towards society, potential participants and investigators.

OBJECTIVES

To examine the criteria used by LRECs in arriving at their decisions concerning approval of research protocols through an analysis of letters sent to investigators.

DESIGN

Four LRECs each provided copies of 50 letters sent to investigators after their submitted proposals had been considered by the committees. These letters were subjected to a content analysis, in which specific comments and requests for additional information and changes in the protocols were recorded and compared.

FINDINGS

Overall 24% of proposals were approved without request for changes or clarifications, but this varied by committee: one committee approved only 6% of proposals without change or clarification while the others ranged from 26% to 32%. The content analyses of responses indicated that they could be placed into four categories: (i) further information for the committee to aid in their deliberations; (ii) requests for changes to the design or justification for the design used; (iii) changes to the information sheets provided to potential participants; and (iv) changes to consent procedures. Of these, alterations to information sheets were the most common type of request. These four types of response could be seen as safeguarding the wellbeing of potential participants (the principle of non-maleficence), of promoting the scientific validity of the research (the principle of beneficence), and of enhancing the rights of potential participants (the principle of autonomy).

CONCLUSIONS

The committees were consistent in the types of requests they made of investigators, which can be seen as attempts to protect participants' rights and ensure the scientific validity of studies. Without an analysis of the proposals sent to the committees, however, it is difficult to account for the variation in the requirements set by the committees before approval was given.

Synergistic effects of cAMP- and calcium-mediated amylase secretion in isolated pancreatic acini from cystic fibrosis mice

We evaluated pancreatic enzyme secretory response to secretagogues (cAMP- and Ca2+-mediating) involved in exocytosis and in chloride channel activation in an exon 10 knockout cystic fibrosis (CF) mouse model. Experiments were performed in isolated pancreatic acini from liquid-fed Cftr-/- mice (5-6 wk of age) and age-matched Cftr+/+ controls fed a solid or liquid diet. BrcAMP and forskolin alone induced higher amylase secretion (% initial amylase content) in the Cftr+/+ acini than carbachol (p < 0.05). Carbachol and BrcAMP or BrcAMP and forskolin, given in combination, produced additive effects on enzyme secretion in the Cftr+/+ acini. Ca2+- and cAMP-mediated amylase secretion in isolated pancreatic acini from the Cftr-/- mice was no different to that observed in the age- and diet-matched Cftr+/+ animals. However, Cftr-/- pancreatic acini showed a significantly greater amylase response to the combination of BrcAMP and carbachol than the sum of the individual responses in separate experiments (p < 0.05). The amylase response was not different in acini from solid-fed or liquid-fed Cftr+/+ controls. In summary, this study suggests that cystic fibrosis transmembrane conductance regulator is not essential for enzyme secretion as evidenced by no reduction in cAMP-mediated amylase secretion in Cftr-/- mice. The results in Cftr+/+ acini suggest pancreatic enzyme secretion is mediated via multiple intracellular pathways acting in parallel and probably converge at a distal step in the secretory process. However, Cftr-/- pancreatic acini exhibited a synergistic secretory response following stimulation by BrcAMP plus carbachol. The enhanced secretory response may partially contribute to the development of pancreatic dysfunction in CF patients by facilitating occlusion of digestive enzymes in the secretory canaliculus of the pancreatic acini.

Mexiletine for HIV-infected patients with painful peripheral neuropathy: a double-blind, placebo-controlled, crossover treatment trial

Although mexiletine, an antiarrhythmic with local anesthetic properties, has been reported to relieve discomfort in diabetic neuropathy, its usefulness in the treatment of HIV-related painful peripheral neuropathy (PPN) has not been determined. The tolerance and effectiveness of mexiletine in HIV-related PPN were assessed in 22 patients who were randomized to receive mexiletine (maximum dose, 600 mg/day) or placebo for 6 weeks, followed by the alternative intervention for 6 weeks after a 1-week washout period. The daily pain response was assessed using a visual analogue scale card in 19 patients who received at least 2 weeks of the drug, 16 of whom were crossed-over to receive the alternate agent. No statistically significant difference was found between the mean daily pain scores for patients receiving mexiletine versus placebo, irrespective of the order in which the agents were received. Comparing the mean individual daily pain scores for each phase of study, 5 patients (31%) had significantly less pain while receiving mexiletine compared with their response to placebo, 5 patients (31%) had significantly less pain while receiving placebo, and no difference was noted in 6 patients (38%). Crossover and multivariate analyses for repeated measures showed no apparent difference in the response to mexiletine versus placebo. Dose-limiting adverse events occurred in 39% of those receiving mexiletine, but only 1 patient (5%) discontinued placebo. Mexiletine was only modestly well tolerated despite its relatively brief period of administration, and no evidence was found to support its benefit in HIV-related PPN. Although a first-drug effect was not demonstrated, a powerful placebo effect was seen in some patients.

Impaired ability of Cftr knockout mice to control lung infection with Pseudomonas aeruginosa

The present study was aimed at investigating the innate susceptibility of C57BL/6-Cftrunc/Cftrunc knockout [B6-Cftr (-/-)] mice to pulmonary infection with Pseudomonas aeruginosa. Our results indicate that 58.4% of B6-Cftr (-/-) mice died within 6 d following lung infection with 10(5) P. aeruginosa entrapped in agar beads, whereas only 12.1% of B6-Cftr (+/+) mice died over the same period of time. Moreover, the number of bacteria recovered from the lungs of B6-Cftr (-/-) mice 3 and 6 d after infection was significantly higher than that observed in their littermate controls. No correlation was found between the weight or age of the animals and the number of viable bacteria recovered from the lungs of mice. Histopathological examination of lung sections from P. aeruginosa-infected mice revealed that the infection results in a severe bronchopneumonia. Both B6-Cftr (-/-) knockout mice and their littermate controls developed similar lung pathology during the course of infection. Overall, results reported in the present study suggest that a defect at the Cftr locus leads to an exacerbation of P. aeruginosa lung infection resulting in a dramatically increased mortality rate and higher bacterial load.

Assessment of the efficacy of in vivo CFTR protein replacement therapy in CF mice

Cystic Fibrosis (CF) is caused by mutations in the CF gene that lead, for the most part, to mislocalization of the protein product, the cystic fibrosis transmembrane conductance regulatory (CFTR). CFTR is a chloride channel normally situated in the apical membrane of epithelial cells where it contributes to transepithelial ion transport. In this study we demonstrated the feasibility of in vivo transfer of purified CFTR protein via phospholipid liposomes into the apical membrane of nasal epithelia of CFTR knockout mice. Membrane incorporation of immunogold-labeled CFTR could be visualized by electron microscopy and correction of CF-related defects in ion transport measured by nasal potential difference (PD) measurements in about one-third of the animals treated. Although these initial results are promising, effectiveness of this therapeutic approach appears to be limited by the inefficient incorporation of CFTR into the apical epithelial cell membrane.

Lung disease in mice with cystic fibrosis

The leading cause of mortality and morbidity in humans with cystic fibrosis is lung disease. Advances in our understanding of the pathogenesis of the lung disease of cystic fibrosis, as well as development of innovative therapeutic interventions, have been compromised by the lack of a natural animal model. The utility of the CFTR-knockout mouse in studying the pathogenesis of cystic fibrosis has been limited because of their failure, despite the presence of severe intestinal disease, to develop lung disease. Herein, we describe the phenotype of an inbred congenic strain of CFTR-knockout mouse that develops spontaneous and progressive lung disease of early onset. The major features of the lung disease include failure of effective mucociliary transport, postbronchiolar over inflation of alveoli and parenchymal interstitial thickening, with evidence of fibrosis and inflammatory cell recruitment. We speculate that the basis for development of lung disease in the congenic CFTR-knockout mice is their observed lack of a non-CFTR chloride channel normally found in CFTR-knockout mice of mixed genetic background.

Coping with auditory hallucinations: a cross-cultural comparison between western (British) and non-western (Saudi Arabian) patients

The majority of schizophrenic patients from Western backgrounds develop strategies to cope with the positive symptoms of their condition. However, there is little evidence to indicate how these coping mechanisms are affected by cultural background. Seventy schizophrenic patients from Saudi Arabia (SA) and the United Kingdom (UK) who reported auditory hallucinations were interviewed to explore the ways in which they coped with their voices and sounds. Patients from both cultures had several coping mechanisms, but these varied between cultures. The majority of SA patients used strategies associated with their religion whereas UK patients were more likely to use distraction or physiologically based approaches. The majority of patients were slightly or not at all confident about the effectiveness of their coping strategies. This study suggests that clinicians, when they attempt to facilitate the use of such strategies, may find greater patient acceptance and efficacy if they are familiar with culturally specific factors.

Mergers. Going with the flow

A successful merger requires intense concentration on the people involved. Those affected are likely to show a grief reaction, including denial, resistance and eventual acceptance. You will never get it completely right, but good communication helps.

The views of members of Local Research Ethics Committees, researchers and members of the public towards the roles and functions of LRECs

BACKGROUND

It can be argued that the ethical conduct of research involves achieving a balance between the rights and needs of three parties-potential research participants, society, and researchers. Local Research Ethics Committees (LRECs) have a number of roles and functions in the research enterprise, but there have been some indications that LREC members, researchers and the public can have different views about these responsibilities. Any such differences are potential sources of disagreement and misunderstanding.

OBJECTIVES

To compare the views of LREC members, researchers and the public towards the roles and functions of LRECs.

DESIGN

A questionnaire that contained items concerned with a variety of such roles was distributed to general practice patients (as proxies for potential research participants), researchers and LREC members.

FINDINGS

While general practice patients believed that the main function of LRECs is to ensure that research participants come to no harm, LREC members were more concerned with the protection of participants' rights. There was also some disagreement between members and researchers with regard to the consideration of proposals on the grounds of scientific merit.

CONCLUSIONS

Local Research Ethics Committee members need to be aware of potential differences in views, that they ought to make their priorities clear, and that membership of LRECs ought to reflect the views of both researchers and potential research participants.

A comparison of public attitudes in Britain and Saudi Arabia towards auditory hallucinations

BACKGROUND

The successful introduction of community interventions is partly dependent on public beliefs about the aetiology and treatment of psychiatric difficulties and tolerance of community integration.

METHOD

This study examined community attitudes towards auditory hallucinations in Saudi Arabia (SA) and the United Kingdom (UK) concerning (a) causes of auditory hallucinations, (b) the efficacy of interventions and (c) levels of social rejection.

RESULTS

Responses from 281 patients attending their general practitioners indicated that those living in Saudi Arabia were most likely to believe that hallucinations are caused by Satan or due to magic, while the UK sample were more likely to cite schizophrenia or brain damage. While the Saudi sample believed that religious assistance would be most effective, the UK sample supported medication and psychological therapies. Beliefs about aetiology and treatment were unrelated to educational attainment. There was a greater degree of social rejection of patients in Saudi Arabia, but here educational attainment was of significance.

CONCLUSIONS

These results suggest that beliefs about aetiology are related to treatment recommendations and social distancing, and thus have implications for the care of Arabic patients living in Western countries as well as for the use of Western interventions in non-Western cultures.

A cross-cultural study of the attitudes of mental health professionals towards auditory hallucinations

The usefulness of psychological interventions for auditory hallucinations is becoming increasingly accepted in Western cultures, but there are few data concerning the views of professionals working in non-Western societies. In this study, 195 psychologists and psychiatrists working in Saudi Arabia (SA) and Britain (UK) responded to a questionnaire regarding their (a) attitudes towards various clinical aspects of auditory hallucinations, (b) perceptions of the clinical value of psychological and pharmacological treatments and of the inputs of the two professions and (c) levels of social distance from people who experience auditory hallucinations. UK staff believed that there is a greater range of possible causes and diagnoses for auditory hallucinations than SA staff, who in turn had more confidence in the efficacy of psychological and pharmacological treatments. UK staff reported significantly less social distance from this group of patients. The results suggest that the use of psychological approaches to helping people with auditory hallucinations could be affected by cultural views of the causes and treatment.

Psychologic effects of vitiligo: a critical incident analysis

BACKGROUND

Qualitative and quantitative studies have shown that cutaneous diseases can have significant effects on psychologic well-being and social functioning in a variety of interpersonal situations.

OBJECTIVE

Our purpose was to assess the nature and extent of the social and psychologic difficulties associated with vitiligo using a combination of qualitative and quantitative methods.

METHODS

Six hundred fourteen members of the U.K. Vitiligo Society completed a questionnaire that included the 12-item version of the General Health Questionnaire (GHQ) and an open-ended question concerning the effects of the disease on their life.

RESULTS

Thirty-five percent of the respondents scored above the threshold on the GHQ. Analysis of the qualitative data indicated that vitiligo affects lives in a variety of ways consistent with perceived stigma and that some categories of response (such as avoidance of activities and negative reactions by others) were associated with higher GHQ scores.

CONCLUSION

Many persons with vitiligo show indications of significant distress that are related to specific types of social encounters and emotional disturbance.

Development of a scale to measure the social and psychological effects of severe dental anxiety: social attributes of the Dental Anxiety Scale

This paper describes the development of a scale designed to measure the extent to which severe dental anxiety or phobia affects patients' social wellbeing outside of the dental setting. Items initially selected on the basis of clinical experience were administered to two groups: 78 patients seeking help for severe anxiety and 88 patients attending the general clinic of a dental hospital. Items on the scale discriminated between these two groups and also between patients who were reluctant to attend even when experiencing symptoms and those who attend more regularly. Although the scale correlated moderately well with Corah's Dental Anxiety Scale, factor analysis indicated that its items assess the effects of severe anxiety on the two domains of psychological reactions and social inhibition as they occur as indirect effects of dental care. The scale could be included in assessments designed to measure the social and psychological effects of severe dental anxiety.

The content and characteristics of auditory hallucinations in Saudi Arabia and the UK: a cross-cultural comparison

This study investigated the content and characteristics of auditory hallucinations reported by 75 patients in Saudi Arabia (SA) and the UK. Each patient was asked to report on the content and characteristics of their hallucinations with regard to several dimensions, including loudness, frequency, clarity and perceived validity. In general, the characteristics of the voices did not vary between the SA and UK patients, but the content differed between cultures. Much of the content of the hallucinations of SA patients was religious and superstitious in nature, whereas instructional themes and running commentary were common in the UK patients. The results suggest that cultural differences need to be taken into account when applying psychological methods to this group of patients.

Ownership and uses of human tissue: does the Nuffield bioethics report accord with opinion of surgical inpatients?

OBJECTIVE

To compare opinion of surgical inpatients with the conclusions of the report of the Nuffield Council on Bioethics regarding the ownership and uses of human tissue.

DESIGN

Survey of results of questionnaires completed by patients.

SETTING

Large teaching hospital.

SUBJECTS

384 postoperative adult surgical patients.

RESULTS

There was strong support among patients for the use of tissues in medical education, research, and science with the exception of those tissues which may transmit disease to others. Few patients (39; 10%) believed that they retained ownership of tissue removed at surgery. Most believed that the tissue belonged to the hospital (103; 27%), to nobody (103; 27%), or to the laboratory (77; 20%). Most patients had not been given any information about the possible uses of their tissues after removal.

CONCLUSIONS

Surgical inpatients seem to endorse the conclusions of the Nuffield report regarding the ownership and uses of human tissue. The recommendations regarding patient information and consent procedures should be implemented at the earliest opportunity.

Visual signals and the communication abilities of children

The communication abilities of children of differing ages (4-, 6-, and 11 years) were compared. The children performed two communication tasks and were interviewed in both face-to-face and audio-only contexts. While older children adapted to the loss of visual signals the younger age groups did not and their communication suffered. It appears that a significant amount of information which young children transmit occurs in a non-verbal format, and that visual signals are less demanding for young listeners. Such findings have implications for professionals working with young children since they show the importance of addressing both the child's visual signals and one's own.

Shared understandings for informed consent: the relevance of psychological research on the provision of information

The achievement of informed consent from patients and potential research participants is considered a basic requirement in clinical care and clinical research, but ethicists have paid little attention to the psychological processes and social factors involved in sharing information between individuals. Although many studies on consent have provided useful results, they are rarely informed by basic research in the social sciences. As a result, there are a large number of methodological and conceptual issues which have not been adequately addressed. The purpose of this paper is to illustrate how the work of cognitive and social psychologists can provide insights that are both relevant and valuable to the process of attaining consent. Research in these areas within psychology has indicated that there are important individual differences in how much information people require and that patients' current state of mind can affect estimates of probability, thus making analogue studies misleading. Collaboration between psychologists and ethicists would be of great value in identifying likely areas of mutual interest, particularly the choice of language in consent forms and information sheets, the design of consent forms, the amount of information provided, and the specification of risks and benefits.

Factors affecting responses on Dermatology Life Quality Index items among vitiligo sufferers

Finlay and Khan have recently suggested that the Dermatology Life Quality Index (DLQI) can be used to measure the effects of dermatological conditions on the quality of patients' lives. The aims of this study were to assess its applicability in a nonclinic sample of vitiligo sufferers and to measure its relationship with questionnaires designed to measure a variety of psychological and demographic factors. The DLQI was completed by 614 members of the Vitiligo Society in a postal survey. The results supported the validity of the DLQI for this sample. DLQI scores were related to perceived stigma (a version of Ginsburg and Link's psoriasis stigma questionnaire), recent experiences, self-esteem (Rosenberg's scale), personal distress (both a symptom checklist and the 12-item General Health Questionnaire) and race, suggesting that levels of disability might be reduced by interventions that target these variables.

Exocrine pancreatic alterations in long-lived surviving cystic fibrosis mice

We investigated the development of the exocrine pancreas in Cftr-/- mice in comparison with age-matched littermates (Cftr+/+, Cftr+/-) up to 100 d postnatally. Controls were weaned either to mouse chow or a liquid diet; Cftr-/- mice were weaned solely to a liquid diet. Solid-fed control mice gained weight and showed a progressive increase in pancreatic protein, DNA, amylase, lipase, trypsin, and chymotrypsin activities. Liquid-fed control mice showed similar postnatal somatic and pancreatic growth, except that amylase and lipase activities were lower than in the solid-fed controls. Cftr-/- mice exhibited significantly lower body and pancreatic weights than did controls. Pancreatic protein content and enzyme activities (notably amylase and lipase) were consistently lower than in the age-matched litter-mates fed either diet. The reduction in lipase activity in Cftr-/- mice was noted before weaning. We concluded that the liquid diet influenced postnatal exocrine pancreatic development in mice. However, a further reduction in postnatal pancreatic growth and enzymatic activities in the Cftr-/- mice was noted. These alterations could be due to the primary cystic fibrosis defect, although secondary factors, such as malnutrition induced by decreased dietary intake or abnormal absorptive capacity, may be responsible.

Detection and classification of inappropriate hospital stay

OBJECTIVE

To study the reliability and validity of concurrent review of hospital-bed utilization carried out by a trained nurse.

DESIGN

Analysis of interrater reliability and validity of utilization review.

SETTING

Tertiary care hospital associated with a university.

PATIENTS

Eighty patients randomly selected from 203 patients admitted to the hospital.

INTERVENTIONS

Appropriateness of days of stay in hospital was classified prospectively, on the basis of clinical judgement, by two nurses working independently, by a third nurse working with the Appropriateness Evaluation Protocol (AEP) and by a multidisciplinary review panel of nurses and physicians working retrospectively with the use of data gathered by the first nurse.

MAIN OUTCOME MEASURES

Agreement between different rates on the number of and reason for inappropriate admission days, total number of inappropriate days and of inappropriate days due to delayed discharge, to diagnostic procedures or to inefficient medical management.

RESULTS

Agreement between the two nurses who used clinical judgement was substantial (kappa or the intraclass correlation coefficient [RI] 0.77 to 0.98 on the number of and reason for inappropriate admission days, on the total number of inappropriate hospital days and on days due to delayed discharge, diagnostic procedures or inefficient medical management. Agreement was moderate (RI 0.47) on the number of inappropriate day's stay awaiting surgery. Agreement was substantial (kappa or RI 0.69 to 0.94) between the two nurses who used clinical judgement and the panel, except on the total number of inappropriate days; however, for this variable, exclusion of one case increased the RI from 0.35 to 0.80. Agreement was substantial between the two nurses who used clinical judgement and the nurse who used the AEP on appropriateness of admission days and the number of inappropriate days. Agreement between the panel and the nurse who used the AEP on the number of inappropriate days rose from 0.36 to 0.88 when the one outlying case was excluded. Some admissions were classified as premature when the AEP was used, whereas other raters considered the admissions unnecessary. There was poor agreement between the nurse who used the AEP and the other raters on the number of inappropriate days' stay awaiting surgery or diagnostic tests.

CONCLUSIONS

Data collection and judgement of appropriateness of hospital stay by a trained nurse is feasible and reliable. A nurse working prospectively and a panel working retrospectively sometimes disagree. The AEP provides a similar estimate of the number of inappropriate days but may be insensitive to patient factors that influence the timing of admission.

Phenotypic abnormalities in long-term surviving cystic fibrosis mice

Mouse models for cystic fibrosis (CF) with no CFTR function (Cftr-/-) have the disadvantage that most animals die of intestinal obstruction shortly after weaning. The objective of this research was to extend the lifespan of CF mice and characterize their phenotype. Weanlings were placed on a nutrient liquid diet, and histologic and functional aspects of organs implicated in the disease were subsequently examined. Approximately 90% of Cftr-/- mice survived to 60 d, the majority beyond 100 d. Cftr-/- mice were underweight and had markedly abnormal intestinal histology. The intestinal epithelia did not respond to challenges with agents that raised intracellular cAMP, consistent with the absence of functional CFTR. No lesions or functional abnormalities were evident in the lungs. Liquid-fed Cftr-/- mice were infertile, although some males weaned to a solid diet were fertile before they died. Thus, we have succeeded in using dietary means to prolong the lives of Cftr-/- mice.

Patient reactions to met and unmet psychological need: a critical incident analysis

Patients with cancer must deal with a variety of psychological and social difficulties, but the extent to which staff assist patients with these difficulties is not clear. Using the Critical Incident Technique (CIT), patients attending a Cancer Centre were asked to describe situations in which their emotional needs were, and were not, met by staff. Although most patients were able to describe a situation in which their needs were met by staff, 23% also described a situation in which this was not the case. These latter incidents were often related to anxiety, confusion and a wish to sever links with the hospital. Patients who reported that their needs were not met requested more staff time and further information about their diagnosis and treatment.

In vivo measurements of ion transport in long-living CF mice

The Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) gene codes for an epithelial chloride (C1) channel essential for fluid secretion into the respiratory and gastrointestinal tract and from exocrine glands. Mice lacking CFTR function due to a disruption of Cftr exon 10 or exon 1 (Cftr (m1UNC/m1UNC) or Cftr(m1HSC/m1HFC) mice, respectively) generally suffer from severe gastrointestinal disease resulting in death shortly after birth or at the time of weaning. However, a subgroup of the Cftr(m1HSC/m1HSC) mice have been characterized which exhibit relatively mild intestinal pathology resulting in a noncompromised lifespan compared to the more severely affected Cftr(m1UNC/m1UNC) mice. We compared the ion transport capacity of the intestinal mucosa of the mildly and severely affected CF mice using the in vivo technique of rectal potential difference (PD) measurement and found that the net calcium-activated chloride conductance toward the lumen was much greater in the rectum of mildly affected mice than in the severely affected mice. Hence, the milder phenotype may be related to the expression of a factor which enhances the net calcium-activated chloride conductance into the lumen of the intestinal tract.

Can we prevent accidental injury to adolescents? A systematic review of the evidence

OBJECTIVES

As part of the Department of Health strategy The Health of the Nation, a systematic review of published and unpublished literature relating to the effectiveness of interventions in reducing accidental injury in the population aged 15-24 years was carried out.

METHODS

The literature was reviewed under the standard setting headings of road, work, home, and sports and leisure, and graded for quality of evidence and strength of recommendation using a scale published in the UK national epidemiologically based needs assessment programme.

RESULTS

The most effective measures appear to be legislative and regulatory controls in road, sport, and workplace settings. Environmental engineering measures on the road and in sports have relatively low implementation costs and result in fewer injuries at all ages. There is little evidence that purely educational measures reduced injuries in the short term. Community based approaches may be effective in all age groups, and incentives to encourage safer behaviour hold promise but require further evaluation. The potential of multifactorial approaches seems greater than narrowly based linear approaches.

CONCLUSIONS

Few interventions to reduce injury in adolescents have been rigorously evaluated using good quality randomised controlled trials, and where such evidence is available, fewer have been shown to be definitely worthwhile. Many studies relied on surrogate measures rather than actual injury rates, and substantial issues relating to the efficacy or implementation of preventive measures in adolescent and young adult populations remain unresolved.

Differential stimulation of somatostatin but not neuropeptide Y gene expression by quinolinic acid in cultured cortical neurons

Somatostatin (SS) and neuropeptide Y (NPY) are coproduced in a subpopulation of neurons that are selectively resistant to NMDA neurotoxicity. We have previously reported that quinolinic acid (QUIN), an NMDA receptor agonist, augments SS mRNA in cultured fetal rat cortical neurons. This study examines coregulation of SS and NPY by QUIN and NMDA in cultured cortical neurons and compares the effects of these agents with those of forskolin and phorbol 12-myristate 13-acetate (PMA), known to activate SS and NPY gene transcription by protein kinase A- and protein kinase C-dependent mechanisms. In addition, transcriptional regulation of the SS gene was investigated by acute transfection of cortical cultures with an SS promoter-chloramphenicol acetyltransferase (CAT) construct. QUIN and NMDA displayed dose-dependent fourfold augmentation of levels of mRNA for SS but not for NPY. In contrast, forskolin and PMA increased both SS and NPY mRNA levels. QUIN- and NMDA-mediated induction of SS mRNA was blocked by the NMDA receptor antagonist (-)-2-amino-5-phosphonovaleric acid and displayed regional brain specificity because it was not observed in fetal hypothalamic cell cultures. In time course studies, the effects of QUIN/NMDA on SS mRNA occurred after a latency of 8 h, indicating a delayed effect. Cortical cells transfected with pSS-750 CAT showed three- to fourfold stimulation of CAT activity with forskolin but not by QUIN or NMDA. These data reveal a dose-dependent, tissue-specific, NMDA receptor-mediated stimulation of SS but not NPY mRNA.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of deception in nursing

Arguments about the morality of the use of deception in patient care have been conducted largely in an empirical vacuum, with few data about the situations in which deception occurs. Do staff frequently deceive their patients and, if so, under what conditions? Can the consequences of deception always be foreseen? What justifications do staff use to explain their behaviour? The small-scale study reported here on the uses of deception by nurses when attempting to reassure patients provides information on these questions. The results suggest that deception can have deleterious effects on trust and increase the emotional distance between patients and staff.

Quality indicators for patient information in short-stay units

In 1993, a prospective audit of short-stay, general surgery patients assessed consumer knowledge and satisfaction with available information, identifying how current practice might be improved. The audit revealed that more formalised discharge procedures might improve patients' understanding of what to expect as convalescence progressed, increasing their knowledge for appropriate self-care. Community costs were also assessed.

Penile absorption of EMLA cream in piglets: implications for use of EMLA in neonatal circumcision

EMLA (eutectic mixture of lidocaine and prilocaine) cream is currently not recommended for use in infants < 1 month of age because of the potential risk of methemoglobinemia as a result of the o-toluidine metabolite of prilocaine. We studied bioavailability and changes in methemoglobin levels following topical penile exposure to 1 g of EMLA cream for 1 hour in piglets. Lidocaine, prilocaine, and o-toluidine concentrations were measured simultaneously using a high-performance liquid chromatography method. The systemic bioavailability of EMLA was low: 4.0 +/- (SD) 4.7% for lidocaine (range 0-13.6; n = 8) and 7.2 +/- 5.7% for prilocaine (range 0-14.5; n = 8). The ratio between exposure to o-toluidine with EMLA versus intravenous administration (i.e., AUCEMLA/AUCIV; see text) was also low: 4.2 +/- 9.3% (range 0-28.6; n = 9). The mean maximum methemoglobin value after intravenous administration was 1.23 +/- 0.64% (range 0.5-3.0; n = 12) and after penile application 0.99 +/- 0.36% (range 0.5-2.0; n = 12). The methemoglobin value was elevated significantly above baseline after intravenous administration (p = 0.03), but not after penile application of EMLA. These findings suggest that penile administration of 1 g of EMLA may be safe for neonatal circumcision, but further study is required.

Self-reported long-term effects of diving and decompression illness in recreational scuba divers

The aim of this study was to examine the long-term effects of neurological decompression illness (NDCI) on recreational divers. Thirty-seven divers who had been treated for neurological decompression illness at least 2 years previously, and a control group of 50 divers with no history of decompression illness, responded to a postal questionnaire. Divers in the accident group reported more symptoms of neurological damage, were more likely to believe that diving had a deleterious effect on their health and were more likely to indicate symptoms of psychiatric morbidity. The quantity of diving in the year preceding the survey was associated with reports of neurological damage in both groups and with symptoms of psychiatric morbidity in the accident group. Although requiring confirmation from a longitudinal study, these results suggest that recreational diving can have negative long-term consequences for health, particularly after decompression illness.

Simultaneous determination of lidocaine, prilocaine and the prilocaine metabolite o-toluidine in plasma by high-performance liquid chromatography

An HPLC assay is described for the measurement of prilocaine and lidocaine (components of the local anesthetic cream EMLA) as well as the prilocaine metabolite, o-toluidine, in plasma. The method uses UV detection, is simple, sensitive and most important, only a single 200-microliters plasma sample is needed for simultaneous analysis of prilocaine, lidocaine and o-toluidine with a detection limit of 4 ng/ml. The plasma, together with the internal standard (bupivacaine) is extracted with diethyl ether under alkaline conditions, followed by the extraction of the analytes from the organic phase into dilute sulphuric acid. An aliquot of the acid extract is injected onto the HPLC system and the effluent is monitored by a UV detector.

The relationship between disease severity, disability and psychological distress in patients undergoing PUVA treatment for psoriasis

BACKGROUND

Patients suffering from severe psoriasis report high levels of personal distress and disability as a result of their disease.

OBJECTIVE

The purpose of this study was to examine the relationship between disease severity, personal distress and disability.

METHODS

Twenty-two patients provided a self-rating of disease severity and completed the Psoriasis Disability Index (PDI) and the General Health Questionnaire (GHQ). A dermatologist provided a clinical assessment from the case notes.

RESULTS

Although the clinical assessment was not related to patient ratings, patient-rated severity scores, GHQ and PDI were correlated with each other. GHQ could only be predicted by disease severity when it was mediated by PDI scores.

CONCLUSIONS

These results indicated that psoriasis affects psychological distress through its effects on the patients' everyday lives.

Measurement of changes in complete mandibular denture security using visual analogue scales

The security of mandibular dentures for edentulous patients has been quantified using a visual analogue scale. Relining "loose" dentures was shown to produce an increase in the patients' assessments of denture security for 21 out of 23 patients. The security of a denture after relining was found to correlate with the form of the residual mandibular ridge as measured by the mean anterior ridge height.

Effects of osseointegrated implants on psychological and social well-being: a comparison with replacement removable prostheses

Sixty-one patients participated in a longitudinal study designed to compare the psychological effects of osseointegrated implants with those of conventional denture replacements. Thirty-two patients who requested either relining or reconstruction of their dentures were asked to complete questionnaires designed to measure their psychological well-being while they were on a waiting list and then again 6 months after treatment. Their responses were compared with those of 29 patients who had received an osseointegrated implant. While the implant patients had reported significant declines in psychological distress, there was no such change for the denture patients. Although both groups experienced fewer disabling symptoms, the decline was greater for the implant group. Finally, neither group showed evidence of any change in self-esteem. The results suggest that osseointegrated implants can have a more positive effect on well-being than denture replacements.

The Psoriasis Disability Index--further analyses

Clinicians have become increasingly aware of the important effects of psoriasis on patients' quality of life. As a result, several measures of the disabilities and handicaps associated with psoriasis have been developed. The Psoriasis Disability Index (PDI) has been shown to be sensitive to changes in the extent of lesions and to co-vary with the Sickness Impact Profile, a more general measure of the effects of disease on quality of life. In this study, patients with psoriasis and patients with other skin diseases completed the PDI. Although most items on the PDI were specific to psoriasis, some items applied to patients with urticaria, eczema, melanomas and other skin diseases. A factor analysis of the items indicated that the PDI contained two subscales, one concerning most aspects of everyday activities, the other concerning specific public situations such as the use of communal facilities.