Factors influencing the use of different methods of consent in a randomized acute stroke trial: The Third International Stroke Trial (IST-3)

BACKGROUND

Obtaining informed consent in people with acute stroke is complex since many, as a direct result of their stroke, lose capacity to make important decisions. Furthermore, reperfusion interventions are time dependent necessitating rapid consent. We developed four different consent approaches to facilitate recruitment of a broad range of patients in the Third International Stroke Trial (IST-3).

AIMS

To describe the clinical characteristics of patients recruited by different consent methods and the association between these methods and time from stroke onset to randomization.

METHODS

IST-3 was a randomized controlled trial of thrombolysis for acute ischemic stroke. Clinicians could use one of four consent procedures: written consent, witnessed consent, assent, or a waiver of consent. We analyzed the relationship between consent procedure and baseline variables. The effect of consent procedure on delay time from onset to randomization was determined using analysis of variance to adjust for confounding effects.

RESULTS

Of the 3035 patients recruited, the method of consent was known for 3034 (99.9%), and it was written in 985 subjects (32.5%), witnessed verbal consent in 280 (9.2%), assent by relative in 1727 (56.9%), and waiver of consent in 42 subjects (1.4%). Assent was required in 63.4% for those presenting 0-3 h from stroke onset (written consent in 25.3%). Patients with more severe neurological deficits (or with a non-lacunar hemispheric stroke syndrome) were less likely to give written consent. Mean delay between onset and randomization varied significantly between consent types (one-way analysis of variance: F = 15.7 on 3 df, p < 0.0001) (longest at 4.06 h for signed consent and 3.46 h for waiver of consent).

CONCLUSIONS

Acute stroke trials requiring written informed consent would result in substantial selection bias. Flexible consent methods will ensure a broad range of patients are recruited, enabling trial results to be widely generalizable.Registration: This study's registered number is ISRCTN25765518.

12-month interim results of a prospective study of patients with mild to moderate open-angle glaucoma undergoing combined viscodilation of Schlemm's canal and collector channels and 360° trabeculotomy as a standalone procedure or combined with cataract surgery

PURPOSE

To characterize clinical outcomes of combined viscodilation of Schlemm's canal and collector channels and 360° trabeculotomy as a standalone procedure or combined with cataract surgery in eyes with mild to moderate open-angle glaucoma (OAG).

METHODS

In this prospective case series, the OMNI glaucoma surgical platform (Sight Sciences, Menlo Park, CA) was utilized to perform the procedure either combined with phacoemulsification or as a standalone procedure. Changes from baseline in intraocular pressure (IOP) and IOP-lowering medications were evaluated through the first 12 months of a planned 24-month follow-up period.

RESULTS

Among 17 eyes of 15 subjects, mean IOP was reduced from 20.4 mmHg to 12.7-13.7 mmHg through 12 months of follow-up (p < 0.001 at every time point) and mean medications reduced from 2.5 to 0.1-0.6 (p < 0.001 at every time point). IOP reductions in eyes undergoing standalone surgery were approximately 2-4 mmHg greater at each time point compared to eyes undergoing surgery combined with phacoemulsification; this may be related to a higher baseline IOP in the former eyes (22.1 vs 18.5 mmHg). Six eyes developed hyphema, of which three required washout for elevated IOP on the first postoperative day; six additional eyes had IOP elevations that resolved with medical management.

CONCLUSION

Viscodilation of Schlemm's canal and collector channels paired with ab interno trabeculotomy performed with a single integrated instrument (OMNI), whether as standalone or combined with phacoemulsification, effectively lowers both IOP and the need for IOP-lowering medications through 12 months of follow-up.

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

BACKGROUND

Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.

METHODS

FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762.

FINDINGS

Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839-1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26-6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38-2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months.

INTERPRETATION

Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function.

FUNDING

UK Stroke Association and NIHR Health Technology Assessment Programme.

Reasons for non-recruitment of eligible patients to a randomised controlled trial of secondary prevention after intracerebral haemorrhage: observational study

Background

Recruitment to randomised prevention trials is challenging, not least for intracerebral haemorrhage (ICH) associated with antithrombotic drug use. We investigated reasons for not recruiting apparently eligible patients at hospital sites that keep screening logs in the ongoing REstart or STop Antithrombotics Randomised Trial (RESTART), which seeks to determine whether to start antiplatelet drugs after ICH.

Method

By the end of May 2015, 158 participants had been recruited at 108 active sites in RESTART. The trial coordinating centre invited all sites that kept screening logs to submit screening log data, followed by one reminder. We checked the integrity of data, focused on the completeness of data about potentially eligible patients and categorised the reasons they were not randomised.

Results

Of 108 active sites, 39 (36%) provided usable screening log data over a median of ten (interquartile range = 5–13) months of recruitment per site. During this time, sites screened 633 potentially eligible patients and randomised 53 (8%) of them. The main reasons why 580 patients were not randomised were: 43 (7%) patients started anticoagulation, 51 (9%) patients declined, 148 (26%) patients’ stroke physicians were not uncertain about using antiplatelet drugs, 162 (28%) patients were too unwell and 176 (30%) patients were not randomised due to other reasons.

Conclusion

RESTART recruited ~8% of eligible patients. If more physicians were uncertain about the therapeutic dilemma that RESTART is addressing, RESTART could have recruited up to four times as many participants. The trial coordinating centre continues to engage with physicians about their uncertainty.

Trial registration

EU Clinical Trials, EudraCT 2012-003190-26. Registered on 3 July 2012.

Decreased consciousness: bilateral thalamic infarction and its relation to the artery of Percheron

This case series highlights two patients seen in the same stroke centre presenting with unusual symptoms. They were later diagnosed with bilateral thalamic infarcts, probably related to an unusual anatomical variant. The difficulties in establishing the diagnoses due to their relative rarity and complexity could have impacted on patient outcomes.

Feasibility of pedometers for adults with schizophrenia: pilot study

The purpose of this prospective and observational design study was to assess the feasibility of using a pedometer and step log to explore level of physical activity (PA) and to assess motivation to be physically active in adults with schizophrenia. Descriptive statistics were used to analyse data of 7 male and 5 female subjects. Pedometer data indicated that subjects walked an average of 4731.03 (±3318.19) steps and 5002.58 (±3041.03) during the first week and second week of the study, respectively. A minimum 30-min walk was recorded on an average of 3.67 (±1.82) days (week one) and 4.5 (±1.88) days (week two). Step logs, inconsistently maintained by subjects, were not able to be analysed. Examination of the Motives for Physical Activity Measure-Revised (MPAM-R) at baseline indicates that exercise fitness and body appearance were subjects' primary motives for PA participation. Study findings indicate that it is feasible to use a pedometer to monitor the level of PA. However, maintenance of a concurrent step log requires further consideration to determine realistic outcomes. Extrinsically focused motivations for PA in this study sample may predict low PA adherence.

Update on the third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke and baseline features of the 3035 patients recruited

Background

Intravenous recombinant tissue plasminogen activator (rtPA) is approved in Europe for use in patients with acute ischaemic stroke who meet strictly defined criteria. IST-3 sought to improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of rtPA in acute ischaemic stroke, and to determine whether a wider range of patients might benefit.

Design

International, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rtPA in acute ischaemic stroke. Suitable patients had to be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracranial haemorrhage and stroke mimics.

Results

The initial pilot phase was double blind and then, on 01/08/2003, changed to an open design. Recruitment began on 05/05/2000 and closed on 31/07/2011, by which time 3035 patients had been included, only 61 (2%) of whom met the criteria for the 2003 European approval for thrombolysis. 1617 patients were aged over 80 years at trial entry. The analysis plan will be finalised, without reference to the unblinded data, and published before the trial data are unblinded in early 2012. The main trial results will be presented at the European Stroke Conference in Lisbon in May 2012 with the aim to publish simultaneously in a peer-reviewed journal. The trial result will be presented in the context of an updated Cochrane systematic review. We also intend to include the trial data in an individual patient data meta-analysis of all the relevant randomised trials.

Conclusion

The data from the trial will: improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of iv rtPA in acute ischaemic stroke; provide: new evidence on the balance of risk and benefit of intravenous rtPA among types of patients who do not clearly meet the terms of the current EU approval; and, provide the first large-scale randomised evidence on effects in patients over 80, an age group which had largely been excluded from previous acute stroke trials.

Trial registration

ISRCTN25765518

Medication-taking behaviours in young adults with schizophrenia: a pilot study

The purpose of this prospective and observational study was to explore medication-taking behaviours in community-based young adults with schizophrenia using an electronic monitoring system and patient self-report questionnaires. The Medication Event Monitoring System (MEMS®), the Index for Medication Adherence (IMA) and the Brief Evaluation of Medication Influences and Beliefs (BEMIB) measured medication-taking behaviours. Data were collected at baseline, 4 and 8 weeks. Descriptive statistics were used in analysis. A total of 11 subjects were recruited; one dropped out. Five were male, and five were female. Average age was 32.64 (SD = 5.70) years. Four (40%) were White people; six (60%) were non-White people. The average number of medications treating schizophrenia was 1.9 (SD = 0.57). MEMS® identified 71.77% (SD = 30.47) dose adherence and 55.92% (SD = 31.27) day adherence. Most subjects took medications irregularly (early, late or missing). The BEMIB demonstrated that 50%, 20% and 30% of subjects considered themselves to be adherent to their medications at baseline, 4 weeks and 8 weeks, while the IMA reported 90%, 90% and 80% at baseline, 4 weeks and 8 weeks, respectively. Regarding the observed discrepancies between patients' reports and their actual medication-taking behaviours, clinical implications were discussed. Effective interventions improving medication adherence in schizophrenia are needed for practice and for future studies.

A practical assessment of magnetic resonance diffusion-perfusion mismatch in acute stroke: observer variation and outcome

MR diffusion/perfusion mismatch may help identify patients for acute stroke treatment, but mixed results from clinical trials suggest that further evaluation of the mismatch concept is required. To work effectively, mismatch should predict prognosis on arrival at hospital. We assessed mismatch duration and associations with functional outcome in acute stroke. We recruited consecutive patients with acute stroke, recorded baseline clinical variables, performed MR diffusion and perfusion imaging and assessed 3-month functional outcome. We assessed practicalities, agreement between mismatch on mean transit time (MTT) or cerebral blood flow (CBF) maps, visually and with lesion volume, and the relationship of each to functional outcome. Of 82 patients starting imaging, 14 (17%) failed perfusion imaging. Overall, 42% had mismatch (56% at <6 h; 41% at 12-24 h; 23% at 24-48 h). Agreement for mismatch by visual versus volume assessment was fair using MTT (kappa 0.59, 95% CI 0.34-0.84) but poor using CBF (kappa 0.24, 95% CI 0.01-0.48). Mismatch by either definition was not associated with functional outcome, even when the analysis was restricted to just those with mismatch. Visual estimation is a reasonable proxy for mismatch volume on MTT but not CBF. Perfusion is more difficult for acute stroke patients than diffusion imaging. Mismatch is present in many patients beyond 12 h after stroke. Mismatch alone does not distinguish patients with good and poor prognosis; both can do well or poorly. Other factors, e.g. reperfusion, may influence outcome more strongly, even in patients without mismatch.

Comparison of 10 Different Magnetic Resonance Perfusion Imaging Processing Methods in Acute Ischemic Stroke

Background and Purpose— Several methods are available to assess the magnetic resonance perfusion lesion in acute ischemic stroke. We tested 10 of these to compare perfusion lesion sizes and to assess the relation to clinical scores and final infarct extent.

Methods— We recruited patients with acute ischemic stroke, performed diffusion- and perfusion-weighted imaging, and recorded stroke severity at baseline, final infarct size on T2-weighted imaging at ≥1 month, and Rankin Scale score at 3 months. We calculated 10 perfusion parameters (6 of mean transit time, MTT; 3 of cerebral blood flow; 1 of cerebral blood volume; 7 relative and 3 quantitative), measured the perfusion-weighted imaging lesion and diffusion/perfusion mismatch volumes, and compared each with clinical and radiologic outcomes.

Results— Among 32 patients, the median perfusion lesion volume varied from 0 to 14 882 voxels ( P <0.0001); the proportion of patients with mismatch varied from 9% to 72% ( P <0.05), depending on the perfusion parameter. Five measures of relative MTT were associated with baseline National Institutes of Health Stroke Scale score; 1 (arrival time fitted) was also associated with clinical outcome. Final infarct size was most strongly associated with MTT measures, including arrival time fitted. There was no advantage of quantitative perfusion measures and no relation between mismatch presence/absence and infarct expansion with any of the 10 perfusion measures.

Conclusions— Perfusion lesion size differs markedly depending on the parameter calculated. Relative perfusion parameters performed as well as quantitative ones. Some parameters (mainly representing MTT measures) were correlated with clinical scores; others were correlated with final infarct size; and arrival time fitted was correlated with both. These findings should be validated in other datasets. A consensus is required on which perfusion measurement and processing methods should be used.

Magnetic resonance perfusion diffusion mismatch and thrombolysis in acute ischaemic stroke: a systematic review of the evidence to date

BACKGROUND

The mismatch between perfusion and diffusion lesions on magnetic resonance perfusion-weighted imaging (PWI)/diffusion-weighted imaging (DWI) may help identify patients for thrombolysis. Evidence underlying this hypothesis was assessed.

METHODS

All papers describing magnetic resonance PWI/DWI findings in patients with acute ischaemic stroke, and their functional and/or radiological outcome at 1 month, with or without thrombolysis were systematically reviewed.

RESULTS

11 papers fulfilled the inclusion criteria. Among these, there were 5 different mismatch definitions and at least 7 different PWI methods. Only 3 papers including 61 patients with and 18 without mismatch provided data on mismatch, outcome and influence of thrombolysis. Mismatch (v no mismatch) without thrombolysis was associated with a non-significant twofold increase in the odds of infarct expansion (odds ratio (OR) 2.2, 95% confidence interval (CI) 0.34 to 14.1), which did not change with thrombolysis (OR 2.0, 95% CI 0.37 to 10.9). Half of the patients without mismatch also had infarct growth (with or without thrombolysis). No data were available on functional outcome.

CONCLUSIONS

Standardised definitions of mismatch and perfusion are needed. Infarct growth may occur even in the absence of mismatch. Currently, data available on mismatch are too limited to guide thrombolysis in routine practice. More data are needed from studies including patients with and without mismatch, and randomised treatment allocation, to determine the role of mismatch.

Impact of Stroke Syndrome and Stroke Severity on the Process of Consent in the Third International Stroke Trial

BACKGROUND

Obtaining informed consent for a patient's participation in a randomized trial of treatment for use in a medical emergency may be achieved in a variety of ways. We sought to assess the process of consent and to evaluate the influence of the patient's neurological deficit on the method used to obtain consent in the first 300 patients recruited into the Third International Stroke Trial (IST-3).

METHODS

IST-3 is the first large-scale randomized controlled trial of intravenous thrombolysis in acute ischaemic stroke. The clinician could use one of four procedures to recruit the patient: written consent, witnessed consent, assent, or a waiver of consent. The patient's neurological deficits were recorded at baseline. We analysed the relationship between the neurological deficits at baseline and the consent procedure.

RESULTS

The method of consent used was written consent in 71 subjects (24%), witnessed verbal consent in 30 subjects (10%), assent by a relative in 197 subjects (66%), and waiver of consent in 2 subjects (1%). Patients with severe neurological deficits (as measured either by their stroke syndrome or their lower predicted probability of being alive and independent at 6 months) were more likely to be recruited by assent. Patients able to give written consent had less severe strokes.

CONCLUSIONS

Patients with non-lacunar hemispheric stroke syndromes or with a more severe neurological deficit were less likely to give written consent. Excluding such patients from acute stroke treatment trials would eliminate many otherwise eligible subjects, who have a poor predicted outcome without treatment and yet might benefit from acute treatments such as thrombolysis. Flexible consent procedures developed for IST-3 have made it feasible to recruit the target population.

Variations in the provision of resuscitation equipment: survey of acute hospitals

BACKGROUND

There are wide variations in survival after cardiopulmonary resuscitation. The aim of this survey was to describe how equipment provision of resuscitation trolleys was deployed in a range of clinical ward areas.

METHODS

The equipment in randomly selected resuscitation trolleys in all 14 South West Thames Region hospitals was surveyed. The gold standard for equipment provision was referenced from the document CPR Guidance for Clinical Practice and Training in Hospital.

RESULTS

There were significant differences in the provision of circulation equipment (p = 0.004) and in the rates of drug items present (p = 0.001). There was no significant difference in provision of airways equipment (p = 0.24) or immediate access items (p = 0.55).

CONCLUSIONS

There are variations in the provision of resuscitation equipment in many clinical areas. Hospitals need to review the procedures for ensuring adequate provision of resuscitation equipment in all clinical areas.

[Cost analysis of an official campaign for animal disease control: the example of Senegal in 1996]

A realistic estimation of the cost of government campaigns to control rinderpest and contagious bovine pleuropneumonia is essential in order to determine profitable fees for private veterinarians with a health mandate in Senegal. A cost analysis of a vaccination campaign, organised by the Veterinary Services in Senegal between 1995 and 1996, involving 547,735 cattle, was conducted. Revenue and total costs were 50 CFA francs and 110 +/- 37 CFA francs per head, respectively. Staff-related costs accounted for 39.41% +/- 7.62% of the total cost. The gross and net margins corresponded to the average subsidies of 42 +/- 27 CFA francs and 60 +/- 37 CFA francs, respectively. Simulations showed better relative efficiency for private veterinarians who vaccinate at a price of between 97 and 84 CFA francs per head. Economies of scale varied from 8 to 13 CFA francs per head when the vaccination team increased the number of animals initially vaccinated (16,000 head) by 25% and 44%, respectively. This indicates that a fee of 125 CFA francs per head should guarantee the profitability of compulsory vaccination for private veterinarians.

[Intestinal parasitic infections and schistosomiasis in the valley of the Senegal river in the Islamic Republic of Mauritania]

An epidemiological survey was carried out in the Trarza and Brakna regions of the Senegal River valley in Mauritania prior to implementation of a program to control intestinal parasitic infection and schistosomiasis. A total of 1297 school children between the ages of 5 and 12 years from a randomized selection of villages in the region were examined to determine the prevalence and intensity of intestinal parasitic infections and schistosomiasis. Overall prevalence was 38.1% for intestinal parasitic infection, 7.1% for intestinal schistosomiasis, and 17.1% for urinary schistosomiasis. Analysis of weight and height as indicators of nutritional status indicated that 40.9% of the children examined were under the 10th percentile of the weight-for-height indicator and that there was a statistically significant correlation between malnutrition, diarrhea, and intestinal parasitic infection (p < 0.0001). Measurement of hemoglobin levels showed that 50.4% of children were anemic (hemoglobin level < 11 g/dl) and that there was a correlation between anemia and infection by Schistosoma haematobium. This is the first epidemiological survey on intestinal parasitic infections in Mauritania and the first study on Schistosoma mansoni on the Mauritanian side of the Senegal River. Findings suggest not only that implementation of a program to control intestinal parasitic infection and schistosomiasis is needed in the region but also that it should be associated with a food/iron supplementation program and growth monitoring.

Variant-sequence transthyretin (isoleucine 122) in late-onset cardiac amyloidosis in black Americans

BACKGROUND

After the age of 60, isolated cardiac amyloidosis is four times more common among blacks than whites in the United States; 3.9 percent of blacks are heterozygous for an amyloidogenic allele of the normal serum carrier protein transthyretin in which isoleucine is substituted for valine at position 122 (Ile 122). We hypothesized that the high prevalence of transthyretin Ile 122 is at least partially responsible for the increased frequency of senile cardiac amyloidosis among blacks.

METHODS

Paraffin blocks of cardiac tissue were obtained from an earlier study of 52,370 autopsies in Los Angeles and were examined by immunohistochemical and DNA analyses. Samples were available from 32 of 55 blacks and 20 of 78 whites over 60 years of age with isolated cardiac amyloidosis and from two control groups (228 cases).

RESULTS

Transthyretin amyloidosis was identified in 31 of the 32 cardiac-tissue samples from the black patients and in 19 of the 20 samples from the white patients. Six of the 26 analyzable DNA samples (23 percent) from the black patients and none of the 19 samples from the white patients were heterozygous for the Ile 122 variant. Four of 125 DNA samples obtained at autopsy (3.2 percent) from a second, more recent, age-matched cohort of blacks without amyloidosis at the same institution were heterozygous for the transthyretin Ile 122 allele. On reexamination the cardiac tissue from these four patients contained small amounts of amyloid not detected at the initial autopsies. All subjects with the Ile 122 variant had ventricular amyloid.

CONCLUSIONS

The assessment of elderly black patients with unexplained heart disease should include a consideration of transthyretin amyloidosis, particularly that related to the Ile 122 allele.

Revised transthyretin Ile 122 allele frequency in African-Americans

The transthyretin (TTR) Ile 122 variant is associated with cardiac amyloidosis in individuals of African descent. To determine the prevalence of the allele encoding TTR Ile 122 in African-Americans, we have used PCR and restriction analysis to test DNA from African-Americans from various geographic areas, and found an allele frequency of 66/3376 (0.020), which is higher than the value we previously reported in a much smaller pilot study. Our data indicate that this TTR variant is present at equal frequency in African-Americans throughout the U.S., and suggest that this mutation may be a common, often unrecognized cause of cardiac disease in African-Americans.

Methodological factors affecting esophageal clearance

To define some methodological factors that could affect the measurement of the esophageal clearance, we used three different protocols, on 41 healthy control subjects. In 20 subjects, we studied the influence of a naso-esophageal probe on the frequency of swallowing. We observed a significant (44 +/- 5%) decrease in the frequency of spontaneous swallows after 15 minutes, with stabilization after this 15 minute period of adaptation. In 11 subjects, we studied the influence of the pH of the esophageal content on esophageal clearance. We found an exponential relationship between the esophageal clearance (C) expressed in minutes and the initial pH of the lumen contents: C = 43.3 exp (-0.54 pH) In 10 other subjects, we studied the influence of the volume of the esophageal contents on esophageal clearance. We found no influence for volumes less than 30 ml and a significant increase of clearance for volumes greater than 30 ml. In summary, this study of the effects of methodological factors on esophageal clearance: Gives new information about the "accommodation phase" of the esophagus after distension by a naso-gastric probe; Allows us to propose a new quantitative method for evaluation of esophageal clearance Shows the small importance of the ingested volume.

Transthyretin Pro55, a variant associated with early-onset, aggressive, diffuse amyloidosis with cardiac and neurologic involvement

Mutations in the protein transthyretin cause amyloidosis involving the heart, peripheral nerves, and other organs. A family from West Virginia developed an unusually aggressive form of widespread transthyretin amyloidosis. Single-strand conformation polymorphism analysis revealed a variant in the transthyretin gene, which was found on sequencing to be a T----C transversion at position 2 of codon 55, corresponding to a Leu----Pro substitution. The variant sequence was confirmed by restriction analysis and polymerase chain reaction (PCR)-primer introduced restriction analysis.

Correlating nursing care, nursing practice, and nursing performance standards

All too often nursing standards have been viewed as a cumbersome paperwork task with little day-to-day practical relevance. Using a matrix approach that incorporates nursing role functions and the nursing process, the authors developed a model that provides the basis for job descriptions, performance appraisals, peer review, and quality management activities.