Quality of life of women with urinary incontinence: further development of the incontinence quality of life instrument (I-QOL)

OBJECTIVES

To report on the further development of the Incontinence Quality of Life Instrument (I-QOL), a self-report quality of life measure specific to urinary incontinence (UI), including its measurement model, responsiveness, and effect size.

METHODS

Incontinent female patients (141 with stress, 147 with mixed UI) completed the I-QOL and comparative measures at screening, pretreatment, and four subsequent follow-up visits during participation in a multicenter, double-blind, placebo-controlled, randomized trial assessing the efficacy of duloxetine. Psychometric testing followed standardized procedures.

RESULTS

Factor analysis confirmed an overall score and three subscale scores (avoidance and limiting behaviors, psychosocial impacts, and social embarrassment). All scores were internally consistent (alpha = 0.87 to 0.93) and reproducible (ICC = 0.87 to 0.91). The pattern of previously reported correlations with the Short-Form 36-item Health Survey and Psychological Well-Being Schedule were confirmed. Responsiveness statistics using changes in the independent measures of stress test pad weight, number of incontinent episodes, and patient global impression of improvement ranged from 0.4 to 0.8. Minimally important changes ranged from 2% to 5% in association with these measures and effect sizes.

CONCLUSIONS

In a clinical trial, the I-QOL proved to be valid, reproducible, and responsive to treatment for UI in women.

Quality of life of persons with urinary incontinence: development of a new measure

OBJECTIVES

Our objective was to develop a self-report quality of life measure specific to urinary incontinence (I-QOL) that could be used as an outcome measure in clinical trials and in patient care centers.

METHODS

The I-QOL was developed from interviews of 20 individuals with urinary incontinence. Refining the questionnaire was accomplished by structured interviews of 17 individuals with urinary incontinence. Testing the I-QOL's psychometric properties involved two administrations (n = 62) along with measures of psychologic well-being and functional status.

RESULTS

The rigorous development process ensured that the measure was complete and understandable. The I-QOL proved to be internally consistent (alpha 0.95) and highly reproducible (r = 0.93; 18 days; SD 4). For discriminant validity, severity of incontinence (P < 0.0001) and number of medical appointments in the past year to treat incontinence (P < 0.0001) significantly predicted I-QOL scores. Convergent validity analyses confirmed our predictions that the I-QOL scores were more closely related to overall well-being than bodily pain.

CONCLUSIONS

The I-QOL proved to be valid and reproducible as a self-administered measure for assessing quality of life of patients with urinary incontinence.

Isolation of Escherichia coli serotype O157:H7 and other Shiga-like-toxin-producing E. coli from dairy cattle

We examined 1,266 fecal specimens from healthy cattle during the investigations of two sporadic cases of hemolytic uremic syndrome associated with raw milk consumption and an outbreak of gastroenteritis and hemolytic uremic syndrome caused by Escherichia coli serotype O157:H7. We collected specimens from heifers, calves, and adult cows on 22 farms, in a stockyard, and in a packing house. We also collected 3 raw hamburger specimens from a restaurant and 23 raw milk samples from two farms. All specimens were examined for E. coli O157:H7 by using sorbitol-MacConkey agar, H immobilization, O157 agglutination, and tissue culture cytotoxicity. E. coli O157:H7 was isolated from 16 heifers or calves and 1 adult cow on 22 farms, 1 stockyard calf, 2 beef specimens, and 1 raw milk sample. Selected fecal specimens were also examined for the presence of other Shiga-like-toxin-producing E. coli (SLTEC) by testing polymyxin B extracts of colony sweeps and then testing individual colonies for toxin production. SLTEC other than O157 was isolated from 8 of 10 farms investigated and from the stockyard; 8% of adult cows and 19% of heifers and calves were positive for SLTEC. Several animals were positive for SLTEC by colony sweep only. This investigation demonstrates that dairy cattle are a reservoir of E. coli O157:H7 and other SLTEC.

Clinical virology of Ebola hemorrhagic fever (EHF): virus, virus antigen, and IgG and IgM antibody findings among EHF patients in Kikwit, Democratic Republic of the Congo, 1995

Ebola hemorrhagic fever (EHF) patients treated at Kikwit General Hospital during the 1995 outbreak were tested for viral antigen, IgG and IgM antibody, and infectious virus. Viral antigen could be detected in virtually all patients during the acute phase of illness, while antibody was not always detectable before death. Virus was also isolated from patients during the course of their febrile illness, but attempts to quantify virus in Vero E6 cells by standard plaque assay were often unsuccessful. IgG and IgM antibody appeared at approximately the same time after disease onset (8-10 days), but IgM persisted for a much shorter period among the surviving convalescent patients. IgG antibody was detectable in surviving patients through about 2 years after onset, the latest time that samples were obtained. Detection of Ebola virus antigens or virus isolation appears to be the most reliable means of diagnosis for patients with suspected acute EHF, since patients with this often-fatal disease (80% mortality) may not develop detectable antibodies before death.

Effects of body fat distribution on regional lipolysis in obesity

To determine the contribution of the major body fat depots to systemic free fatty acid (FFA) availability, palmitate ([1-14C]-palmitate) release was measured from leg (lower body) and non-leg (upper body) fat in eight upper body obese (UB Ob), six lower body obese (LB Ob), and six nonobese (Non Ob) age-matched premenopausal women in the overnight postabsorptive state. Splanchnic palmitate release was determined in 16 of these subjects.

RESULTS

total palmitate release was greater in UB Ob (P less than 0.005) than LB Ob or Non Ob women (161 +/- 16 vs. 111 +/- 9 vs. 92 +/- 9 mumol/min, respectively). Despite increased leg fat mass in obese women, leg palmitate release was similar in each group. Therefore, leg fat palmitate release was greater in Non Ob women than LB Ob (P less than 0.01) or UB Ob (P = 0.06) women (3.7 +/- 0.3 vs. 2.4 +/- 0.2 vs. 2.7 +/- 0.2 mumol.kg fat-1.min-1, respectively). Upper body fat palmitate release was less (P less than 0.01) in LB Ob than Non Ob or UB Ob women (3.0 +/- 0.4 vs. 5.0 +/- 0.3 vs. 4.9 +/- 0.4 mumol.kg fat-1.min-1, respectively). Splanchnic palmitate release accounted for 20-32% of upper body fat palmitate release in each group (P = NS between groups). Leg fat palmitate release was significantly less than upper body fat palmitate release. We conclude that the major difference in resting FFA metabolism between UB Ob and LB Ob women is the ability of the later to down-regulate upper body fat lipolysis to maintain normal FFA availability.

Longitudinal investigation of depression outcomes in primary care in six countries: the LIDO study. Functional status, health service use and treatment of people with depressive symptoms

BACKGROUND

Screening surveys of depressive symptoms were conducted among primary care patients at six sites in different countries. The LIDO Study was designed to assess quality of life and economic correlates of depression and its treatment in culturally diverse primary health care settings. This paper describes: (1) the association between depressive symptoms and functional status, global health-related quality of life (QoL), and use of general health services across different cultural settings; and (2) among subjects with depressive symptoms, the factors associated with recent treatment for depression.

METHODS

Subjects aged 18 to 75 were recruited from participating primary care facilities in Be'er Sheva (Israel), Porto Alegre (Brazil), Melbourne (Australia), Barcelona (Spain), St Petersburg (Russian Federation) and Seattle (USA). Depressive symptoms were measured using the CES-D. Also administered were the SF-12, global questions on QoL, selected demographic and social measures, and questions on recent treatment for depression, use of health care services, and lost workdays.

RESULTS

A total of 18,489 patients were screened, of whom 37% overall (range 24-55%) scored > or = 16 on the CES-D and 28% (range 17-42%) scored > or = 20. Overall, 13% reported current treatment for depression (range 4 to 23%). Patients with higher depressive symptom scores had worse health, functional status, QoL, and greater use of health services across all sites. Among those with a CES-D score > or = 16, subjects reporting treatment for depression were more likely than those reporting no treatment to be dissatisfied with their health (except in St Petersburg), and to have higher depressive symptom scores.

CONCLUSIONS

Higher depressive symptom scores in primary care patients were consistently associated with poorer health, functional status and QoL, and increased health care use, but not with demographic variables. The likelihood of treatment for depression was associated with perceptions of health, as well as severity of the depression.

T cell-derived interferon-γ programs stem cell death in immune-mediated intestinal damage

Despite the importance of intestinal stem cells (ISCs) for epithelial maintenance, there is limited understanding of how immune-mediated damage affects ISCs and their niche. We found that stem cell compartment injury is a shared feature of both alloreactive and autoreactive intestinal immunopathology, reducing ISCs and impairing their recovery in T cell-mediated injury models. Although imaging revealed few T cells near the stem cell compartment in healthy mice, donor T cells infiltrating the intestinal mucosa after allogeneic bone marrow transplantation (BMT) primarily localized to the crypt region lamina propria. Further modeling with ex vivo epithelial cultures indicated ISC depletion and impaired human as well as murine organoid survival upon coculture with activated T cells, and screening of effector pathways identified interferon-γ (IFNγ) as a principal mediator of ISC compartment damage. IFNγ induced JAK1- and STAT1-dependent toxicity, initiating a proapoptotic gene expression program and stem cell death. BMT with IFNγ-deficient donor T cells, with recipients lacking the IFNγ receptor (IFNγR) specifically in the intestinal epithelium, and with pharmacologic inhibition of JAK signaling all resulted in protection of the stem cell compartment. In addition, epithelial cultures with Paneth cell-deficient organoids, IFNγR-deficient Paneth cells, IFNγR-deficient ISCs, and purified stem cell colonies all indicated direct targeting of the ISCs that was not dependent on injury to the Paneth cell niche. Dysregulated T cell activation and IFNγ production are thus potent mediators of ISC injury, and blockade of JAK/STAT signaling within target tissue stem cells can prevent this T cell-mediated pathology.

Quality of life and Parkinson's disease: translation and validation of the US Parkinson's Disease Questionnaire (PDQ-39)

Parkinson's disease is a common progressive neurodegenerative disorder affecting an estimated 4 million people worldwide. A number of general health status measures exist but few fully capture the subjective evaluation of life quality associated with Parkinson's disease. We report here the results of: (1) translating the British PDQ-39 into a US version, (2) validity and reliability of the new US PDQ-39 questionnaire, and (3) parallel validation analyses following the method published in the development of the British version of the PDQ-39. Data were collected by postal survey on 150 patients recruited from neurology clinics in the Seattle area. A short, generic health status measure (SF-36) was used to test convergent validity, and a three-day test-retest assessed the reliability of the PDQ-39. The US version of the PDQ-39 demonstrated acceptable internal consistency (alpha = 0.51 to 0.96) and proved to be reproducible (0.86 to 0.96). Subscales of the PDQ-39 showed convergence with like scales of the SF-36 and was able to discriminate between levels of symptom severity.

Participation of older adults in health programs and research: a critical review of the literature

This collection of five papers evaluates the participation of older adults in clinical trials, health promotion/disease prevention initiatives, and health programs designed to maintain or improve the functioning of chronically ill older adults. Understanding the willingness or unwillingness of older adults to participate in these programs is critical to the development and implementation of health programs and policies for this population. In this introductory paper we briefly review illustrative literature to provide both an overview of the participation of older adults in health programs as well as background information relevant to the symposium papers.

Treatment of type II endoleaks with Onyx

Endoleaks are defined as persistent perfusion of an abdominal aortic aneurysm (AAA) after endovascular stent-graft deployment. The authors describe their experience treating six endoleaks with the liquid embolic agent Onyx (ethylene-vinyl-alcohol copolymer). Complete endoleak occlusion was achieved in five of six cases. Follow-up imaging has demonstrated decreased aneurysm diameter in all patients 7-29 weeks (mean = 19.2 weeks) after treatment.

Isolation of black creek canal virus, a new hantavirus from Sigmodon hispidus in Florida

Numerous rodents were trapped for serologic and virologic studies following the identification of a hantavirus pulmonary syndrome (HPS) case in Dade County, Florida. Cotton rats (Sigmodon hispidus) were the most frequently capture rodent and displayed the highest seroprevalence to a variety of hantavirus antigens. Hantavirus genome RNA was detected in all the seropositive cotton rats tested, using a reverse transcriptase-polymerase chain reaction (RT-PCR) assay. A virus was isolated from tissues of two seropositive cotton rats by cultivation of lung and spleen homogenates on Vero E6 cells. Nucleotide sequence information obtained by direct RT-PCR and the serologic relationships of this virus with the other hantaviruses indicate that this virus, Black Creek Canal virus, represents a new hantavirus distinct from the previously known serotypes.

Recommendations for enhancing psychosocial support of NICU parents through staff education and support

Providing psychosocial support to parents whose infants are hospitalized in the neonatal intensive care unit (NICU) can improve parents' functioning as well as their relationships with their babies. Yet, few NICUs offer staff education that teaches optimal methods of communication with parents in distress. Limited staff education in how to best provide psychosocial support to families is one factor that may render those who work in the NICU at risk for burnout, compassion fatigue and secondary traumatic stress syndrome. Staff who develop burnout may have further reduced ability to provide effective support to parents and babies. Recommendations for providing NICU staff with education and support are discussed. The goal is to deliver care that exemplifies the belief that providing psychosocial care and support to the family is equal in importance to providing medical care and developmental support to the baby.

Persistent activation of mitogen-activated protein kinases p42 and p44 and ets-2 phosphorylation in response to colony-stimulating factor 1/c-fms signaling

An antibody that specifically recognized phosphothreonine 72 in ets-2 was used to determine the phosphorylation status of endogenous ets-2 in response to colony-stimulating factor 1 (CSF-1)/c-fms signaling. Phosphorylation of ets-2 was detected in primary macrophages, cells that normally express c-fms, and in fibroblasts engineered to express human c-fms. In the former cells, ets-2 was a CSF-1 immediate-early response gene, and phosphorylated ets-2 was detected after 2 to 4 h, coincident with expression of ets-2 protein. In fibroblasts, ets-2 was constitutively expressed and rapidly became phosphorylated in response to CSF-1. In both cell systems, ets-2 phosphorylation was persistent, with maximal phosphorylation detected 8 to 24 h after CSF-1 stimulation, and was correlated with activation of the CSF-1 target urokinase plasminogen activator (uPA) gene. Kinase assays that used recombinant ets-2 protein as a substrate demonstrated that mitogen-activated protein (MAP) kinases p42 and p44 were constitutively activated in both cell types in response to CSF-1. Immune depletion experiments and the use of the MAP kinase kinase inhibitor PD98059 indicate that these two MAP kinases are the major ets-2 kinases activated in response to CSF-1/c-fms signaling. In the macrophage cell line RAW264, conditional expression of raf kinase induced ets-2 expression and phosphorylation, as well as uPA mRNA expression. Transient assays mapped ets/AP-1 response elements as critical for basal and CSF-1-stimulated uPA reporter gene activity. These results indicate that persistent activation of the raf/MAP kinase pathway by CSF-1 is necessary for both ets-2 expression and posttranslational activation in macrophages.

Expired nitric oxide and airway obstruction in asthma patients with an acute exacerbation

Expired nitric oxide (eNO) is a marker of airway inflammation that is increased in asthma. The present study was undertaken to examine the clinical utility of eNO as an aid in the assessment of asthma in the emergency department (ED). Fifty-two adult patients with acute asthma, 53 age- and sex-matched controls, and eight patients with stable asthma were enrolled. Subjects performed spirometry, their eosinophil counts and serum total IgE were measured, and a sample of mixed VC expirate was collected for measurement of NO. Mixed expired NO was 8.2 +/- 0.5 ppb in controls, 8.8 +/- 1.5 ppb in patients with stable asthma, and 15.0 +/- 1.0 ppb in patients with acute asthma. A significant difference in eNO was observed in patients with acute asthma and controls (p < 0.001). Twenty-three of the 52 patients with acute asthma versus two of 53 controls had an eNO >/= 15 ppb (p < 0.001). Expired NO concentration correlated with FEV1% (r = -0.42, p < 0.001) and with the peripheral blood eosinophil count (r = 0.34, p < 0.001) in the group of 60 patients with acute and stable asthma. The sensitivity of eNO > 10 ppb and eosinophilia (> 200 cells/microliter) was 90% in predicting airway obstruction (FEV1/FVC < 0. 8). No relationship of eNO was found to serum IgE, self- reported smoking, or glucocorticoid use. Measurement of eNO is a promising clinical tool for assessing acute asthma.

Cultural adaptation of a quality-of-life measure for urinary incontinence

OBJECTIVES

To translate and validate a urinary incontinence-specific measure of quality of life (I-QOL) in French, Spanish, Swedish, and German and provide translations only into seven other languages and variants of these languages.

METHODS

Quality of life and linguistic experts prepared two forward translations from American English to their native languages and helped to harmonize these translations at a meeting. In the four European countries, the adapted versions of the I-QOL were administered to 259 women with stress, urge, and mixed incontinence. Principal component analyses were used to confirm the proposed measurement model suggested by patient interviews. Psychometric testing was conducted using standardized procedures.

RESULTS

Translation procedures resulted in a change in the original instrument's Likert response scale from 4 to 5 points. Principal component analyses confirmed three patient-derived subscales and higher-order factor analysis confirmed a total summary score. In all countries, the internal consistency (alpha) and reproducibility (ICC) were high (alpha ranged between 0.87 and 0.93); (ICC ranged between 0.92 and 0.95). In all countries, I-QOL scores were significantly worse (p < 0.001) as perceived severity of incontinence, use of services, and number of incontinent episodes increased.

CONCLUSIONS

The I-QOL has been adapted successfully into eleven languages and six variants of these languages. The cross-sectional psychometric properties of the US version were confirmed in four European countries. The I-QOL fills the need for a valid, international quality-of-life instrument for incorporation in clinical trials covering patients with varying types and severity of urinary incontinence.

Electronic versus paper questionnaires: a further comparison in persons with asthma

The use of electronic data capture (EDC) to assess health-related quality of life (HRQOL) using validated questionnaires is increasing; however, it must be determined how data collected electronically correlate with the original mode of administration used in validation. Our objective was to compare paper and electronic administration of the standardized Asthma Quality of Life Questionnaire (AQLQ(S)), Pediatric Asthma Quality of Life Questionnaire (PAQLQ(S)), and Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ). Using a crossover design, adults and children with asthma and caregivers of children with asthma were recruited from clinics. Subjects were asked to complete both forms of the appropriate HRQOL measures at enrollment and 24-48 hours later. In addition, 30 subjects from each group were asked to participate in a 1-week reproducibility assessment of the electronic versions of the three questionnaires. Psychometric properties were assessed for each of the EDC versions. Intraclass correlation coefficients (ICC) and Pearson correlations were calculated to compare EDC and paper versions. A total of 51 adults (mean age 37, 73% females), 52 children (mean age 13, 38% females), and 51 caregivers (mean age 43, 92% females) were evaluated. Internal consistency (Cronbach's alpha) for the overall score of each questionnaire was: 0.96 for the AQLQ(S) and the PAQLQ(S), and 0.92 for the PACQLQ. Overall ICCs comparing paper with EDC were: 0.96 for the AQLQ(S), 0.91 for the PAQLQ(S), and 0.82 for the PACQLQ. Pearson's correlations were identical. One-week reproducibility (ICC) of the EDC versions was: 0.88 for the AQLQ(S), 0.78 for the PAQLQ(S), and 0.85 for the PACQLQ. When asked which method subjects preferred, the electronic version was chosen by 69% of adults, 77% of children, and 73% of caregivers. Additionally, 14% of adults, 14% of children, and 18% of caregivers reported no difference in preference. As in previous studies comparing electronic with paper questionnaires, this study revealed statistical evidence to support the use of EDC of the AQLQ(S), PAQLQ(S), and PACQLQ for populations with asthma.

Cause of ST segment abnormality in ED chest pain patients

The objective of this study was to determine the electrocardiographic diagnoses of chest pain patients with ST segment elevation (STE) on the 12-lead electrocardiogram (ECG). This study was a retrospective ECG review of adult chest pain patients in a university hospital emergency department (ED) over a 3-month period (January 1, 1996 to March 31, 1996). STE was determined if the ST segment was elevated >/=1 mm in the limb leads and >/=2 mm in the precordial leads in at least two anatomically contiguous leads. Results showed 902 patients who met entry criteria and of whom 202 (22.4%) had STE. Thirty-one (15%) patients had STE acute myocardial infarction (AMI) as the final hospital diagnosis which caused the STE; 171 (85%) patients with STE had non-AMI diagnosis responsible for the ST segment elevation, including left ventricular hypertrophy (LVH) 51 (25%), left bundle branch block (LBBB) 31 (15%), benign early repolarization (BER) 25 (12%), right bundle branch block 10 (5%), nonspecific bundle branch block 10 (5%), left ventricular aneurysm 5 (3%), acute pericarditis 2 (1%), ventricular paced rhythm 2 (1%), and undefined ST segment elevation 35 (17%). Forty-four patients had AMI as the final diagnosis of whom 31 showed STE on presentation to the ED. In 2 of 31 (6%) cases of STE AMI, the ST segment waveform was atypical for acute infarction. We concluded that AMI is not the most common cause of STE in ED chest pain patients. LVH is most often responsible for electrocardiographic STE followed by AMI and LBBB which occur at equal frequencies.

Excess second virial coefficients for some dilute binary gas mixtures

Excess and interaction second virial coefficients have been measured in the temperature range 290-320 K for 20 binary gaseous systems. Several of these systems have previously been studied by Brewer. The present values are in excellent agreement with his results. The excess virial coefficients have been used to calculate excess molar enthalpies of mixing at 300 K.

Descriptive epidemiology of small intestinal atresia, Atlanta, Georgia

To describe the epidemiology of small intestinal atresia (SIA) in Atlanta, Georgia, from 1968 through 1989, we used the Metropolitan Atlanta Congenital Defects Program, an active, population-based surveillance system for birth defects diagnosed during the first year of life. We identified 176 infants with SIA, a prevalence of 2.8 per 10,000 livebirths. Among black infants, the prevalence was 3.7 per 10,000 livebirths, significantly higher than the prevalence of 2.4 per 10,000 among white infants [relative risk (RR) = 1.6, 95% confidence interval (CI) = 1.1,2.1]. Nine infants were each one member of a unique pair of twins. The prevalence among twin infants was 7.3 per 10,000, significantly higher than the prevalence of 2.8 per 10,000 among singletons (RR = 2.7, 95% CI = 1.4,5.2). Forty-nine percent of the infants had duodenal atresia, 36% had jejunal atresia, and 14% had ileal atresia. Two infants (1%) had atresia at an unspecified site in the small intestine. We grouped the infants by anatomic location of SIA into four categories: isolated SIA (53%), SIA with multiple unrelated defects (21%), sequences (16%), and syndromes (10%). We then compared the isolated and multiple unrelated defects groups by gender, race, maternal age, birth weight and one-year mortality for each location of SIA. Among black infants the prevalence of isolated jejunal atresia was 1.4 per 10,000, significantly higher than the prevalence of 0.2 per 10,000 among white infants (RR = 6.3, 95% CI = 2.9, 13.5). The increased prevalence of these defects among twins was a particularly interesting finding.

Determination of site-specific carbon isotope ratios at natural abundance by carbon-13 nuclear magnetic resonance spectroscopy

Site-specific natural isotope fractionation of hydrogen studied by deuterium NMR (SNIF-NMR) spectroscopy is a powerful source of information on hydrogen pathways occurring in biosyntheses in natural conditions. The potential of the carbon counterpart of this method has been investigated and compared. Three typical molecular species, ethanol, acetic acid, and vanillin, have been considered. Taking into account the requirements of quantitative 13C NMR, appropriate experimental procedures have been defined and the repeatability and reproducibility of the isotope ratio determinations have been checked in different conditions. It is shown that the carbon version of the SNIF-NMR method is capable of detecting small differences in the carbon-13 content of the ethyl fragment of ethanols from different botanical or synthetic origins. These results are in agreement with mass spectrometry determinations of the overall carbon isotope ratios. Deviations with respect to a statistical distribution of 13C have been detected in the case of acetic acid and vanillin. However, since the method is very sensitive to several kinds of systematic error, only a relative significance can be attached at present to the internal parameters directly accessible. Isotope dilution experiments have also been carried out in order to check the consistency of the results. In the present state of experimental accuracy, the 13C NMR method is of more limited potential than 2H SNIF-NMR spectroscopy. However it may provide complementary information. Moreover it is particularly efficient for detecting and quantifying adulterations that aim to mimic the overall carbon-13 content of a natural compound by adding a selectivity enriched species to a less expensive substrate from a different origin.

The anticonvulsant valproate teratogen restricts the glial cell cycle at a defined point in the mid-G1 phase

Direct cell counting and extent of [3H]thymidine incorporation demonstrated valproate to inhibit C6 glioma proliferation rate in a dose-dependent manner with a 1 mM concentration achieving 50% inhibition. The antiproliferative effect was reversible and could not be attributed to cytotoxicity at the valproate concentrations employed. The site of valproate action within the cell cycle was determined to be in the G1 phase, at a point 6-6.5 h prior to S phase, by estimating the time to increased [3H]thymidine incorporation following release from a 70% proliferative arrest. Synchronised cells obtained by a mitotic selection procedure required 11-12 h to enter S phase and demonstrated the valproate restriction point to be 5 h into the G1 phase of the C6 cell cycle. Exposure of valproate to the part of the G1 period which follows the restriction point was without effect on cell entry into S phase.

Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues

The Wolff-Parkinson-White syndrome (WPW), estimated to occur in approximately 0.1% to 3% of the general population, is a form of ventricular preexcitation involving an accessory conduction pathway. The definition of WPW relies on the following electrocardiographic features: (1) a PR interval less than 0.12 seconds (2) with a slurring of the initial segment of the QRS complex, known as a delta wave, (3) a QRS complex widening with a total duration greater than 0.12 seconds, and (4) secondary repolarization changes reflected in ST segment-T wave changes that are generally directed opposite (discordant) to the major delta wave and QRS complex changes. The accessory pathway bypasses the atrioventricular (AV) node, creating a direct electrical connection between the atria and ventricles. The majority of patients with preexcitation syndromes remain asymptomatic throughout their lives. When symptoms do occur they are usually secondary to tachyarrhythmias; the importance of recognizing this syndrome is that these patients may be at risk to develop a variety of supraventricular tachyarrhythmias which cause disabling symptoms and, in the extreme, sudden cardiac death. The tachyarrhythmias encountered in the WPW patient include paroxysmal supraventricular tachycardia (both the narrow QRS and wide QRS complex varieties), atrial fibrillation, atrial flutter, and ventricular fibrillation. Diagnostic and urgent, initial therapeutic issues based on initial electrocardiographic information are presented via 5 illustrative cases.

Factors influencing movement of chronic psychiatric patients from the orientation to the working phase of the nurse-client relationship on an inpatient unit

PROBLEM

To identify factors influencing movement of nurse-patient dyads from Peplau's orientation phase to the working phase of the nurse-client relationship in a tertiary care psychiatric setting.

METHODS

Ten nurse-client dyads were interviewed after the initial nurse-client assignment until a consensus was reached between client, nurse, and investigator/CNS that the relationship was in the working phase.

FINDINGS

Factors causing the relationship to progress, from the clients' perspective, were the perceived attitude of the nurse, the nature of the planned therapeutic sessions, and what happened between therapeutic sessions. Factors hindering the development of the relationship included a nurse's or client's unavailability, a sense of distance/inequity, differences in realities/values, and mutual withdrawal. The relationship was perceived as supportive and "powerful" when it progressed to the working phase, but as very negative and like "limbo" if instead it moved to a phase of mutual withdrawal.

CONCLUSIONS

Nurses can help clients move from the orientation phase to the working phase by remaining available, consistent, and acting in a way that promotes trust. When the relationship does not progress to the working phase within 6 months, a therapeutic transfer should be considered.