Concept Inventing: A Humanbecoming Perspective on Feeling Ashamed

The author in this manuscript presents a humanbecoming concept inventing of feeling ashamed. It includes a literature review across several disciplines, an exploration of various art forms, discussions with others, and thoughtful contemplation that brings together a creative synthetic definition of feeling ashamed.

An audit of the impact of implementation of a stroke care pathway in an acute teaching hospital

BACKGROUND

In 2002, a survey of stroke management was conducted in our institution benchmarked against the UK National Stroke Audit 2002. The conclusion was that management of stroke patients lacked organised and specialised care. The introduction of a stroke care pathway was recommended.

AIMS

This audit assessed the clinical impact of implementation of a stroke care pathway by the general medical teams in an acute teaching hospital.

METHODS

A random sample of 48/131 patients were surveyed in 2002 compared to 55 consecutive patients admitted with stroke in 2005.

RESULTS

Despite introduction of a stroke care pathway, marked deficits persisted in acute management including delays in brain imaging and aspirin administration, assessment of acute parameters and interdisciplinary care.

CONCLUSIONS

Optimal care of stroke patients cannot be achieved by introducing a stroke care pathway alone. We recommend the urgent establishment of a stroke unit with a specialist consultant-led multidisciplinary stroke team.

A pilot study to investigate the effect of lumbar stabilisation exercise training on functional ability and quality of life in patients with chronic low back pain

In recent times lumbar stabilisation programmes, targeting the local stabilisers in the lumbar region, have increased in popularity in the treatment of chronic low back pain (CLBP) yet their effectiveness in enhancing quality of life remains unclear. The objective of this pilot study was to examine the effectiveness of a programme of lumbar stabilisation exercises in improving quality of life and functional outcomes in patients with CLBP. Forty-one patients with CLBP who volunteered to take part in the study were randomly assigned to a treatment group (n=20) or a control group (n=21). The treatment group underwent a 10-week lumbar stabilisation programme whilst the control group received no intervention. The Roland Disability Questionnaire, Oswestry Disability Questionnaire and the SF-36 survey were administered to subjects in both groups at baseline and follow-up. Significant improvements were seen in all measures in the treatment group whereas control subjects demonstrated either no change or a significant worsening (P<0.05). These results suggest that a programme of lumbar stabilisation is effective in improving quality of life and functional outcome in patients with CLBP.

Utility of antibody in identifying individuals who have or will develop anhydride-induced respiratory disease

OBJECTIVE

To define the utility of serum antibody against trimellitic anhydride (TMA) in predicting which individuals employed, at Amoco Corporation, in the manufacture of TMA have or will develop immunologically mediated respiratory disease, such as asthma, due to exposure to TMA.

METHODS

In 1990 we initiated a clinical and immunologic cross-sectional study of 181 subjects exposed to TMA for at least 1 year who had not been diagnosed with an immunologic respiratory disease. We then clinically and immunologically followed 119 of these subjects for the next 5 years to determine whether they would develop an immunologic respiratory disease due to TMA exposure.

RESULTS

Of the 16 individuals with IgE against TMA conjugated to human serum albumin (TM-HSA) in 1990, 3 had immediate asthma and another 6 developed asthma during the 5-year follow-up. Of the 165 individuals without IgE against TM-HSA, none had immediate asthma in 1990 and only 1 of 102 individuals followed for 5 years developed asthma. Of the 44 subjects with IgG against TM-HSA, 6 had an immunologic respiratory disease in 1990 and 2 more developed it in the ensuing 5 years. Of the 137 subjects without IgG against TM-HSA, none had an immunologic respiratory disease in 1990 and none of the 80 subjects followed for 5 years developed it.

CONCLUSIONS

Development of antibody against TM-HSA, both IgE and IgG, is predictive of subjects who have or will develop immunologically mediated respiratory disease due to TMA exposure. The absence of antibody is a potent negative predictor.

Cervical antibody responses to a herpes simplex virus type 2 glycoprotein subunit vaccine

Effective vaccines against genital herpes simplex virus type 2 (HSV-2) may need to induce genital tract immune responses. To determine local antibody responses to HSV-2 glycoproteins gB2 and gD2 in an intramuscular subunit vaccine, cervical secretions from HSV-seronegative women and HSV-1-seropositive women were tested for IgG and IgA to gB2 and gD2 by enhanced chemiluminescence Western blot. Most (94%) of the seronegative subjects developed cervical IgG to gB2, IgG to gD2, and IgA to gB2; 72% developed IgA to gD2. All HSV-1-seropositive subjects had cervical IgG responses to vaccine gB2 and gD2, 85% had IgA responses to gB2, and 50% had IgA responses to gD2. Responses were more rapid and titers more consistently sustained in the HSV-1-seropositive women. Further, vaccination resulted in cervical IgG and IgA titers comparable to those to HSV-2 gB2 and gD2 in response to recurrent HSV-2 genital infection.

Frequent recovery of HIV-1 from genital herpes simplex virus lesions in HIV-1-infected men

CONTEXT

Genital ulcer disease has been epidemiologically linked as a risk factor in the transmission of the human immunodeficiency virus 1 (HIV-1). While herpes simplex virus 2 (HSV-2) is the most common cause of genital ulcers, no study has systematically evaluated the frequency or titer of HIV-1 virus in HSV-2 lesions.

OBJECTIVE

To compare lesional HIV-1 RNA levels during and after genital HSV-2 reactivation and to evaluate the frequency, titer, and duration of HIV-1 RNA shedding in lesions due to HSV-2.

DESIGN

Convenience sample.

SETTING

Sexually transmitted disease research clinic at the University of Washington, Seattle.

PATIENTS

Twelve HIV-infected men with a history of symptomatic HSV-2 infection who underwent daily sampling of genital lesions for HIV-1 RNA by polymerase chain reaction assay and HSV-2 by culture.

MAIN OUTCOME MEASURE

Detection of lesional HIV RNA and HSV-2.

RESULTS

HIV-1 RNA was detected from lesional swabs in 25 of 26 consecutively studied HSV-2 episodes and on 67% of days in which genital lesions were noted. The HIV-1 RNA titers in lesional swabs exceeded 10000 copies/mL of swab sample in 75% of samples (range, 2.2-3.2 x 10(5) copies/mL of swab sample). HIV-1 RNA in genital lesion swabs was seen in persons with high and low titers of plasma HIV-1 RNA and was not associated with plasma HIV-1 RNA levels.

CONCLUSIONS

HIV-1 virions can consistently be detected in genital ulcers caused by HSV-2, which suggests that genital herpes infection likely increases the efficiency of the sexual transmission of HIV-1.

Famciclovir for the suppression of symptomatic and asymptomatic herpes simplex virus reactivation in HIV-infected persons. A double-blind, placebo-controlled trial

BACKGROUND

Herpes simplex virus (HSV) infection is one of the most common opportunistic infections in HIV-infected persons. However, most documentation of the effectiveness of antiviral therapy in reducing HSV reactivation is anecdotal.

OBJECTIVE

To evaluate the quantitative effect of antiviral therapy on the frequency of HSV reactivation in HIV-infected persons.

DESIGN

Double-blind, placebo-controlled, crossover trial.

SETTING

Research clinic at a university hospital.

PATIENTS

48 persons (45 men and 3 women) who were HIV positive and HSV seropositive.

INTERVENTION

Patients were randomly assigned to receive famciclovir, 500 mg orally twice daily, or placebo for 8 weeks. They then crossed over to receive the other regimen after a 1-week washout period.

MEASUREMENTS

Patients obtained daily cultures of their perirectal, urethral, oral, and genital areas and kept dairy records of signs and symptoms of genital and oral-labial herpes.

RESULTS

The median CD4 cell count at study entry was 384 cells/mm3. In the intention-to-treat analysis of the first study period, HSV was isolated on 122 of 1114 (11%) placebo days compared with 9 of 1071 (1%) famciclovir days (relative risk, 0.15; P < 0.001). For patients who completed the crossover, the median difference in days with symptoms between placebo and famciclovir was 13.8% of days and the median difference in days on which HSV was isolated was 5.4% of days (P < 0.001 for both). Percentage of days with HSV-2 shedding was reduced from 9.7% to 1.3%. Breakthrough reactivations that occurred while patients were receiving famciclovir were infrequent, short, and often asymptomatic, HSV-2 isolates from these reactivations were susceptible to penciclovir in vitro.

CONCLUSIONS

Antiviral chemotherapy with famciclovir results in clinically and statistically significant reductions in the symptoms associated with HSV infection and the symptomatic and asymptomatic shedding of HSV among HIV-positive persons.

DNA sequence analysis of exons 2 through 11 and immunohistochemical staining are required to detect all known p53 alterations in human malignancies

p53 mutations are the most common genetic alterations found in human malignancies. However current estimates of p53 alterations in cancers may be inaccurate because there is evidence that current approaches do not detect all p53 alterations. In this study we determine the status of the p53 gene by complete DNA sequencing of exons 2 through 11 as well as immunohistochemical staining in cohorts of primary human breast, ovarian and non small cell lung cancer. Overall, 24 of 93 (26%) breast cancers, 62 of 108 (57%) ovarian cancers and 88 of 154 (57%) non small cell lung cancers contained DNA sequence mutations, whereas positive immunohistochemical staining was detected in 15 of 64 (23%) breast, 35 of 94 (37%) ovarian, and 63 of 137 (46%) lung cancers. Of those tumors that contained mutations, the mutation occurred outside the 'hot-spot' region in 19% of breast, 18% of ovarian and 17% of lung tumors, indicating that a substantial number of mutations remain undetected in studies that are restricted to exons 5 through 9. We observed a high concordance between the presence of p53 missense mutations and positive immunohistochemical staining, but a poor concordance between other types of mutations and staining in all three types of malignancies. We conclude that a combination of DNA sequence analysis of exons 2 through 11 and immunohistochemical staining are required to detect all known alterations in the p53 gene in human malignancies.

A clinical and immunologic study of employees in a facility manufacturing trimellitic anhydride

We conducted a 1-year cross-sectional survey of 474 employees of a large chemical manufacturing complex to relate trimellitic anhydride (TMA) exposure to serologic and clinical outcomes. In 1988-1989, employees were evaluated by history and immunologic assay of total (T) and IgE antibody to trimellityl human serum albumin (TM-HSA). All employees were assigned to a TMA exposure class, from 1 (highest) to 5 (lowest), by an industrial hygienist, independent of the clinical and immunological data. Thirty-two (6.8%) of 474 employees had a TMA immunologic syndrome, 31.6% with an irritant response and 61.6% with no symptoms. Twelve had asthma/rhinitis, 10 had the late respiratory systemic syndrome (LRSS), four had late onset asthma, one had late onset arthralgia, and five had a distant history of LRSS. Included in this survey of the entire work force were 321 new enrollees, who had not joined the previous (1976 to 1988) voluntary surveillance program. Only four (1.3%) of the new enrollee group had a TMA immunologic syndrome. Among new enrollees, there were lower mean total and IgE serum antibody levels in lower exposure classes and a higher percentage with elevated antibody levels in high exposure classes (for T, x2 = 17.5, p = .0016; for IgE, x2 = 76.7, p less than .0001). In the new enrollee population, demographic variables of age, sex, date of hire, and smoking status were examined related to antibody levels. Only current or former smoking was related to elevated total antibody levels.

Absence of MHC gene expression in lens and cloning of dbpB/YB-1, a DNA-binding protein expressed in mouse lens

The status of major histocompatibility complex (MHC) class I and II gene expression in the normal mouse lens was examined. No mRNA for either class I or II genes was detectable in mouse lens, while the expression of MHC genes in other tissues generally matched immunohistochemical data from human tissues. However it was observed that MHC class I mRNA is present in the mouse lens-derived cell line alpha TN4-1. From a new-born mouse lens cDNA library a clone was obtained for the murine homologue of the DNA-binding protein dbpB/YB-1, a protein originally identified in human lymphocytes and proposed to be a negative regulator of MHC class II gene expression. Northern blots detect dbpB/YB-1 mRNA in all mouse tissues and cells examined, including both mouse lens and alpha TN4-1 cells, suggesting that dbpB/YB-1 has a general and widespread role.

Statewide helicopter utilization review: the Massachusetts experience

Air medical services began in Massachusetts in 1982, and Utilization Review (UR) of both programs in the state began in 1985. The UR program consists of external review of all flights according to screening criteria established by an independent Helicopter Utilization Review Committee (HURC). Between 1982 and 1989, over 2,500 flights were reviewed, with under 2% deemed inappropriate by the committee. Results of this process have helped to improve referrals from specific prehospital and hospital care providers, identified specific patient groups of interest, such as those transported for transplants or because of hospital bed shortages in specific regions, and assisted with improved third party reimbursement. Utilization review has not yet assisted with identification of unmet need or inappropriate resource utilization by ground ambulances, and has not compared the outcome of equal levels of care provided by different transport modes. We conclude that a coordinated utilization review process can be of benefit to both patients and air medical services.