Care-management for mental illness.
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Delivery of Health Care↗
Biomedical subjects
M Conway
Publications and source records attributed to M Conway.
A corporate needs assessment for the purchase of district nursing: a qualitative approach.
A qualitative research methodology was applied to a corporate assessment of need for district nursing services. Semi-structured interviews were held with district nurses and the transcripts analysed for common themes. The major determinants of district nurses' roles were the priorities and practices of other community-based services, particularly social services and primary care. Purchasing and contract setting in this area needs to focus more on the interface with other services.
Attitude of Health Personnel↗
Clearance of microsphere-entrapped 5-fluorouracil and cytosine arabinoside from the vitreous of primates.
Experiments were conducted with biodegradable microspheres containing antimetabolites to assess the release of the drugs from the microspheres into the vitreous cavity of primates. Microspheres containing a mixture of radiolabeled and cold cytosine arabinoside (Ara-C) or 5-fluorouracil (5-FU) were prepared using a solvent evaporation process. The copolymers of poly (lactic) and poly (glycolic) acid (85:15) and drug was dissolved in a mixture of chloroform and acetone. The solutions were then emulsified in an aqueous solution of polyvinyl alcohol and stirred for 24 hours to evaporate the organic solvent. A 0.1 mL aliquot of a suspension of the microspheres was then injected into one eye of eight African Green monkeys. Half received 250 +/- 10 micrograms of Ara-C and the others 375 +/- 15 micrograms of 5-FU. The concentration in the vitreous was then measured by removing a 0.1 mL sample of vitreous at 1, 2, 4 and 11 days after injection. Both drugs released from microspheres were still detectable in the eye 11 days after injection and the clearance kinetics were similar for both drugs. The results indicate that the microspheres appear promising as a slow drug-delivery system for future investigations in conjunction with these and other antimetabolites suitable for the treatment of PVR.
Animals↗
Transferable deaths during 1990 for residents of Camberwell Health Authority.
Almost one quarter of all deaths among residents of Camberwell District Health Authority during 1990 occurred without the district ('transferable deaths'). These deaths differed from total deaths in that the main cause of study deaths was cancer, and many of these cases died in a hospice with which the district has no direct contact. However, the commonest location of deaths was in hospitals (57% of study death locations) and the majority of these cases died in London teaching hospitals with whom there are major contracts. As the three inner London South East Thames districts, including Camberwell, propose to merge into a single purchasing authority in 1993, all London hospitals where Camberwell residents died in this survey would be covered by the current range of contracts set by the three districts. The study identified a small but important group of deaths from HIV/AIDS, where it seems that people travelled, particularly, to West London for terminal care. A high proportion of deaths from injury and poisoning were either suicides or open verdicts. There were less transferable deaths among the major ethnic minorities in the district than expected, particularly among those of African and Caribbean descent. This may be due to the age and disease patterns in these populations, but may also require study into the need for terminal care among these groups. Transferable deaths are a useful source of epidemiological information and can highlight local health service strengths and deficits.
Adult↗
Prevalence of antibodies to hepatitis C in dialysis patients and transplant recipients with possible routes of transmission.
The prevalence of hepatitis C infection and possible predisposing factors was assessed in a renal unit. Of 343 patients at our renal dialysis centre, 37 (10.8%) were anti-HCV positive by a 1st-generation assay (ELISA, Ortho/Chiron) and confirmed positive in 35 (10.2%) with a 2nd-generation test (UBI, New York). Anti-HCV positivity was significantly associated with: duration of renal replacement therapy (P < 0.0001); quantity of blood transfused (P < 0.002); duration of hospital haemodialysis (P = 0.0001); duration with a functional renal transplant (P = 0.039); and aspartate aminotransferase (P < 0.0001). Logistic regression determined the following variables to be independent risk factors: duration of renal replacement therapy with a relative risk of 34.3 for 5-9 years and 87.4 when the duration was in excess of 10 years; renal transplant for less than 1 year (relative risk of 5.0); transfusion in excess of 50 units of blood (relative risk of 11.6). Clinical assessment of anti-HCV-positive patients revealed peripheral signs of chronic liver disease in 40%, hepatomegaly in 34%, and splenomegaly in 9%. This prevalence of hepatitis C infection is similar to other European and North American centres, but contrasts with low prevalence rates reported from dialysis populations in the UK. It adds further support for routine screening of blood and possibly organ donors and implementation of further infection control measures in dialysis centres.
Adult↗
Protective immunization against Epstein-Barr virus-induced disease in cottontop tamarins using the virus envelope glycoprotein gp340 produced from a bovine papillomavirus expression vector.
Inoculation with Epstein-Barr virus (EBV) induces malignant lymphomas in the cottontop tamarin (Saguinus oedipus oedipus). This provides an experimental animal model for assessing the efficacy of candidate EBV vaccines which are intended to reduce the incidence of human tumours associated with EBV infection. Previous work has shown that experimental vaccines based on the major virus envelope glycoprotein gp340 prepared from the membranes of EBV-infected cells are effective in protecting cottontop tamarins against EBV-induced disease. However, not all purified gp340 preparations induce protective immunity against EBV lymphoma in the tamarin. In this work, cottontop tamarins were immunized with recombinant gp340, produced using a bovine papillomavirus (BPV) expression vector, and a threonyl muramyl dipeptide adjuvant formulation. Although the recombinant-derived gp340 lacked the membrane anchor sequence of authentic gp340 and was expressed in mouse cells, it was immunogenic and induced virus-neutralizing antibodies. Healthy vaccinated tamarins were protected against EBV-induced disease. The demonstration that a recombinant gp340 product is able to elicit protective immunity in the cottontop tamarin is a significant step in the development of an EBV vaccine because previously it had not been clear whether a recombinant product would have the exact tertiary structure, including the necessary carbohydrate components, to induce protective immunity. A recombinant gp340 vaccine offers various advantages over production of the authentic molecule by laborious biochemical separation, including lower cost and the absence of potentially oncogenic EBV DNA. Therefore, recombinant gp340 produced using the BPV expression vector is suitable for development as a candidate EBV vaccine for a human Phase I trial and beyond.
Acetylmuramyl-Alanyl-Isoglutamine↗
Postpartum progression of diabetic retinopathy.
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Adult↗
Variability of high-pass resolution perimetry in normals and patients with idiopathic intracranial hypertension.
High-pass resolution perimetry, or the "ring test," is a recently developed type of acuity perimetry. To determine its test-retest variability, we studied 10 normals and 10 patients with idiopathic intracranial hypertension (IIH) by testing both eyes four separate times. There was no increase in variability from the center out to 21 degrees of visual field eccentricity. However, there was a significant increase from 22 degrees to 29 degrees in both normals and IIH patients. Unlike light sensitivity threshold automated perimetry, with an increase in threshold level there was no significant increase in variability in either normals or patients. This may be because of the test's method, which thresholds by target size rather than intensity. As expected, there was a large intersubject variability in the patients, with the visual fields being significantly disturbed by analysis of total field, quadrants, concentric rings, and anatomic nerve fiber bundle regions. Surprisingly, there was no significant difference in the total within subject variability of normals and patients. Because with the ring test there is no increase in variability with an increase in threshold, this method of perimetry may have great utility for following patients with disturbed visual fields. The ring test appears to have advantages that promote low test-retest variability.
Adult↗
Skeletal muscle metabolism in heart failure: a 31P nuclear magnetic resonance spectroscopy study of leg muscle.
1. The gastrocnemius muscle of seven patients with mild to moderate chronic heart failure and of five healthy control subjects was studied using 31P nuclear magnetic resonance spectroscopy. Spectra were collected at rest and during an incremental, symptom-limited, exercise protocol. Blood flow was measured in the same study during brief interruptions to exercise. 2. The phosphocreatine/(phosphocreatine plus inorganic phosphate) ratio was lower in patients with heart failure than in control subjects at an exercise rate of 1.5 W, although intracellular pH and blood flow were similar. 3. The cytosolic free adenosine 5'-diphosphate concentration was markedly increased in patients with heart failure exercising at 1.5 W compared with control subjects exercising at the same workload. 4. Although the maximum workload achieved by patients with heart failure was less than half of that reached by control subjects, the pH and the phosphocreatine/(phosphocreatine plus inorganic phosphate) ratio were lower in patients with heart failure at maximal load. Blood flow was less at maximal exercise in patients with heart failure than in control subjects in keeping with the reduced work load. 5. The phosphocreatine depletion induced in the gastrocnemius muscle by exercise was more severe than previously described in the forearm of patients with heart failure. 6. Metabolic abnormalities in skeletal muscle may contribute to exercise intolerance in heart failure, particularly during submaximal exercise.
Adenosine Diphosphate↗
Perceived intimacy of expressed emotion.
Research on norms for emotional expression and self-disclosure provided the basis for two hypotheses concerning the perceived intimacy of emotional self-disclosure. The first hypothesis was that the perceived intimacy of negative emotional disclosure would be greater than that of positive emotional disclosure; the second was that disclosures of more intense emotional states would be perceived as more intimate than disclosures of less intense emotional states for both negative and positive disclosures. Both hypotheses received support when male students in Canada rated the perceived intimacy of self-disclosures that were equated for topic and that covered a comprehensive sample of emotions and a range of emotional intensities. The effects were observed across all the topics of disclosure examined.
Adolescent↗
Herbal medicine as a cause of combined lead and arsenic poisoning.
1. Combined chronic lead and arsenic poisoning was diagnosed in a 33-year-old Korean woman following consumption of a Korean herbal medicine prescribed for haemorrhoids. 2. The patient had malaise, severe difficulty walking, arthralgia, oedema and abdominal pain with diarrhoea. 3. Investigation showed anaemia with basophilic stippling, fragmentation and a raised reticulocyte count. 4. Raised blood and urine lead levels and urine arsenic levels were found. 5. Analysis of the herbal medicine revealed a high lead and arsenic content. 6. Treatment with the newer chelating agent 2,3-dimercaptosuccinic acid was successful, with no detectable side-effects.
Adult↗
Expression of Epstein-Barr virus membrane antigen gp340/220 in mouse fibroblasts using a bovine papillomavirus vector.
Epstein-Barr virus (EBV) membrane antigen glycoproteins gp340 and gp220 are encoded by a single gene. We have inserted this gene into a bovine papillomavirus (BPV) vector and expressed gp340/220 in mammalian cells under the control of the mouse metallothionein promoter. The proteins produced were of similar Mr, showed similar antigenic specificity and were transported to the same subcellular location as the authentic gp340/220. The inclusion of heavy metal ions in the medium had no effect on the levels of gp340/220, which were approximately the same as those found in standard EBV-transformed lymphoblastoid cell lines, e.g. B95-8. Cells that expressed gp340/220 were selected by several rounds of fluorescence-activated cell sorting, but on passage they rapidly lost the ability to express this glycoprotein. In contrast to this we found that BPV-transformed cells expressing a truncated version of gp340/220 still produced it at significant levels after extended passage.
Animals↗
Evaluating nursing productivity in child health.
As nurses are increasingly concerned with assessing and improving their productivity in a variety of settings, they must make systematic use of an evaluation model. The Discrepancy Evaluation Model (DEM) was used to evaluate the productivity of nurses in child health clinics in five centers in the southeastern United States. The first step in any evaluation is to identify standards against which performance can be measured. In this project, no standards were available, and creating them was the first task. Standards for productivity in child health were developed that accounted for differences in clients and the experience level of nurses, while maintaining quality of care. They were situation specific and allowed for the constraints operating in each of the five centers. Discrepancies between the standards and observed performance were identified and underlying factors examined, resulting in a number of recommendations that could streamline the provision of services and improve nursing productivity. The evaluation process can be applied to public health nursing services in a variety of settings.
Ambulatory Care Facilities↗
Performance indicators for family planning services.
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Family Planning Services↗
Skeletal muscle metabolism during exercise under ischemic conditions in congestive heart failure. Evidence for abnormalities unrelated to blood flow.
Previous studies with 31P nuclear magnetic resonance have demonstrated that patients with chronic congestive heart failure often exhibit increased glycolytic metabolism and impaired oxidative phosphorylation in exercising skeletal muscle, but the mechanism for these changes remains unresolved. This study was conducted to determine whether these abnormalities result from impaired blood flow or oxygen delivery. Nine patients with mild-to-moderate congestive heart failure and nine age- and size-matched, healthy control volunteers were studied during repetitive submaximal finger flexion exercise under aerobic and ischemic conditions. Skeletal muscle metabolism was assessed by 31P nuclear magnetic resonance of the flexor digitorum superficialis muscle. During steady-state aerobic exercise at 33% of each subject's predetermined maximum workload, the patients with congestive heart failure exhibited significantly lower pH values (6.65 +/- 0.22 vs. 6.97 +/- 0.09, p less than 0.002) and phosphocreatine concentrations, expressed as [phosphocreatine]/([phosphocreatine] + [inorganic phosphate]) (0.59 +/- 0.14 vs. 0.79 +/- 0.08, p less than 0.002). Similar differences were also present throughout ischemic exercise at the same workload. Based upon these measurements, calculated lactate production and adenosine 5'-triphosphate consumption rates were significantly higher in the patients with congestive heart failure. These results indicate that in many patients with congestive heart failure exercising muscle exhibits increased glycolytic metabolism and appears to be metabolically less efficient in relation to external work performed. These changes cannot be explained by impaired blood flow or oxygen delivery alone.
Adult↗
Post-ictal blood pressure in aneurysmal subarachnoid haemorrhage.
A prospective study in which the effect of the post-ictal systemic blood pressure levels on the outcome following surgically treated aneurysmal subarachnoid haemorrhage (SAH) in 325 patients is reported. No differentiation was made between pre-existing essential and prolonged reactive hypertension. A significant association was found between the trend for rising diastolic blood pressure levels and the tendency towards a poor outcome. There was a similar trend for rising systolic blood pressure levels which did not reach statistical significance. Patients with definite hypertension (blood pressure of 160/95 mmHg or greater) were 1.6 times as likely to have a poor outcome than were those with lower blood pressures.
Adult↗
Recurrent aneurysmal subarachnoid haemorrhage: incidence, timing and effects. A re-appraisal in a surgical series.
A series of 510 patients with proven aneurysmal subarachnoid haemorrhage (SAH) is reported. The incidence of recurrent haemorrhage during the period awaiting surgery was 13.7%. There was no significant difference in incidence between good and poor grade patients. Following rebleeding there was an immediate mortality of 34% in good grade patients and 52% in poor grade patients. In the long term only 44.4% of good grade and 8% of poor grade patients made a good recovery following a second bleed as compared to 70.6% and 52.8% respectively for those who did not rehaemorrhage.
Humans↗
31P nuclear magnetic resonance evidence of abnormal skeletal muscle metabolism in patients with congestive heart failure.
In patients with congestive heart failure (CHF), exercise limitation correlates poorly with central hemodynamic abnormalities, suggesting that additional abnormalities in skeletal muscle blood flow or metabolism play an important pathophysiologic role. Therefore, muscle metabolism was examined by 31P nuclear magnetic resonance (NMR) at rest and during repetitive bulb squeeze exercise in 11 patients with New York Heart Association class II to IV CHF and 7 age-matched control subjects. Serial spectra were obtained at rest, at 2 levels of exercise and during recovery. At rest, the only abnormal finding was an elevated inorganic phosphate (Pi) concentration (5.0 +/- 1.5 vs 3.6 +/- 0.4 mM, p less than 0.01). At the lower exercise level, phosphocreatine (PCr) utilization, which was followed as the ratio of [PCr]/[( PCr] + [Pi]), was greater (0.36 +/- 0.16 vs 0.53 +/- 0.10, p less than 0.02), and pH fell more rapidly and to a lower value (6.38 +/- 0.25 vs 6.85 +/- 0.17, p less than 0.001). At the higher level of exercise, the patients could not work effectively and the group differences narrowed. Compared with control subjects, acidification was disproportionately greater in relation to PCr depletion in patients, further suggesting excessive dependence on glycolytic metabolism. The Pi peak was prominently double in 5 patients, indicating presence of a population of muscle fibers undergoing unusually active glycolysis. PCr resynthesis, a reflection of oxidative phosphorylation, was delayed in 4 patients. These findings indicate that in many patients with CHF, exercising muscle has marked metabolic changes consistent with impaired substrate availability and altered biochemistry.
Adenosine Triphosphate↗