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Modified replica exchange simulation methods for local structure refinement.

Parallel tempering, also known as replica exchange molecular dynamics (REMD), has recently been successfully used to study the structure and thermodynamic properties of biomolecules such as peptides and small proteins. For large systems, however, applying REMD can be costly since the number of replicas needed increases as the square root of the number of degrees of freedom in the system. Often, enhanced sampling is only needed for a subset of atoms, such as a loop region of a large protein or a small ligand binding to a receptor. In such applications, it is often reasonable to assume a weak dependence of the structure of the larger region on the instantaneous conformation of the smaller region of interest. For these cases, we derived two variant replica exchange methods, partial replica exchange molecular dynamics (PREMD) and local replica exchange molecular dynamics (LREMD). The Hamiltonian for the system is separated, with replica exchange carried out only for terms involving the subsystem of interest while the remainder of the system is maintained at a single temperature. The number of replicas required for efficient exchange thus depends on the number of degrees of freedom in the fragment needing refinement rather than on the size of the full system. The method can be applied to much larger systems than was previously practical. This also provides a means to preserve the integrity of the structure outside the refinement region without introduction of restraints. LREMD takes this weak coupling approximation a step further, employing only a single representation of the large fragment that simultaneously interacts with all of the replicas of the subsystem of interest. This is obtained by combining replica exchange with the locally enhanced sampling approximation (LES), reducing the computational expense of replica exchange simulations to near that of a single standard molecular dynamics (MD) simulation. Use of LREMD also permits the use of LES without requiring the specification of a single temperature, a known difficulty for standard LES simulations. We tested these two methods on the loop region of an RNA hairpin model system and find significant advantages over standard MD and REMD simulations.

Algorithms↗

Oropharyngeal control of ingestion in rats: acquisition of sham-drinking patterns.

Rats with esophageal fistulas, offered a concentrated glucose solution, sham drank relatively small amounts on the first session. This was true whether or not such a solution was familiar. Intake rose to very high levels over ensuing sham-drinking sessions, a result showing that the initial small volumes were not attributable to fixed properties of the solution itself (e.g., aversiveness, viscosity, or input to "satiety" mechanisms). The gradual acquisition of copious sham drinking was not affected by previous "practice" at sham drinking other commodities; it was not simply an alteration in motor habits. Finally, the gradual acquisition of the sham-drinking pattern did not occur with more dilute solutions; in response to these, sham drinking was copious and continuous from the outset. The following conclusions are made: (a) Rats must learn to respond, by continuous drinking, to the absence of the postingestive inhibition normally produced by concentrated solutions. (It is a separate and open question whether the response to the presence of such inhibitory factors must also be learned.) (b) No such learning is required in the case of more dilute solutions. This is further evidence that controlling factors with differing properties operate at different levels even of the single commodity, glucose in solution.

Animals↗

Fluorinated 4-quinolones induce hyperproduction of interleukin 2.

The fluorinated 4-quinolones are a "new" group of antibiotics with a broad antibacterial spectrum. They are already widely used in clinical practice. Previous studies have shown that these drugs increase the uptake of [3H]thymidine into DNA of mitogen-stimulated lymphocytes but inhibit cell growth and immunoglobulin secretion. This study shows that the 4-quinolones strongly (up to 100 times) increase the recovery of interleukin 2 (IL-2) in culture supernatants of phytohemagglutinin (PHA)-stimulated normal human lymphocytes and also prolong the kinetics of IL-2 production. The effect was significant at clinically achievable concentrations (5 micrograms/ml). In addition to hyperproduction of IL-2, the level of RNA hybridizing with a human IL-2 cDNA probe was also intensely elevated (16-32 times) in PHA-stimulated lymphocytes cultured with ciprofloxacin (80 micrograms/ml). The mechanism responsible for 4-quinolone-mediated effects on T cells is at present unclear, but evidence is presented that suggests the effect is not exerted at the level of protein kinase C activation. Ciprofloxacin at 80 micrograms/ml also decreased the expression of IL-2 receptors measured by immunofluorescence with CD 25 antibodies and a radiolabeled IL-2 binding assay. At the same concentration of ciprofloxacin, there was a very low expression of the transferrin receptor and the cell size increased very little in human lymphocytes after PHA stimulation. The enhanced IL-2 production by 4-quinolones may contribute to side effects reported when these drugs are used for treatment of patients.

Ciprofloxacin↗

Complementary and alternative therapy use at end-of-life in community settings.

OBJECTIVE: To investigate the prevalence of complementary and alternative medicine (CAM) use by an end-of- life population. DESIGN: Random selection of death certificates used to locate family caregivers who were interviewed by telephone 2-5 months following decedents' deaths. PARTICIPANTS: Decedent subjects died of natural causes in community settings. Family caregivers were very involved in the care and decision making for decedents during their terminal illness. MEASURE: Family caregivers reported on whether decedents had used CAM, type of modality, and motivation for use. RESULTS: CAM use by decedents was reported by 53.7% of family caregivers. Decedents who had used CAM were more likely to be younger, to have college degrees and higher household incomes, and to have used one or more life-sustaining treatment. The most frequent reason the decedents had used CAM was for symptom relief. CONCLUSIONS: As baby boomers age, bringing their CAM familiarity and previous practices into the end-of-life phase, clinicians will need to be aware that CAM use for symptom control is likely to be prevalent.

Aged↗

Refusal of videorecording: what factors may influence patient consent?

BACKGROUND: Videorecording of the consultation has become a widespread training and research technique in general practice. Previous studies have suggested a good level of patient acceptability. OBJECTIVE: This study aimed to elucidate patient factors associated with refusal to be videoed. METHOD: A research study of GP detection of psychological problems was carried out by opportunistic recruitment of adult attenders in primary care for collection of sociodemographic data, mental health status, and video of consultation. Patients were consented for participation in a research project by a skilled research assistant while waiting to see their general practitioner. This involved a two-stage process, where completion of a brief questionnaire was followed by consent for video before the patient entered the consulting room. RESULTS: Although the overall response rate was 85%, a surprisingly high level of refusal of consent by patients for their consultations to be videoed was found. The data were therefore analysed to examine the characteristics of the patient population, and to look for possible associated factors. The main factors associated with refusal of video consent were decreasing age, and overt presentation of a psychological problem. Although patients who were defined (either in the opinion of the GP or by mental health questionnaire score) as psychologically distressed were more likely to decline to be videoed, this was a less significant predictor of whether the patient would consent. CONCLUSIONS: Consent to be videoed may be more context-specific than previous studies have suggested. Refusal to be videoed appears to be associated with psychological problems, but the relationship is complex, and sociodemographic factors also play a part. The factors which influence consent, including the reason given for recording, need further clarification.

Adult↗

Flexible urethrocystoscopy in nephrological investigation.

Flexible urethrocystoscopy under local anaesthetic was performed on 100 patients as part of their nephrological investigations. This was carried out by a nephrologist, obviating the previous practice of referral to a surgical colleague for rigid instrumentation under general anaesthetic. A pathological diagnosis was made in 69 patients with flexible urethrocystoscopy alone; 17 patients required subsequent rigid cystoscopy to obtain or confirm a diagnosis. Thirty-four patients had normal examinations and of these 13 underwent renal biopsy for diagnosis. Considerable savings in theatre time, man-hours and anaesthetic risk to the patients were made without compromising diagnostic accuracy or patient wellbeing.

Adolescent↗

Intact PTH assay overestimates true 1-84 PTH levels after maxacalcitol therapy in dialysis patients with secondary hyperparathyroidism.

BACKGROUND: Although the so-called intact parathyroid hormone (iPTH) assay detects not only true 1-84 PTH (1-84PTH) but also large C-terminal PTH fragments, it remains inconclusive whether the 1-84PTH assay is more useful in clinical practice. Previous studies have shown that the results of these two PTH assays in dialysis patients are closely correlated. METHODS: Chronic dialysis patients whose plasma iPTH levels were >400 pg/ml were selected for inclusion in the present study. Following a 4 week wash-out time during which all vitamin D administration was halted, maxacalcitol was intravenously injected at the end of dialysis sessions three times per week for 24 weeks, at an initial dosage of 10 micro g. RESULTS: Ninety-seven patients with secondary hyperparathyroidism were included in our analysis. Their serum calcium levels were elevated from the start levels while phosphate levels remained unchanged. The plasma 1-84PTH levels constantly declined throughout the 24 weeks. Although the patients' plasma 1-84PTH and iPTH levels were closely correlated with each other both at the beginning of the study and after 24 weeks of maxacalcitol therapy, the ratio of 1-84PTH/iPTH consistently decreased throughout the study period (P<0.01). The changes in the ratio were significantly correlated with changes in serum calcium levels. CONCLUSIONS: Twenty-four weeks of intravenous maxacalcitol injection therapy significantly reduced the 1-84PTH/iPTH ratio. Estimated 1-84PTH levels from iPTH levels using a conversion formula obtained before the treatment were 21.0+/-20.4% higher than measured 1-84PTH levels after the therapy. Thus, iPTH measurement has a potential risk to overestimate 1-84PTH levels when evaluating the efficacy of maxacalcitol therapy in dialysis patients with secondary hyperparathyroidism.

Calcitriol↗

Reliability of the attraction method for measuring lumbar spine backward bending.

The distraction method is one method used to measure forward bending of the spine. Although this technique, which requires the use of a tape measure held over the spine and the location of anatomical landmarks, appears to be highly practical, previous studies have not examined its use for measuring backward bending. The purpose of our study was to determine the reliability of a similar technique, the attraction method, for measuring backward bending of the lumbar spine and to examine whether subjects with low back pain (LBP) could perform similar motion as subjects without LBP. Two groups composed of 100 subjects each, one with "significant" limiting low back pain (SLBP) and the other without "significant" limiting low back pain (NSLBP), were evaluated twice by a physical therapist to assess intrarater reliability. To assess interrater reliability, 11 subjects from the NSLBP Group were evaluated by a second therapist. For the total sample of 200 subjects, the intraclass correlation coefficient (ICC) for intrarater reliability was .95; for the SLBP Group, the ICC was .93; and for the NSLBP Group, the ICC was .90. For the sample of 11 NSLBP Group subjects examined for interrater reliability, the ICC was .94. Using a Kolmogorov-Smirnov test, we found the distribution for backward bending of the two groups to be significantly different. The attraction method, thus, appears to be a reliable method for measuring backward bending of the lumbar spine.

Adolescent↗

Painless needle insertion in regional anesthesia of the eye.

We examined a new technique of applying topical anesthetic with cotton tip sticks to the conjunctiva before needle insertion in regional anesthesia of the eye. Oxybuprocaine 0.4% and lidocaine 4% were compared with balanced salt solution (BSS) as topical anesthetics of the conjunctiva in Study 1. Ninety patients were randomly assigned into three groups (n = 30) to receive one of the three topical anesthetics in a double-blind manner. Pain of the needle insertions was measured with visual analog scale score (VAS) and quantitative surface electromography (qEMG). Both oxybuprocaine and lidocaine reduced pain significantly when compared to BSS. In Study 2, with healthy volunteers, we compared our previous practice of merely applying three consecutive drops of oxybuprocaine on the conjunctiva before needle insertions to the new technique of placing additional cotton tip sticks soaked in oxybuprocaine on the conjunctiva. We found the needle insertion virtually pain free when the cotton tip sticks were added to the topical anesthesia. The use of this simple method of topical anesthesia before the eye block increases patient comfort significantly.

Adult↗

Improved survival after massive burns.

Sixteen patients with massive burns (exceeding 50% of total body surface) were treated at the University of California--Davis Burn Center in the period of 1980 and 1981. Fifteen had flame burns, and eight had inhalation injuries. Mean burn size was 72% total body surface (range, 51-94) with 20-81% full thickness. Mean age was 27 years. Survival results were compared with a similar group of 13 patients treated in 1978 and 1979, mean age 25, and burn size 65% total body surface. Fifteen of the 16 survived, compared with six of 13 in the early group. Substantial changes in therapy between the time periods resulted in the improvements. These include: 1) early endotracheal intubation with application of PEEP before evidence of pulmonary dysfunction; 2) elimination of Swan-Ganz and central venous lines for early volume resuscitation unless absolutely necessary; 3) the addition of hypertonic saline and protein infusions during the first 24 hours of resuscitation along with Ringer's lactate alone resulting in 30% decrease in fluid requirements; 4) rapid institution of nutritional support beginning by day three using a combination of peripheral hyperalimentation and tube feeding; 5) early eschar excision and grafting beginning in the first week rather than the second or third week as previously practiced. Septic complications and hospital stay were also decreased. Cadaver skin or artificial skin were unavailable. A significant improvement in survival rate was noted after a more aggressive treatment protocol was instituted.

Adolescent↗

Are the recommendations of the French consensus conference on the management of colon cancer followed up?

The aim of this study was to determine how the guidelines published after this conference have spread. Pretherapeutic evaluation and treatment were assessed for all colon cancers diagnosed in a well-defined French population in 2000. Patients were classified either as managed according to the recommendations, or as undermanaged or overmanaged. Outside the emergency context, pretherapeutic work-up was classified as in conformity with the consensus in 48.0% of the cases, as undervalued in 21.9% and as overvalued in 30.1%. The resection rate at 90% was not far from the optimum. Pathological data allowed us to classify nearly all cases according to the tumour node metastasis classification; however, the number of examined nodes was below the recommendations in 30.8% of cases. Chemotherapy was performed according to the recommendations in 71.4% of cases, 23.1% were undertreated and 5.5% were overtreated. The multivariate analysis indicates that patients aged 75 years or more were less likely to receive chemotherapy than was recommended (P<0.001). This study suggested that the main reasons for not following guideline recommendations were inertia due to previous practices, difficulty to perform a recommended behaviour and lack of familiarity.

Aged↗

Nurses' attitudes toward patients with AIDS and AIDS-related risk factors.

Three variables were experimentally manipulated by simulation measurement using six vignettes in a completely randomized, partial hierarchical, experimental design: medical diagnosis (AIDS v. non-AIDS), sexual orientation (heterosexual v. homosexual) and intravenous drug-use history (IVDU v. non-IVDU). Following each vignette, the same Prejudicial Evaluation Scale (PES) and Social Interaction Scale (SIS) were used to measure nurses' attitudes toward patients and their willingness to interact with patients. Vignette questionnaires were randomly assigned to 360 acute-care nurses. Although sexual orientation was found not to influence PES and SIS scores, an AIDS medical diagnosis and a history of intravenous drug use were found to increase nurses' negative attitudes toward patients significantly and reduce their willingness to interact with patients. Study findings did not vary according to nurses' age, academic preparation or previous practice experience with patients with AIDS.

Acquired Immunodeficiency Syndrome↗

Mental health triage nursing: an Australian perspective.

This paper presents the findings of a doctoral research project that involved a state-wide investigation into mental health triage nursing in Victoria, Australia. Mental health triage is a specialized domain of nursing practice that has emerged within the context of wider mental health reform in the State. The overall aim of the study was to produce a comprehensive definition and description of psychiatric triage nursing in Victoria. Methodological triangulation was used in the design of the study to enable the use of both survey (n = 139) and semi-structured interview (n = 21) data collection methods. Mental health triage nursing was found to be a complex, stressful role that involves high levels of responsibility, clinical decision making, and multiple role functions, many of which overlap into areas of practice previously the exclusive domain of medicine, such as assessment, diagnosis, and referral. The paper raises discussion on contemporary professional issues of concern to mental health triage nursing, and concludes with recommendations for the future development of the discipline.

Adult↗

Extracorporeal shockwave lithotripsy using ultrasonic imaging: urologists' experience.

The EDAP LT.01 is a second generation shockwave lithotripter which employs ultrasound imaging and piezoelectric shockwave generation. We describe the first 12 months of its use in the treatment of urinary calculi by urologists with no previous practical experience of ultrasonography. A total of 406 calculi (359 renal and 47 ureteric) in 317 patients were treated. Analgesia or sedation was not routinely used and 59% of all treatments were performed as outpatient procedures. The clearance rate of renal calculi smaller than 1 cm was 81%, while that of calculi larger than 3 cm was 80% (mean clearance 77.5%). Lithotripsy of ureteric calculi following retrograde manipulation to a renal site resulted in 94.4% clearance compared with 39% for those treated at a ureteric site; 93% of 684 lithotripsy treatments were either painless or caused only mild pain. Our experience with imaging and treating urinary calculi with the EDAP LT.01 lithotripter has been excellent. Patients are treated effectively and inexpensively as out-patients without analgesia or sedation.

Adolescent↗

Ultrasonic imaging for extracorporeal shockwave lithotripsy: analysis of factors in successful treatment.

The emergence of real-time ultrasonic imaging for extracorporeal shockwave lithotripsy poses questions regarding the factors and techniques which facilitate stone imaging for clinicians with no previous practical experience in ultrasonography. The ability of these clinicians to assess when stone disintegration has been achieved also needs to be confirmed. A wide range of data was recorded from each of 2688 lithotripsy treatments performed over a 2-year period using the EDAP LT.01 ultrasound-imaged piezoelectric lithotriptor. An analysis of these data was performed using a comprehensive microcomputer-based statistics package. The mean time taken for stone imaging and positioning was reduced from 11.2 to 7.5 min over the 2-year period. Obese patients and those with renal pelvic stones were best imaged in a lateral position. Overall there was no difference in percentage stone disintegration or clearance between treatments in the supine or lateral positions, but a significant reduction in the clearance of small caliceal stones resulted when the lateral position was used. Factors associated with a significantly greater percentage of stone disintegration and clearance included pain experienced by the patient during fine adjustment of the processing head during treatment, acoustic focus attenuation and widening and acoustic shadow widening as detected by the urologist at the end of treatment. Among the factors not associated with significant alterations in the percentage of stone disintegration or clearance were the lithotriptor operator, the side or site of the calculus, obesity and shockwave frequency or power. This study confirmed the ability of urologists to develop expertise in ultrasonography for renal stone imaging and to interpret successfully the subtle signs of stone disintegration.

Adolescent↗

Management of hyperhidrosis axillaris.

To many people, particularly women, hyperhidrosis of the axillae is a personal discomfort and a social handicap. Previously practiced topical and internal medicinal measures and surgical techniques of management are reviewed and a modified surgical technique is described.

Axilla↗

Central line mechanical complication rate in emergency medicine patients.

UNLABELLED: Central line (CL) placement in the emergency department (ED) is a common practice. Previously published small-scale studies have quoted mechanical complication rates in emergency medicine patients of 10-15%. OBJECTIVE: To determine the mechanical complication rate of central venous catheterization in a large (65,000 visits/year) academic urban ED. METHODS: This was a retrospective review of all ED-placed CLs over a three-year period from May 1995 to May 1998. Data were collected as part of a monthly quality assurance project and analyzed using Fisher's exact test (significance = p < 0.05). Central lines were defined as subclavian, internal jugular, femoral, and interosseous lines. Mechanical complication was defined as a pneumothorax, hematoma, line misplacement, or hemothorax. RESULTS: There were 22 complications of a total of 643 CLs placed [complication rate 3.4% (95% CI = 1.9% to 4.8%)]. The complication rate for patients with a confirmatory chest x-ray receiving a subclavian or internal jugular CL (excluding all patients who died prior to x-ray evaluation of CL) was 6.2% (22/355) (95% CI = 3.9% to 9.3%). There were 402 (63%) CLs placed during a code with a complication rate of 2.2% (95% CI = 1.0% to 4.2%), 79% (317/402) medical and 21% (85/402) trauma codes. Thirty-seven percent (241) of the CLs were placed on an "elective urgent" basis. Residents placed the majority of CLs (567/643), with a complication rate of 3%. There was no statistically significant difference in complication rates based on level of resident training. CONCLUSIONS: The CL mechanical complication rate in the ED at this institution is 3.4%. This is substantially lower than previously reported mechanical complication rates.

Catheterization, Central Venous↗

Fire fighters: a study of stress and coping.

Fifty-eight non-professional fire fighters, 91% of all firefighters from different industries who participated in a hotel fire rescue operation, were investigated by means of a structured self-report questionnaire about their stress experience during and after the rescue action. Together with 57 professional fire fighters, they participated in rescuing hotel guests confined for as much as three hours in a 12 storeyed hotel building on fire. Fourteen persons (11%) died, 114 guests survived. Forty-seven percent of the non-professional fire fighters reported that the disaster experience was the worst they had ever experienced. Even so, 80% thought that they had coped with the job well to fairly well and for as many as 66% the rescue action represented something positive to them in retrospect. Ten percent claimed that stress reactions disturbed them in executing effective rescue work. Fifty-eight percent maintained that more preparation and training could have improved their effort. Fire fighters with previous practical experience seemed to "digest" the disaster experience more easily than inexperienced fire fighters as measured by the Impact of Event Scale. High level of competence and opportunity for debriefing as well as disaster characteristics are discussed as factors explaining the favourable coping with extreme stress.

Adaptation, Psychological↗