A study of 'crisis cards' in a community psychiatric service

OBJECTIVE

'Crisis cards' state patients' treatment details and preferences in anticipation of a later occasion when the patient might be too ill to express them directly. We assessed the feasibility of introducing 'crisis cards', or a collaborative form of them, 'joint crisis plans', into a sectorized community psychiatric service.

METHOD

All patients with a psychosis and at high risk of crisis were invited to participate. Follow-up examined patients' satisfaction and how the cards were used.

RESULTS

In total, 106 eligible patients were identified and offered a card, and 40% agreed to participate. Patients with an affective psychosis, past suicide attempts and less frequent admissions were over-represented among those who agreed to take part. Patients chose to include a wide range of information. For participants, admissions fell by 30% in the follow-up year.

CONCLUSION

Crisis cards serve both a 'manifest', practical function (to provide important information when the patient is too ill to do so) and a 'latent' psychological one (positive effects on the patient's attitude to self, their illness and treatment, and their relationship with the clinical team).

Screening high-risk patients for methicillin-resistant Staphylococcus aureus on admission to the hospital: is it cost effective?

OBJECTIVES

To determine the cost-effectiveness of a policy of screening high-risk patients for methicillin-resistant Staphylococcus aureus (MRSA) colonization on admission to hospital.

SETTING

980-bed university-affiliated tertiary-care hospital.

PATIENTS

Between June 1996 and May 1997, patients directly transferred from another hospital or nursing home, or who had been hospitalized in the previous 3 months, were screened for MRSA within 72 hours of hospital admission.

DESIGN

Nasal, perineal, and wound swabs were obtained for MRSA screening using standard laboratory methods. Laboratory and nursing costs associated with screening patients for MRSA on admission to hospital were calculated. The costs associated with the implementation of recommended infection control measures for patients with MRSA also were determined.

RESULTS

3,673 specimens were obtained from 1,743 patients. MRSA was found on admission in 23 patients (1.3%), representing 36% of the 64 patients with MRSA identified in the hospital during the year. MRSA-colonized patients were more likely to have been transferred from a nursing home (odds ratio [OR], 6.4; P =.04) or to have had a previous history of MRSA colonization (OR, 13.1; P =.05). Laboratory and nursing costs were found to be $8.34 per specimen, for a total cost of $30,632 during the year. The average cost of implementing recommended infection control measures for patients colonized with MRSA was approximately $5,235 per patient.

CONCLUSION

If early identification of MRSA in colonized patients prevents nosocomial transmission of the organism to as few as six new patients, the screening program would save money.

Physical and pharmacologic restraints in long-term care facilities

This study examined the effects of education on the attitudes and practices of long-term care staff toward use of restraints. The intervention, a 1-day educational seminar, used a collaborative team of speakers from the Utah Survey Agency and medical professions. Seminar goals were threefold: first, to provide information about best practices for managing behaviors of individuals with dementia in long-term care settings; second, to provide an explanation of the Omnibus Budget Reconciliation Act regulations pertaining to restraint use; and third, to present alternative strategies to link best practice guidelines to the provision of care. Results showed significant changes in participants' attitudes toward use of restraints. Participants reported replicating the seminar for nursing home staff, revisiting facility policies on restraints, and modifying resident care plans.

Exposure to traumatic incidents and prevalence of posttraumatic stress symptomatology in urban firefighters in two countries

Urban firefighters are at risk for posttraumatic stress disorder (PTSD) due in part to their exposure to duty-related trauma. This study compared duty-related trauma exposures and the prevalences of posttraumatic stress in U.S. and Canadian firefighters. Both samples reported relatively numerous and frequent posttrauma symptoms, and the rates of self-reported PTSD prevalence did not differ significantly. However, analysis of departmental records for respondents' previous year on duty revealed significant differences in both frequencies and categories of traumatic incident exposures. Some of the vulnerability and moderating risk factors associated with PTSD caseness differed between the U.S. and Canadian samples. Potential explanations for the observed differences in risk factors for PTSD in these 2 firefighter samples are considered.

Spinal anesthesia for cesarean section: isobaric versus hyperbaric solution

BACKGROUND

The present study was undertaken to compare the outcomes of hyperbaric versus isobaric spinal anesthesia in Cesarean delivery.

METHODS

The anesthetic solution was administered in sitting position as this posture is commonly used in this clinical setting. Except for the baricity of the anesthetic solution, identical technique was employed for every parturient in the study. Following administration of anesthetic solution the parturient immediately resumed horizontal supine position. The solutions used were 2.0 mL of 0.5% tetracaine in 5% dextrose (hyperbaric) for Group H (n = 30) and in cerebrospinal fluid (isobaric) for Group I (n = 30).

RESULTS

Both hyperbaric and isobaric tetracaine given in sitting position provided adequate analgesic levels. However, hyperbaric tetracaine solution produced a slightly higher median peak level of wilder range, and caused a higher incidence of hemodynamic changes and subjective sensation of "feeling sick" than isobaric tetracaine. Additionally, the duration of surgical anesthesia was shorter and the sacral block was longer for hyperbaric tetracaine solution than for isobaric tetracaine solution at same dose and concentration. Only one mother in Group H needed supplemental inhalation anesthesia for a subsequent hysterectomy due to uncontrollable bleeding. There were no complications, including postpuncture headache in either group.

CONCLUSIONS

Our results indicated that numerous variables must be taken into consideration in predicting the outcome of a spinal anesthesia. Alternation in the technique and individual patient factor may individually or collectively produce different results.

Extraction and high-performance liquid chromatographic separation of selected pyrene and benzo[a]pyrene sulfates and glucuronides: preliminary application to the analysis of smokers' urine

In the study of the complex mixture of urinary metabolites derived from polycyclic aromatic hydrocarbon compounds, it is desirable to simplify the analysis through separation of classes of compounds. We have developed a liquid chromatography (LC) method for the separation of selected sulfate and glucuronide conjugate isomers derived from hydroxybenzo[a]pyrenes (OH-BaP) and hydroxypyrenes. This LC method was utilized in the preliminary analysis of the urine of smokers by combining it with an extraction technique employing tetra-n-butyl-ammonium ion as a coupling agent to generate a 1:1 complex, extractable in chloroform at low pH prior to LC analysis.

An audit of postoperative analgesia after pyloromyotomy

Seventy-two cases of pyloric stenosis treated in our institution in the last five years were reviewed in an attempt to determine the need for postoperative analgesia after pyloromyotomy in infants. All children had their wound infiltrated with a mean dose of 2.16+/-1.43 mg x kg(-1) of bupivacaine, and first analgesia was required 9.12+/-8.04 h after surgery. Paracetamol was the main analgesic administered (average of two doses of approximately 20 mg x kg(-1)). Only three patients required postoperative opioids. In conclusion, there was a low consumption of analgesics after pyloromyotomy. Furthermore, infiltration of the wound appeared to be beneficial since time to administration of first postoperative analgesia was delayed.

Maternal blood lead level during pregnancy in South Central Los Angeles

Twenty-five years of public health efforts produced a striking reduction in lead exposure; the blood lead average in the United States has decreased to less than 20% of levels measured in the 1970s. However, poor minority groups that live in large urban centers are still at high risk for elevated lead levels. In this study, our data showed that pregnant immigrants (n = 1,428) who live in South Central Los Angeles--one of the most economically depressed regions of California--have significantly higher (p < .0001) blood lead levels (geometric mean = 2.3 microg/dl [0.11 micromol/l]) than 504 pregnant nonimmigrants (geometric mean = 1.9 microg/dl [0.09 micromol/l]). The most important factors associated with lower blood lead levels in both groups were younger age; more-recent date of blood sampling (i.e., decreasing secular trend); and blood sampling in mid-autumn, instead of mid-spring (i.e., seasonal trend). Blood lead levels of immigrants were strongly dependent on time elapsed since immigration to the United States; each natural log increase in years of residence was associated with an approximately 19% decrease in blood lead levels. Although blood lead means for both groups were almost the same as the estimated national average, 25 of the 30 cases of elevated blood lead (i.e., > or = 10 microg/dl [0.48 micromol/l) occurred in the immigrant group. The odds ratio (95% confidence intervals within parentheses) for having elevated blood lead levels (a) was 9.3 (1.9, 45.8) if the immigrant engaged in pica; (b) was 3.8 (1.4, 10.5) if the immigrant had low dietary calcium intake during pregnancy; and (c) was .65 (.43, .98) for every natural log unit increase of years of residence in the United States. The control of pica and dietary calcium intake may offer a means of reducing lead exposure in immigrants.

Optical tomography using the SCIRun problem solving environment: Preliminary results for three-dimensional geometries and parallel processing

We present a 3D implementation of the UCL imaging package for absorption and scatter reconstruction from time-resolved data (TOAST), embedded in the SCIRun interactive simulation and visualization package developed at the University of Utah. SCIRun is a scientific programming environment that allows the interactive donstruction, debugging, and steering of large-scale scientific computations. Using this "computational workbench," a scientist can design and modify simulations interactively via a dataflow programming model. SCIRun enables scientists to design and modify model geometry, interactively change simulation parameters and boundary condititions, and interactively visualize geometric models and simulation results. Reconstruction of a segmented 3D head model is used as an example for demonstrating the capabilities of the combined TOAST/SCIRun approach.

Cobalt chloride-induced signaling in endothelium leading to the augmented adherence of sickle red blood cells and transendothelial migration of monocyte-like HL-60 cells is blocked by PAF-receptor antagonist

In response to hypoxia, sickle red blood cells (SS RBC) and leukocytes exhibit increased adherence to the vascular endothelium, while diapedesis of leukocytes through the blood vessel increases. However, the cellular signaling pathway(s) caused by hypoxia is poorly understood. We utilized CoCl2 as a mimetic molecule for hypoxia to study cellular signaling pathways. We found that in human umbilical vein endothelial cells (HUVEC), CoCl2 at 2 mM concentration induced the surface expression of a subset of CAMs (VCAM-1) and activation of transcription factor NF-kappaB in the nuclear extracts of HUVEC. Furthermore, CoCl2 also caused time-dependent tyrosine phosphorylation of mitogen-activated protein (MAP) kinase isoform ERK2 without significantly affecting ERK1, indicating ERK2 is the preferred substrate for upstream kinase of the MAPK pathway. Inhibitors of MAP kinase (PD98059) or platelet-activating factor (PAF)- receptor antagonist (CV3988) inhibited the CoCl2-induced NF-kappaB activation and VCAM-1 expression. Augmented expression of VCAM-1 led to increased SS RBC adhesion, inhibitable by a VCAM-1 antibody. Additionally, CoCl2 caused a two- to threefold increase in the rate of transendothelial migration of monocyte-like HL-60 cells and a twentyfold increase in phosphorylation of platelet endothelial cell adhesion molecules (PECAM-1). The transendothelial migration of monocytes was inhibited by an antibody to PECAM-1. Both phosphorylation of PECAM-1 and transendothelial migration of monocytes in response to CoCl2 were inhibited by protein kinase inhibitor (GF109203X) and augmented by protein phosphatase inhibitor (Calyculin A). Our data suggests that CoCl2-induced cellular signals directing increased expression of VCAM-1 in HUVEC involve downstream activation of MAP kinase and NF-kappaB, while the phosphorylation of PECAM-1 occurs as a result of activation of PKC. We conclude that PAF-receptor antagonist inhibits the CoCl2- or hypoxia-induced increase in the adhesion of SS RBC, PECAM-1 phosphorylation, and the concomitant transendothelial migration of monocytes.

Exposure to traumatic incidents and prevalence of posttraumatic stress symptomatology in urban firefighters in two countries

Urban firefighters are at risk for posttraumatic stress disorder (PTSD) due in part to their exposure to duty-related trauma. This study compared duty-related trauma exposures and the prevalences of posttraumatic stress in U.S. and Canadian firefighters. Both samples reported relatively numerous and frequent posttrauma symptoms, and the rates of self-reported PTSD prevalence did not differ significantly. However, analysis of departmental records for respondents' previous year on duty revealed significant differences in both frequencies and categories of traumatic incident exposures. Some of the vulnerability and moderating risk factors associated with PTSD caseness differed between the U.S. and Canadian samples. Potential explanations for the observed differences in risk factors for PTSD in these 2 firefighter samples are considered.

Knowledge, attitudes, and practices related to fruit and vegetable consumption of high school students

PURPOSE

To assess the level of nutrition knowledge, attitudes and practices related to fruit and vegetable consumption of high school students attending participating parochial schools in the New Orleans area.

METHODS

The baseline data reported in this study, "Gimme 5: A Fresh Nutrition Concept for Students," represents one of the nine National Cancer Institute-funded projects from the national "5-A-Day for Better Health Program" initiated in 1991. A survey containing 22 nutrition-related items about fruit and vegetables was used to assess knowledge in 2213 students.

RESULTS

On average, adolescents reported 39% correct knowledge scores. A significant ethnic effect (p < .001) was noted, with White adolescents scoring higher than African American adolescents. Significant ethnic differences in the frequency of fruit and vegetable consumption were also observed, with African-American adolescents reporting a lower mean consumption (2.17 servings) than white adolescents (2.69 servings). Consumption by Hispanic youth (2.48 servings) was similar to those in the "other" ethnic category (2.55 servings). Girls reported being more confident in their ability to eat five servings of fruits and vegetables per day than did boys (p < .05).

CONCLUSIONS

Although the knowledge and consumption levels of adolescents with regard to fruits and vegetables were low, their attitudes toward learning about healthier eating practices were favorable.

Coping responses and posttraumatic stress symptomatology in urban fire service personnel

Emergency workers, including urban fire fighters and paramedics, must cope with a variety of duty-related stressors including traumatic incident exposures. Little is known about coping responses of emergency workers or whether their coping responses predict future mental health outcomes. The previously formulated Coping Responses of Rescue Workers Inventory (CRRWI) underwent a principal components analysis employing a sample (N = 220) of urban fire fighters and paramedics. Six empirically and theoretically distinct CRRWI components were identified which were relatively stable over a 6-month period. Scores on one of the CRRWI scales, but neither years of service nor their past half year's traumatic incident exposures, predicted future changes in self-reports of posttraumatic stress symptomatology.

Outcomes and costs of a community support worker service for the severely mentally ill

There has recently been an expansion of paraprofessional staff involved in the provision of care for the severely mentally ill. In this paper we shall evaluate the effects of a community support worker (CSW) service in South London. A sample of patients with severe mental illness receiving the service was assessed over a 6-month period in order to examine the effects of continuing use of CSWs on outcomes, service use and costs. During the study period there were improvements in outcome reflecting service satisfaction, needs, quality of life and social behaviour. Whilst provision of the CSW service did not lead to extra total service costs, service use and cost data suggest that CSWs are associated with the substitution of in-patient use by community-based services.

Mutations in CUBN, encoding the intrinsic factor-vitamin B12 receptor, cubilin, cause hereditary megaloblastic anaemia 1

Megaloblastic anaemia 1 (MGA1, OMIM 261100) is a rare, autosomal recessive disorder characterized by juvenile megaloblastic anaemia, as well as neurological symptoms that may be the only manifestations. At the cellular level, MGA1 is characterized by selective intestinal vitamin B12 (B12, cobalamin) malabsorption. MGA1 occurs worldwide, but its prevalence is higher in several Middle Eastern countries and Norway, and highest in Finland (0.8/100,000). We previously mapped the MGA1 locus by linkage analysis in Finnish and Norwegian families to a 6-cM region on chromosome 10p12.1 (ref. 8). A functional candidate gene encoding the intrinsic factor (IF)-B12 receptor, cubilin, was recently cloned; the human homologue, CUBN, was mapped to the same region. We have now refined the MGA1 region by linkage disequilibrium (LD) mapping, fine-mapped CUBN and identified two independent disease-specific CUBN mutations in 17 Finnish MGA1 families. Our genetic and molecular data indicate that mutations in CUBN cause MGA1.

Isobaric spinal anesthesia for paraplegic patients

It has long been understood that patients with spinal cord injury (SCI) above T6-7 may develop autonomic hyperreflexia (AH) and pose an anesthetic challenge. To date, there is no consensus regarding anesthesia management of these patients among anesthesiologists. Many anesthetic techniques have been proposed and used with varying success, but none of them is uniformly successful. Topical anesthetics may not block the stretch receptors and AH might still be initiated. A deep anesthesia with potent volatile agents is often necessary to prevent or treat AH. Thus, the incidence of hypotension is no different than that associated with neuraxial anesthesia. Failures with potent vasodilators such as sodium nitroprusside also have been reported. Currently, the block of the afferent pathways by neuraxial anesthesia is considered to be the most effective means of preventing AH. However, because the level of neuraxial anesthesia is difficult to detect in SCI patients, excessive high level block and subsequent severe hypotension may occur. When an isobaric solution is used, due to the lack of baricity/patient position interaction, migration of the local anesthetic is usually insignificant, so the level of anesthesia is easier to control and predict. In the past fifteen years (1982-1997), we have used isobaric spinal anesthesia (ISA) in thirteen patients with SCI for various surgical procedures. Although four of these patients had previous history of AH, there was not a single incidence of AH during the perioperative period. Our favorable experiences lead us to believe that ISA is a useful anesthetic technique for SCI patients undergoing surgery.

Effect of 131I-induced hypothyroidism on indices of reproductive function in adult male dogs

Hypothyroidism has been cited as a cause of infertility, abnormal semen quality, and poor libido in people and animals. The purpose of this study was to evaluate the effect of hypothyroidism on variables indicative of reproductive function in adult male dogs. Nine normal dogs were randomly assigned to 2 groups. Hypothyroidism was induced with 131I in 6 dogs. Three dogs remained untreated, normal, and euthyroid. Thyroid hormone concentrations, body weight, clinical signs, and reproductive function were determined for each dog every 3 months for 2 years. Reproductive function was assessed by determining daily sperm output, total scrotal width, spermatozoal motility and morphology, libido, and serum testosterone and luteinizing hormone concentration responses to exogenous gonadotropin-releasing hormone. The 131I-treated dogs developed clinical and laboratory signs of hypothyroidism. In the hypothyroid dogs, serum concentrations of thyroid hormones were consistently below the reference range and were significantly lower than that in the euthyroid dogs. There was no difference in reproductive function between the hypothyroid and euthyroid dogs. The results of this study show that 131I-induced hypothyroidism does not affect indices of reproductive function in adult male dogs.

Accuracy of four commercially available serologic tests, including two office-based tests and a commercially available 13C urea breath test, for diagnosis of Helicobacter pylori

BACKGROUND

Diagnosis of H. pylori infection may be made by endoscopic (invasive) tests, or by nonendoscopic (noninvasive) tests. Our aim was to evaluate recently available nonendoscopic tests, including two office-based serologic tests and a commercially available 13C urea breath test.

METHODS

Gastric biopsy specimens (for culture and stain) from 178 patients (mean age 46 +/- 13.3 years, 79 men and 99 women), none of whom had received anti-H. pylori therapy, were tested for H. pylori infection. These tests were compared against two commercial serum IgG antibody immunoassays (Biowhittaker's Pyloristat, and Quidel), 2 office-based serum qualitative IgG antibody tests (FlexSure HP, and QuickVue One-Step), the Meretek 13C urea breath test, and the CLOtest (a biopsy urease test).

RESULTS

The breath test (n = 147) had the best accuracy (96%) of the noninvasive tests studied. The serologic tests had similar accuracy to one another (84%-90%). The major drawback of the serologic tests was suboptimal specificity (75%-87%). Diagnosis of H. pylori based on the two office-based tests were not significantly different compared to the quantitative IgG antibody tests. The CLOtest had an accuracy of 97%.

CONCLUSIONS

The Meretek 13C urea breath test is an excellent test, but is considerably more expensive than serologic tests. The FlexSure HP and the QuickVue One-Step office-based qualitative IgG serologic antibody tests gave similar results to laboratory based quantitative antibody tests, and are acceptable for initial diagnosis of H. pylori infection. The advantages of the office-based tests are low cost, simplicity, and immediacy of results.

Elevated cytokine concentrations in the nasopharyngeal and tracheal secretions of children with respiratory syncytial virus disease

BACKGROUND

Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract disease in infants. The role of inflammatory mediators in the pathogenesis of RSV disease is not well-understood. The present study was designed (1) to determine whether RANTES (regulated on activation, normal T cell expressed and presumably secreted), macrophage-inflammatory protein-1-alpha (MIP-1-alpha), interleukin (IL)-6, IL-8 and IL-10 can be detected in respiratory secretions of children with RSV infection and (2) to assess whether the concentrations of these cytokines in respiratory secretions correlate with white blood cell (WBC) counts and RSV concentrations and with disease severity.

METHODS

During the 1996 to 1997 RSV season, we studied prospectively 14 intubated and 14 nonintubated children hospitalized with RSV disease. Nasal wash (NW) and tracheal aspirate (TA) samples were obtained from intubated patients on Hospital Days 1, 3 and 5. NW samples were obtained from nonintubated patients on hospital days 1 and 3. Seven healthy children undergoing elective surgery served as controls. All samples were analyzed for: (1) WBC and differential counts; (2) concentrations of RANTES, MIP-1-alpha, IL-6, IL-8 and IL-10; and (3) quantitative RSV cultures, except in control patients.

RESULTS

RANTES, MIP-1-alpha, IL-6, IL-8 and IL-10 were detected in NW and TA samples from all children with RSV infection. The concentrations of these cytokines in samples obtained from children with RSV infection were significantly greater than those in samples obtained from control children. NW WBC counts significantly correlated with NW RANTES, IL-6, IL-8 and IL-10 concentrations, whereas TA WBC counts significantly correlated with TA IL-6, IL-8, IL-10 and MIP-1-alpha concentrations. NW RSV concentrations correlated with NW WBC counts and with NW cytokine concentrations. Among children with RSV infection nonintubated patients had greater NW WBC counts and NW RANTES concentrations than intubated patients. TA RANTES, IL-8 and IL-10 concentrations inversely correlated with clinical markers of RSV disease severity.

CONCLUSION

The presence of cytokines in NW and TA samples of children with RSV infection suggests that they have a role in mediating the respiratory tract inflammation induced by RSV. These observations could have implications for designing new therapeutic strategies directed at immunomodulation of RSV disease.

Splinting in the treatment of arthritis of the first carpometacarpal joint

Although much has been written about surgical treatment of arthritis of the first carpometacarpal joint, no literature exists on splinting as a conservative treatment. One hundred fourteen patients (130 thumbs) were retrospectively reviewed to determine the efficacy of splinting. Patients were grouped according to their stage of disease and whether they had carpometacarpal joint surgery. Seventy-six percent of patients with stage I and II disease and 54% of patients with stage III and IV disease had improvement in their symptoms with splinting. There was no significant difference in the degree of improvement between the 2 groups. All patients who had initial improvement in their symptoms with splinting had between 54% and 61% average improvement in symptom severity 6 months after splinting. All groups were found to be equally tolerant of the splinting protocol and no group had a significantly higher rate of activity modification. Overall, splinting was found to be a well-tolerated and effective conservative treatment to diminish, but not completely eliminate, the symptoms of carpometacarpal joint arthritis and inflammation.