Violence in mental health care: the experiences of mental health nurses and psychiatrists

Violence against mental health service personnel is a serious workplace problem and one that appears to be increasing. This study aimed to ascertain the extent and nature of violence against mental health nurses and psychiatrists, and to identify what support, if any, they received following exposure to violence. Mental health staff working within five West Midlands Trusts in the United Kingdom were surveyed using a postal questionnaire to investigate the extent and nature of violence they encountered in their daily work. There was an overall response rate of 47%, which included a response rate for psychiatrists of 60% (n=74) and for mental health nurses of 45% (n=301). Though both groups experienced violence at work, nurses were found: to have been exposed to violence significantly more during their career; to have been a victim of violence within the previous 12 months of the survey; and to have suffered a violent incident involving physical contact. Whilst a higher proportion of nurses than psychiatrists received some support following a violent incident, a large proportion of both groups did not receive any, although most felt in need of it. The implications of this study for training and management are discussed.

Individual and organizational well-being in psychiatric nursing: a cross-cultural study

Although health care systems around the world are undergoing rapid changes, there is an absence of comparative studies of how these changes affect nurses' well-being and work life. The purpose of this study was (i) to identify and describe possible differences between the psycho-social work environments of English and Swedish mental health nurses, and (ii) to attempt to explain these differences. 1016 psychiatric nurses from Stockholm (Sweden) and Birmingham (England) responded to a postal questionnaire on their psycho-social work environment and feelings of professional fulfillment, mental energy and work-related exhaustion. The study was given ethical clearance in Stockholm and Birmingham. Results indicated that while the English nurses rated their organizational well-being more favourably, Swedish psychiatric nurses reported greater individual well-being than their counterparts. Multiple regression analyses indicated that self-esteem was important for explaining mental energy and work-related exhaustion, but less so for explaining professional fulfillment, which was predicted primarily by organizational factors. When controlling for self-esteem, which was higher amongst the Swedish nurses, the differences in professional fulfillment and mental health were no longer significant. Reasons for the differences in self-esteem and experiences of the workplace are discussed. Low response rate may have contributed to a selection bias.

Annie Altschul's legacy to 20th century British mental health nursing

Being knowledgeable about, learning from and building upon one's history is the hallmark of an enlightened and progressive profession. This includes an appreciation of the work of those who contributed to moulding the profession into what it currently is. Mental health nursing has not distinguished itself by respect for its former leaders. In this paper, the life and times of one of the most outstanding mental health nurses of the century, Professor Annie Altschul, are recalled and examined. She sought constantly to establish what should be the essence of mental health nursing and what its role should be in the alleviation of human suffering. As an outsider herself, she identified strongly with those marginalized by society. Always a spokesperson for the centrality of nursing in patient care, she saw nurses as those best placed to provide holistic care to patients whilst other professionals specialized in their biomedical, social and financial needs. Long after her retirement, Altschul remains active in supervising and examining postgraduate nursing students. She is still a voice in the mental health debate, someone whose opinions are sought and valued.

Practice nurses' perceptions of services for clients with psychological problems in primary care

Over a third of people presenting in primary care in the United Kingdom (UK) have a mental health problem causing some degree of disruption in their lives. Approximately 90% of these are treated and managed by primary care staff without any support from mental health services. Following the White Paper published by the UK Department of Health in 1997 (Department of Health, 1997. The New NHS--Modern and Dependable, HMSO, London), the influence of primary care both in the commissioning and provision of mental health services is likely to increase. By far the largest professional group currently involved in mental health in primary care are practice nurses. Although their numbers have increased dramatically during this decade, little is known of the work they do or of their perceptions of it. The present questionnaire-based study sought to elicit the types of mental health problems encountered by practice nurses in primary care, the interventions they provide and the skills they utilise. The data indicates that practice nurses care for people with a wide variety of mental health problems ranging from mild to severe. Many feel unprepared for this type of work and are reluctant to get too involved with clients in case they uncover problems they are not able to cope with. Lack of access to appropriate educational support is identified as the main problem currently faced by practice nurses alongside poor inter-professional relationships with mental health personnel. This paper discusses ways of meeting the needs of practice nurses and of improving collaboration in primary care settings.

First Report of Entyloma Polysporum on Sunflower (Helianthus annuus) in Southern California

During a period of wet weather from December 1996 to March 1997, commercial plantings of sunflower in San Diego County, CA, were infected by a leaf smut, Entyloma polysporum (Peck) Farl. The fungus was observed on sunflowers grown in a greenhouse in San Diego County and also on sunflowers from nurseries in Ventura and Riverside counties. Although the disease was first noticed in 1996, the infection was not of economic significance so no attempt was made to identify the causal agent. However, with continuous cropping of sunflowers year round significant losses were observed on seedlings that were systemically infected as they emerged. This is the first report of E. polysporum causing economic losses on sunflowers. The distinguishing characteristics of this fungus are masses of globose to subglobose spores, pale green to yellow green in color, approximately 12 μm in diameter, with a double wall consisting of an inner pale green wall and outer hyaline sheath. The spores occur in dense masses called sori that completely replace the leaf cells. Young spores are difficult to distinguish from leaf cells in a cursory examination. Older sori form discolored lesions in the leaf ranging from circular to irregular in shape and replace most of the chlorenchyma tissue in the infected lesions. Identification of species of smut fungi such as Entyloma is based on the location of the sori in the vegetative parts of the host, the identification of the host, and the spore morphology (4). Savile (3) reviewed the genus on North American composites and, based on morphological characteristics, concluded that almost all the pathogens were either E. compositarum or E. polysporum, with a few intermediate forms. E. polysporum is characterized by globose spores 10 to 17 μm in diameter, surrounded by cell walls 1 μm thick encased in a 1.5- to 2.5-μm thick smooth hyaline sheath (1). Spores of E. compositarum are smaller, 9 to 12 μm in diameter, thin walled (1 to 1.5 μm), smooth, and without a sheath (2). Vánky (4) lists 33 different species on composites according to their host. He believes E. polysporum only occurs on Ambrosia spp., and does not include E. compositarum in his list of Entyloma spp. Neither author mentions Entyloma infecting any species of Helianthus. Savile concluded that E. calendulae (Oudem.) de Bary, described in Europe, is very similar morphologically to E. polysporum, and is probably the same species. E. polysporum was first described in 1881 by Peck as Protomyces polysporus infecting Ambrosia trifida in New York State. In 1996, it was described on Ambrosia artemesifolia in Hungary (3). In the United States it has been reported on sunflowers in Montana (1,2). References: (1) D. F. Farr et al. 1989. Fungi on Plants and Plant Products in the United States. American Phytopathological Society, St. Paul, MN. (2) G. W. Fischer. 1953. Manual of the North American Smut Fungi. Ronald Press, New York. (3) D. B. O. Savile. Can. J. Res. 25(C):109, 1947. (4) K. Vánky. 1994. European Smut Fungi. Gustav Fischer, New York.

Nursing language: uses and abuses

Nurses communicate with a variety of people on many different levels. Yet the full importance of nurse language is not fully appreciated. This article examines the use of nursing language and suggests that nurses can increase their professional potential through using language more consciously.

A comparative study of the perceptions of British mental health nurses and psychiatrists of their work environment

This comparative study of the perceptions of mental health nurses and psychiatrists about aspects of their work environment was undertaken in the West Midlands in England. The aim of the study was to ascertain the extent to which the environment in which mental health professionals' work impacts on their own mental and physical well-being. Seventy-four psychiatrists and 301 mental health nurses responded to a postal questionnaire. Analysis of data indicated that significant differences exist between nurses and psychiatrists in their working conditions, their physical working environment, their sources of support with a work-related problem, and the effects of their work on their own mental and physical health. The main recommendation derived from this study was to improve communication between mental health professionals and their managers by giving more structured feedback and guidance about one's work performance. This may help to alleviate the mental strain many mental health professionals experience in their work.

Predictors of a healthy workplace for Swedish and English psychiatrists

BACKGROUND

Few studies have attempted to analyse the organisational aspects of the workplace that may affect the well-being of psychiatrists and even fewer have offered insights into what a positive workplace might look like. This study provides an outline of such a workplace, with reference to individual and organisational factors. In addition, a comparison is made between two European cities to check for cultural differences.

METHOD

Three hundred and eighty psychiatrists from Stockholm and Birmingham responded to a previously tested questionnaire on their work environment.

RESULTS

Predictors of a positive workplace for psychiatrists were: high self-esteem, satisfactory support with work-related problems, lower perceived workload, positive view of leadership, low work-related exhaustion and having a sense of participation in the organisation. There were few cultural differences.

CONCLUSIONS

Measures should be taken to improve leadership skills for managers, to offer more support for work-related problems, and to allow psychiatrists to participate more in the organisation.

The role of lateral cephalometric radiography and fluoroscopy in assessing mandibular advancement in sleep-related disorders

Mandibular advancement splints are successful in managing obstructive sleep apnoea (OSA) in selected subjects. For these to be effective, some improvement in the dimensions of the oropharyngeal airway must occur. Twenty subjects with proven obstructive sleep apnoea were examined using lateral cephalometric radiography and a fluoroscopic technique. Cephalograms were analysed, and assessed for both skeletal and soft tissue abnormalities known to be present in OSA subjects. On the basis of these, a prediction was made as to whether the subject's oropharyngeal airway would increase during mandibular protrusion. From the fluoroscopic sequences, the narrowest antero-posterior dimensions of the post-palatal and post-lingual airways were recorded as the mandible moved from the intercuspal position into maximal protrusion. The changes in airway size were noted and these were compared with the predictions made from the static films. In nine subjects, fluoroscopy indicated that the airway opened well during mandibular protrusion, seven did not improve and in four the changes were minimal. Post-palatally the mean airway increase was 2.6 mm, whilst behind the tongue a mean improvement of 3.1 mm was seen. In all but two instances, the cephalometric prediction agreed exactly with the outcome demonstrated by fluoroscopy. All subjects whose airways clearly increased were correctly identified by the cephalogram alone. Cephalometric features associated with a good airway response to protrusion were a reduced lower facial height, low maxillomandibular planes angle and a high hyoid position, accompanied by a normal anteroposterior relationship of the jaws, relatively normal mandibular body length and soft palate area. The more abnormal the skeletal and soft tissue dimensions, the poorer the prognosis. Thus, whilst a single radiograph could indicate whether a positive mandibular response to protrusion could be expected, where doubt existed, a fluoroscopic analysis could provide a useful adjunct to diagnosis.

Competencies drive decision making

Staff nurses, using the Nursing Interventions Classification, selected the core competencies, performance criteria and interventions relevant to their practice. A performance-based approach highlights performance outcomes and previous experience. A preceptor and self-directed learning activities help apply the knowledge in the work setting.

A survey of patients placed on the supervision register in one mental health trust

Mental health nurses, in common with other health care groups, are charged with monitoring the quality of care for severely mentally ill clients. It is now apparent that improving the social functioning of these clients is far more complex than was previously thought and demands better coordinated services. To improve services is especially challenging at a time when resources are diminishing and existing generic mental health services find themselves under severe pressure. The introduction of the Supervision Register (1994) was one response to a number of high profile incidents in the U.K. which suggested that greater collaboration between health services, social services and voluntary agencies needed to be sought. This study aimed to ascertain the characteristics of clients placed on the Register and the reaction of the mental health professionals who have to implement it. Although the majority of staff interviewed in the course of the study acknowledged that the Register served to highlight and perhaps potentiate the constituents of good practice, a number were concerned that in the absence of appropriate and sufficient community-based resources, procedural mechanisms such as the Supervision Register were merely a cosmetic purpose.

Mental health nursing in the 1950s and 1960s revisited

From the post-War period to the 1960s, immense changes took place in the philosophy, organization and delivery of mental health care in the UK. These changes were driven by the financial burden that Bevan's National Health Service imposed on the British Government, by the dynamism and vision of psychiatrists and mental health nurses returning from the War, and by a new social and cultural consciousness, which put minority groups such as the mentally ill onto the political agenda. This paper seeks to explore some of these complex interactions and to show how the closure of mental hospitals was the inevitable outcome of movements both inside psychiatry and far beyond it. An awareness of the historical context of mental health care can assist planners and providers to avoid the many pitfalls that have been made by our predecessors.

Post polio syndrome. The late sequelae of poliomyelitis

Patients who in earlier life suffered from acute poliomyelitis are reporting new and disabling symptoms that have been variously labelled the 'late sequelae' or 'post polio syndrome'. Systematic review of such patients has identified specific categories of disability. A practical investigation and management plan for such patients presenting to a general practitioner is proposed.

Towards a rhetoric of spirituality in mental health care

The spiritual dimension of care is frequently alluded to in the nursing literature, but rarely examined in terms of what it means in practice or how it might be taught to students entering the profession. Some of those most in need of spiritual care are people suffering from mental illness or psychological distress. The aim of this paper is to explore the different meanings of spirituality and to suggest ways in which the spiritual care of clients can be implemented. It further recommends which aspects of spirituality could usefully be included in nursing curricula. The paper concludes by alerting nurses to the causes and manifestations of spiritual apathy in contemporary health care and calls for a rhetoric that will counter the jargon of cost analysis which currently prevails in the health services.

Potassium and ventilation during exercise above and below the ventilatory threshold

Increases in arterial plasma potassium during exercise may provide an important drive to ventilation. We examined the changes in arterialized venous plasma potassium concentration ([K +]av) and ventilation that occur during sustained exercise at workloads above and below the ventilatory threshold (Vt) in young health humans. After the onset of exercise at a workload below-Vt, [K +]av rose by 0.3 (+/- 0.1) mmol l-1 (mean +/- SEM). Following 30 min of exercise at this intensity [K +]av had fallen (P < 0.05, ANOVA) by an amount approximately equal to one third of the initial increase. While [K +]av fell, ventilation remained stable. At 5 min after the onset of sustained exercise above the Vt [K +]av had risen by 0.7 (+/- 0.1) mmol l-1 and thereafter remained constant. Ventilation slowly increased throughout the above-Vt protocol. These results show significant differences in the time course of the changes in [K +]av and ventilation. They do not support the hypothesis that changes in [K +]a during moderate exercise cause linearly related changes in ventilation.

A critique of the concept of quality of life

Taking a philosophical approach, ancient Greek philosophers and Christians began to investigate the concept of quality of life. Later, such philisophical pursuit was replaced by the school of positivism, which indicated that science was and still is the only valid form of enquiry. Through such positivistic science, the metaphysical nature of the concept of quality of life is thought to be uncovered. However, the later Wittgensteinian philosophical thoughts demonstrated that there is no metaphysical understanding of any concepts but there is only knowledge of playing language games. In the light of this philosophy, prior to any scientific investigations, researchers have already understood and agreed on the concept of quality of life by playing language games. From the above philosophical analyses, outlines some implications for health care research.

Evaluation of health promotion activities in community nursing practice

The purpose of this research was to study the extent to which community nurses (CNs) were involved in health promotion activities and to investigate whether these activities were meeting the needs of their clients. A cross-sectional survey by multiple methods was designed and carried out in four district health authorities (DHAs) in one regional health authority in England. Two hundred and fifty-one (83.67%) completed questionnaires were returned by CNs working in primary health care (PHC). Sixty sessions with CNs were observed and 249 interviews were conducted with clients. Additionally, as part of the observation 155 clinical records were examined. CNs reported involvement in a wide range of opportunistic and organized health promotion activities. Lifestyle advice and ill-health prevention were most frequently used by all groups. Health visitors (HVs) were involved significantly more in group and community wide activities. District nurses (DNs) were mainly involved in opportunistic health promotion. Practice nurses (PNs) were found to be involved significantly more in health promotion activities organized on an individual basis. Observation revealed that opportunistic health promotion was carried out in almost half of the consultations observed, of which lifestyle advice was the most frequent. Records however showed that this information was rarely recorded. The clients of PNs were mostly aware of other health promotion activities available within the general practice, while almost half of the HVs' clients knew what other health promotion activities were available to them and few DNs' clients were aware of any.

Interaction, language and the "narrative turn" in psychotherapy and psychiatry

The traditional emphasis in psychiatry about "listening to patients" has recently been added to by the development of what we call the "narrative turn" in mental health care where clients' narratives are emphasised. We shall argue however that both approaches tend to embody similar assumptions about therapeutic transactions and roles, and that much work emphasising narratives reveals little about how therapists and researchers work to reconstruct the clients' accounts. It is therefore vital that the emphasis on narratives be supplemented by a more thoroughgoing approach to shared structures of knowledge which act to prefigure clients' distress, how professional records are a profoundly transformative medium, and how therapeutic encounters work to co-construct clients' narratives, rather than simply reflect or explore them. The radical implications of thinking about therapy in terms of narrative and language need to be more fully discussed in the therapy literature, so the narrative turn does not simply reproduce the common-sense assumptions of more conventional approaches.

Chronic lymphatic leukaemia presenting as severe obstructive sleep apnoea

A case of adenotonsillar enlargement from chronic lymphatic leukaemia leading to severe obstructive sleep apnoea (OSA) is described. Nasal continuous positive airway pressure (nCPAP) therapy was poorly tolerated because even at high pressures (+15 cm H2O) obstructive hypopnoeas persisted. Tonsillectomy resulted in significant improvement, though OSA persisted. nCPAP was reintroduced and at low pressures (+6 cm H2O) was efficacious in alleviating the patient's symptoms. This report highlights the need to consider OSA as a cause of constitutional symptoms in adults with lymphoreticular disease, especially where there is involvement of Waldeyer's ring.

Clinical features predictive of exercise-induced asthma in children

Exercise-induced asthma (EIA) is a common symptom among young asthmatics. The hypothesis that asymptomatic day-to-day wide fluctuations in lung function and asymptomatic persistent airflow obstruction are risk factors for the development of EIA was studied. The study population was a cohort of known asthmatic children aged 9-14 years attending a residential asthma camp. The method involved the observation of baseline expiratory peak flow recordings (PEFR) for 5 days while the children were receiving their usual maintenance therapy. The method also included the determination of FEV1 pre- and post- 15 min of continuous aerobic exercise. Exercise-induced asthma was expressed as the Lability index (LI). The findings were that LI was significantly correlated (P < 0.01) with the mean PEFR as a per cent of each child's predicted PEFR. The lability index also correlated (P < 0.01) with the degree of day-to-day variability in PEFR expressed as the coefficient of variance (CV). It is concluded that there is a significant correlation between baseline asthma control and the development of EIA. In addition to recommending pre-exercise prophylaxis, practitioners should investigate overall asthma control in children reporting EIA.

Science and early development of mental health nursing

Until very recently, the history of mental health care received little critical investigation. This paper seeks to explore how the western scientific tradition shaped mental health nursing and investigates the pivotal influences which affected its early development, emphasising the role played by mid-19th century asylum care.

Effects of positive airway pressure on upper airway dilator muscle activity and ventilatory timing

To determine upper airway (UA) and ventilatory responses to nasal continuous positive airway pressure (CPAP) and expiratory positive airway pressure (EPAP), we quantitated changes in alae nasi (AN) and genioglossus (GG) electromyographic (EMG) activity, ventilatory timing, and end-expiratory lung volume (EELV) at various levels of CPAP and EPAP in six normal subjects during wakefulness and in seven during sleep. The same measurements were also made before and after UA anesthesia in six normal subjects during wakefulness. During both wakefulness and sleep, CPAP application significantly increased EELV and decreased AN and GG EMG activities. In contrast, EPAP significantly increased EMG activities of both muscles while also increasing EELV during wakefulness. The EMG responses were less marked during sleep. Anesthesia of the UA abolished the EMG responses to CPAP but not to EPAP. These results suggest that, in normal subjects, CPAP application causes a reflex reduction in UA dilator muscle activity mediated by UA sensory receptors. In contrast, EPAP increases UA dilator muscle activity, with the response mediated by conscious influences or reflexes arising outside of the UA.

Utilization of a personal health record in a general medicine clinic

To determine the baseline use of personal medical records maintained by patients, to initiate utilization of a personal health record (PHR), and to assess outcomes associated with its use, a survey, intervention, and outcome study was conducted with follow-up at 2, 7, and 14 months. One hundred randomly selected adult patients of the General Medicine Clinic at The University of Iowa Hospitals and Clinics were evaluated. At onset, 44% maintained no records. At 14-month follow-up, 69% maintained the PHR. The change in documentation was statistically significant (p = .013 x 10(-8), McNemar's Test for Paired Data; 95% confidence interval 0.065, 0.54). The baseline use of personal medical records was poor, but it was improved following introduction of the PHR, and most patients continued using the record 14 months later.

Development of a stress scale for mental health professionals

This paper describes the development of the Mental Health Professionals Stress Scale (MHPSS): a self-report method of identifying sources of stress for mental health professionals. The 42-item scale, which includes seven subscales, was administered to 154 clinical psychologists and 111 mental health nurses. The MHPSS was found to have good internal consistency (alpha = .87 for clinical psychologists; alpha = .94 for mental health nurses). The preliminary evidence suggests that the concurrent validity of the MHPSS is good. The expected relationships between the scale and between the criterion measures--General Health Questionnaire, a symptom check list, job satisfaction, self-reported stress level and quality of social support--were demonstrated. The results also provide evidence for the discriminant validity of the subscales to measure different aspects of the stress experience. The MHPSS was shown to discriminate between two groups of health professionals who might be expected to differ in their sources of stress. For clinical psychologists the most important source of stress was 'professional self-doubt' whereas the major source of stress for mental health nurses was found to be the difficulty of handling potentially violent or difficult patients in the context of scarce staff resources. For both groups, however, 'home-work conflict' was the subscale most strongly and consistently associated with mental health outcome. It is concluded that the preliminary evidence regarding the utility of the MHPSS is encouraging, although further data are clearly needed.

Linguistic entrapment: medico-nursing biographies as fictions

This paper argues that in their trainings health professionals are encouraged to use language naively as if it were a transparent medium of scientific communication. We contend that language use, particularly in the field of mental health care, should be studied in terms of its social functions and attention should be paid to the inevitably constructive nature of language in patients' records, in order that a 'fictional distance' opens up between patients and their records. Recent developments in literary theory and narrative analysis can be deployed as theoretical frameworks to understand this process, and we suggest that more attention to the use of language should be included in the educational programmes for health care professionals to counteract the risk of 'linguistic entrapment' or 'incarceration'.

A measurement tool for assessing stress among mental health nurses

There is growing evidence that nursing is a stressful occupation, particularly mental health nursing. However, the lack of an appropriate measurement tool has meant it has been difficult to investigate the nature of this stress. The aim of this study was to assess the efficacy of one such scale for measuring stress in mental health nurses, the Mental Health Professional Stress Scale. A total of six questionnaires was sent to a sample of 210 community and hospital mental health nurses. The findings suggested that the scale was a useful measure and predictor of stress. The most consistent predictor of poor mental health outcomes for nurses was home/work conflict, outweighing the significance of client/patient-related difficulties.

Survey of the social networks of people with severe mental health problems

The social functioning of people with severe mental health problems is an indicator of general physical and emotional well-being. There exists a wealth of literature on the topic from the professional carer's perspective but relatively little from the perspective of the clients themselves. Thirty clients were interviewed in order to explore their understanding of the nature and value of the social networks in which they were currently involved. Despite having participated in a variety of rehabilitation interventions, these clients remained insecure and lacking in confidence. They had few friends beyond members of their immediate family and were generally leading lonely, friendless existences without the capacity to establish new relationships. Although this study suggests that clients often have grandiose plans for the future, mental health nurses may best meet their needs by helping to sustain existing relationships and using them at all levels of therapeutic intervention, rather than attempting to nurture new relationships for which clients are unready and the failure of which may result in a relapse in clients' mental health status.

The effects of oesophageal distension on diaphragm and laryngeal muscle activity in the anaesthetized cat

The electromyographic (EMG) activities of diaphragm and laryngeal muscles were recorded during oesophageal distension in anesthetized cats. The responses to distension of the thoracic oesophagus differed from those evoked by distension of the cervical oesophagus. The crural component of the diaphragm (CD) was inhibited by distension of the thoracic oesophagus; distension of the cervical oesophagus did not affect CD EMG. Thyroarytenoid (TA) muscle EMG increased markedly and consistently in response to distension of the cervical oesophagus. Distension of the thoracic oesophagus only produced statistically significant increases in TA EMG with high distending volume (10 ml) at the level of the gastro-oesophageal junction. The main abductor of the vocal cords, the posterior cricoarytenoid (PCA) was either unchanged or decreased by oesophageal distension. The electrical activities of left paratendinous diaphragm, left costal diaphragm, internal intercostal and external intercostal muscles remained unchanged. The entire pattern would appear to constitute a means to aid passage of a bolus into the stomach, and simultaneously guard the respiratory tract from reflux or aspiration.

The influence of positivistic thought on nineteenth century asylum nursing

The development of positivism, which had a considerable influence on the evolution of psychiatric thought and practice during the second half of the nineteenth century, is outlined. It was within this intellectual framework that figures such as Kraepelin, Bleuler and Schneider developed psychiatric nosologies and diagnostic criteria for certain mental illnesses. While there was little scientific evidence to support the claim that medical treatments had any beneficial effects on pyschiatric disorders, nevertheless psychiatric institutions were established in the mid-nineteenth century based on the medical model. Nurses were expected to observe, collect and report data on mental patients which were then presented to doctors for analysis. The intellectual climate of the asylums was such that nurses were not encouraged to question the scientific principles upon which the therapeutic regime was based, nor were they encouraged to seek a rationale for their daily observations and data collection. The specialized training for asylum nurses which was introduced towards the end of the nineteenth century did not give nurses their own professional identity, but rather reinforced the supremacy of medical knowledge in the care of the mentally ill. Trained nurses enhanced medical credibility, but did not progress care of the mentally ill because their training did not imply or encourage questioning of the positivistic basis of psychiatric treatment.

DiGeorge anomaly with renal agenesis in infants of mothers with diabetes

We report on 2 infants with the DiGeorge anomaly born to diabetic mothers treated with insulin. Both infants had unilateral renal agenesis. One of the mothers has manifestations suggestive of velo-cardio-facial syndrome (VCFS). Cytogenetic studies on both patients and the mother with apparent VCFS were normal. Molecular studies utilizing probes from the DiGeorge critical region did not demonstrate a 22q11 microdeletion in either patient or the mother with apparent VCFS. We conclude that maternal diabetes is a pathogenetic factor in the DiGeorge anomaly, and infants of diabetic mothers who have this anomaly should also be screened for renal agenesis.

Carbon dioxide-sensitive superior laryngeal nerve afferents in the anaesthetized cat

The effects of CO2 on laryngeal receptors were studied in ten anaesthetized, paralysed, artificially ventilated cats using a preparation in which the upper airway was isolated in situ and artificially ventilated. This allowed CO2 to be confined to the upper airway and enabled responses to CO2 to be recorded whilst the larynx was being ventilated under physiological conditions. Single-unit afferent activity was recorded from the superior laryngeal nerve and the pressure and thermal sensitivity of receptors determined. Carbon dioxide responses were tested by switching from upper airway ventilation with room air to mixtures containing 5 and 9% CO2 with 21% O2 in N2. Fibres were classified into two broad groups, tonic and quiescent, depending on their level of activity when the larynx was not being ventilated. All tonic fibres responded to either positive or negative pressure. Quiescent fibres were either positive or negative pressure receptors, cold receptors or had no response to pressure or cold airflow. The majority of all categories of fibres were significantly affected by CO2 in a reversible and usually concentration-dependent manner. Tonic fibres were inhibited, regardless of pressure sensitivity. Quiescent negative and positive pressure receptors were excited and inhibited respectively whilst cold receptors and fibres with no response to occlusion were excited. Laryngeal hypoxia and systemic asphyxia and hypercapnia had no effect on receptor activity. We conclude that the majority of laryngeal receptors are sensitive to CO2 and that this receptivity may be important in the control of ventilation and upper airway muscle activity.

Comparative mapping of 9 human chromosome 22q loci in the laboratory mouse

We present a comparative map of genes on human chromosome 22q and homologous loci in the mouse genome. Gene order in humans was established using a panel of somatic cell hybrids. Genetic maps spanning homologous segments on three mouse chromosomes were generated using an interspecific backcross. The conserved linkage between human chromosome 22 and mouse chromosome 16 includes two closely linked loci, Comt and IgI-1. The second conserved linkage involves human chromosome 22 and mouse chromosome 11 and contains two genetically and physically linked loci, Lif and Nfh. Finally, conserved synteny involving mouse chromosome 15 and human chromosome 22 spans 30 cM and contains five loci (Acr, Bzrp, Dia-1, Il2rb and Pdgfb). Loci within this conserved synteny have been sublocalized to different portions of human chromosome 22. The order of genes on mouse chromosome 15 and human chromosome 22 provides further evidence for chromosomal rearrangements within the conserved synteny that have occurred since the divergence of lineages leading to mice and humans.