CT pulmonary angiography in lower limb arthroplasty

Aims

The aims of this study were to determine the indications and frequency of ordering a CT pulmonary angiography (CTPA) following primary arthroplasty of the hip and knee, and to determine the number of positive scans in these patients, the location of emboli and the outcome for patients undergoing CTPA.

Patients and Methods

We analyzed the use of CTPA, as an inpatient and up to 90 days as an outpatient, in a cohort of patients and reviewed the medical records and imaging for each patient undergoing CTPA.

Results

Out of 11 249 patients, scans were requested in 229 (2.04%) and 86 (38%) were positive. No patient undergoing CTPA died within 90 days. The rate of mortality from pulmonary embolism (PE) overall was 0.08%. CTPA was performed twice as often following total knee arthroplasty (TKA) compared with total hip arthroplasty (THA), and when performed was twice as likely to be positive. Hypoxia was the main indication for a scan, being the indication in 149 scans (65%); and in 23% (11 of 47), the PE was peripheral and unilateral. Three patients suffered complications resulting from therapeutic anticoagulation for possible PE, two of whom had a negative CTPA.

Conclusion

CTPA is more likely to be performed following TKA compared with THA. Hypoxia was the main presenting feature of PE. A quarter of PEs which were diagnosed were unilateral and peripheral. Further study may indicate which patients who have a PE after lower limb arthroplasty require treatment, and which can avoid the complications associated with anticoagulation. Cite this article: Bone Joint J 2018;100-B:938–44.

Tollip SNP rs5743899 modulates human airway epithelial responses to rhinovirus infection

BACKGROUND

Rhinovirus (RV) infection in asthma induces varying degrees of airway inflammation (e.g. neutrophils), but the underlying mechanisms remain unclear.

OBJECTIVE

The major goal was to determine the role of genetic variation [e.g. single nucleotide polymorphisms (SNPs)] of Toll-interacting protein (Tollip) in airway epithelial responses to RV in a type 2 cytokine milieu.

METHODS

DNA from blood of asthmatic and normal subjects was genotyped for Tollip SNP rs5743899 AA, AG and GG genotypes. Human tracheobronchial epithelial (HTBE) cells from donors without lung disease were cultured to determine pro-inflammatory and antiviral responses to IL-13 and RV16. Tollip knockout and wild-type mice were challenged with house dust mite (HDM) and infected with RV1B to determine lung inflammation and antiviral response.

RESULTS

Asthmatic subjects carrying the AG or GG genotype (AG/GG) compared with the AA genotype demonstrated greater airflow limitation. HTBE cells with AG/GG expressed less Tollip. Upon IL-13 and RV16 treatment, cells with AG/GG (vs. AA) produced more IL-8 and expressed less antiviral genes, which was coupled with increased NF-κB activity and decreased expression of LC3, a hallmark of the autophagic pathway. Tollip co-localized and interacted with LC3. Inhibition of autophagy decreased antiviral genes in IL-13- and RV16-treated cells. Upon HDM and RV1B, Tollip knockout (vs. wild-type) mice demonstrated higher levels of lung neutrophilic inflammation and viral load, but lower levels of antiviral gene expression.

CONCLUSIONS AND CLINICAL RELEVANCE

Our data suggest that Tollip SNP rs5743899 may predict varying airway response to RV infection in asthma.

Predictors of outcome in palliative colonic stent placement for malignant obstruction

BACKGROUND

Emergency surgery for large bowel obstruction carries significant morbidity and mortality. After initially promising results, concerns have been raised over complication rates for self-expandable metal stents (SEMS) in both the palliative and bridge-to-surgery settings. This article documents the technique used at the authors' institution, and reports on success and complication rates, as well as identifying predictors of endoscopic reintervention or surgical treatment.

METHODS

Data were collected for a prospective cohort of consecutive patients undergoing attempted colonoscopic SEMS insertion at a single institution between 1998 and 2013. Multivariable logistic models were fitted to assess possible predictors of endoscopic reintervention and surgical treatment.

RESULTS

Palliative SEMS insertion was attempted in 146 patients. Primary colorectal cancer was the most common cause of obstruction (95.2 per cent). The majority of patients (77.4 per cent) were treated in an acute setting, with a high technical success rate of 97.3 per cent. The perforation rate was 4.8 per cent and the 30-day procedural mortality rate 2.7 per cent. No predictors of early complications were identified, although patients with metastases and those who received chemotherapy were more likely to have late complications. Some 30.8 per cent of patients required at least one further intervention, with 11.0 per cent of the cohort requiring a stoma. Endoscopic reintervention was largely successful.

CONCLUSION

SEMS offer a valid alternative to operative intervention in the palliative management of malignant large bowel obstruction. Patients receiving chemotherapy are more likely to receive endoscopic reintervention, which is largely successful.

Health and social care services for older male adults in prison: the identification of current service provision and piloting of an assessment and care planning model

Background

Older prisoners are the fastest growing subgroup in the English and Welsh prison estate. Existing research highlights that older prisoners have high health and social care needs and that, currently, these needs routinely remain unmet.

Objectives

(1) To explore the needs of men entering and leaving prison; (2) to describe current provision of services, including integration between health and social care services; and (3) to develop and pilot an intervention for identifying health and social care needs on reception into prison, ensuring that these are systematically addressed during custody.

Methods

The research programme was a mixed-methods study comprising four parts: (1) a study of all prisons in England and Wales housing older adult men, establishing current availability and degree of integration between health and social care services through a national survey and qualitative interviews; (2) establishing the health and social care needs of older men entering prison, including experiences of reception into custody, through structured (n = 100) and semistructured (n = 27) interviews; (3) the development and implementation of an intervention to identify and manage the health, social care and custodial needs of older men entering prison; and (4) exploration of the health and social care needs of older men released from prison into the community through qualitative interviews with older prisoners prior to and following discharge from prison. Descriptive statistics were produced for all quantitative data, and qualitative data were analysed using the constant comparison method.

Results

The number of older prisoner leads has increased in recent years but they do not all appear always to be active in their roles, nor in receipt of specialist training. Nearly half (44%) of establishments do not have an older prisoner policy. There is a lack of integration between health and social care services because of ambiguity regarding responsibility for older prisoners' social care. The responsible social service may be located a considerable distance from where the prisoner is held; in such instances, local social services do not co-ordinate their care. The most frequent unmet need on prison entry was the provision of information about care and treatment. Release planning for older prisoners was frequently non-existent.

Limitations

The study used a cut-off age of 60 years as the lower limit for the definition of an older prisoner; evidence has emerged that supports a redefinition of that cut-off to 50 years. Our study examined the care provided for men and this should be considered if contemplating using the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) with older women in prison.

Conclusion

The OHSCAP, developed as part of this study, provided a feasible and acceptable means of identifying and systematically addressing older prisoners' health and social care needs. Future work will include the conduct of a randomised controlled trial to examine the impact of the OHSCAP in terms of improving a range of outcomes, including economic impact.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The impact of hospitalisation on discrimination experiences

Background

The aim of the study was to assess the experiences of discrimination as reported by people with mental health problems and to explore the impact of hospitalisation.

Methods

306 people with mental health problems provided sociodemographic data and data on discrimination using the discrimination and stigma scale version 12 (DISC-12) with the domains negative experienced discrimination, anticipated discrimination, overcoming stigma and discrimination, and positive experienced discrimination. Logistic regression analysis was used to test the impact of hospitalisation on discrimination, controlled for age, gender, education, employment, diagnosis and having been prescribed medication.

Results

Hospitalisation had a major impact on negative discrimination: People were more likely to be treated unfairly in making or keeping friends, in marriage or divorce, by people in their neighbourhood, in social life, by mental health staff and in terms of privacy, if they had been hospitalised. They were also more likely to be avoided or shunned by people who knew about the mental health problem. People with a history of hospitalisation also reported more anticipated discrimination: They had stopped themselves more often from having a close personal relationship and concealed their mental health problem from others more often than those without a history of hospitalisation. However, people who had been hospitalised also experienced more positive discrimination in terms of being treated more positively in getting welfare benefits or disability pensions and in housing.

Conclusion

Findings suggest that treatment in hospital contributed to a higher extent to experienced discrimination than treatment in the community.

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) plasma concentrations in residents of Paritutu, New Zealand: evidence of historical exposure

An assessment of community exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) was undertaken in Paritutu, New Zealand. The suburb lies adjacent to an agrichemical facility that produced 2,4,5-trichlorophenoxyacetic acid (2,4,5-T), between 1962 and 1987. Soil TCDD measurements from 73 nearby addresses demonstrated a pattern of TCDD deposition consistent with an aerial plume following the prevailing local wind patterns and the agrichemical plant as the point source. Blood samples were taken from 52 volunteers having lived for three or more years in Paritutu between 1962 and 1987. Candidate selection focused primarily on individuals who were most likely to show elevated TCDD blood lipid levels when compared to age and gender stratified national average blood concentrations, and secondarily on individuals that provided additional information about specific exposure periods, potential exposures of younger age groups, and specific dietary patterns. A multipathway exposure model was used to estimate serum TCDD levels in each participant. Age and gender-specific TCDD elimination kinetics were also considered. Historical TCDD environmental concentrations were back-calculated from soil concentrations at each residence assuming TCDD releases occurred pre-dominantly between 1962 and 1975. Serum was analysed for chlorinated dibenzodioxins and dibenzofurans, and a subset was analysed for dioxin-like polychlorinated biphenyls. TCDD in serum lipid exceeded two standard deviations above national background levels for 14 participants, and 3 standard deviations for 10 participants. The highest TCDD lipid concentration was 33.3 ng/kg-lipid, or 11 times higher than the comparative 1997 national average. Elevated TCDD concentrations were observed primarily, but not exclusively, in the older study participants who had been in residence in Paritutu before 1968. The study demonstrated TCDD exposure in this community, occurring most likely through the aerial route, and most probably from fugitive emissions during manufacture.

The relationship of glycaemic control and triglycerides in patients with diabetes mellitus: a PreCIS Database Study

AIMS

A common therapeutic approach in patients with type 2 diabetes mellitus who have elevated triglycerides (TGs) is to treat the hyperglycaemia before specifically targeting high TG. The aims of the current study were (i) to determine whether there was a relationship between glycated haemoglobin (HgbA1c) and TG levels at the baseline visit and (ii) to analyse the relationship between DeltaHgbA1c and DeltaTG after treatment.

METHODS

Among 650 consecutive diabetic patients seen in the Cleveland Clinic Preventive Cardiology Department, 372 had both baseline and post-treatment HgbA1c and TG values. We analysed the relationship between baseline HgbA1c and TG as well as between the change in HgbA1c and the change in TG. For analysis, patients were divided into nine groups by tertiles of HgbA1c (< or =6.6, 6.7-7.8 and >7.8%) and TG (< or =1.75, 1.76-3.89 and >3.89 mmol/l) at baseline.

RESULTS

At baseline, there was a small correlation between HgbA1c and TG (r(2) = 0.051; p < 0.001). For the entire group, there was a significant correlation between DeltaHgbA1c and DeltaTG from baseline to follow-up (r(2) = 0.077; p < 0.001). Analyses by tertiles showed that DeltaTG were only associated with changes in two groups: HgbA1c tertile 3 (>7.8%) and TG tertiles 2 (r(2) = 0.24; p < 0.0001) and 3 (r(2) = 0.187; p = 0.003). For every 1% change in the top tertile HgbA1c, there was a 9.3% change in TG (tertile 2) and a 9.8% change in TG (tertile 3).

CONCLUSIONS

These observations suggest that for patients with diabetes mellitus and elevated TG, the effect of HgbA1c reduction has limited effects on TG reduction. Patients may benefit from TG-specific therapy initiated earlier rather than waiting to see effects of glycaemic control.

Mechanisms underlying the metabolic actions of galegine that contribute to weight loss in mice

BACKGROUND AND PURPOSE

Galegine and guanidine, originally isolated from Galega officinalis, led to the development of the biguanides. The weight-reducing effects of galegine have not previously been studied and the present investigation was undertaken to determine its mechanism(s) of action.

EXPERIMENTAL APPROACH

Body weight and food intake were examined in mice. Glucose uptake and acetyl-CoA carboxylase activity were studied in 3T3-L1 adipocytes and L6 myotubes and AMP activated protein kinase (AMPK) activity was examined in cell lines. The gene expression of some enzymes involved in fat metabolism was examined in 3T3-L1 adipocytes.

KEY RESULTS

Galegine administered in the diet reduced body weight in mice. Pair-feeding indicated that at least part of this effect was independent of reduced food intake. In 3T3-L1 adipocytes and L6 myotubes, galegine (50 microM-3 mM) stimulated glucose uptake. Galegine (1-300 microM) also reduced isoprenaline-mediated lipolysis in 3T3-L1 adipocytes and inhibited acetyl-CoA carboxylase activity in 3T3-L1 adipocytes and L6 myotubes. Galegine (500 microM) down-regulated genes concerned with fatty acid synthesis, including fatty acid synthase and its upstream regulator SREBP. Galegine (10 microM and above) produced a concentration-dependent activation of AMP activated protein kinase (AMPK) in H4IIE rat hepatoma, HEK293 human kidney cells, 3T3-L1 adipocytes and L6 myotubes.

CONCLUSIONS AND IMPLICATIONS

Activation of AMPK can explain many of the effects of galegine, including enhanced glucose uptake and inhibition of acetyl-CoA carboxylase. Inhibition of acetyl-CoA carboxylase both inhibits fatty acid synthesis and stimulates fatty acid oxidation, and this may to contribute to the in vivo effect of galegine on body weight.

Problematizing special observation in psychiatry: Foucault, archaeology, genealogy, discourse and power/knowledge

Special observation by mental health professionals is the recommended approach for those people deemed as at risk or risky. Recent research and academic writing have challenged the benefits of observing people/patients who are defined as 'at risk', and a more human engagement process is being recommended. Despite this assault, practice has not changed substantively, suggesting a need for a thorough exploration and questioning of the practices and process. The paper outlines three Foucaultian approaches to historical analysis. It applies aspects of Foucault's archaeology/genealogy, discourse and power/knowledge to explore the practices of special observation as a means of controlling risk, especially suicide risk. We identify the regulatory function of the 'gaze', professional codes and government policy in relation to restricting professional practices. We argue that observation can be related to moral therapy, wherein the person relinquishes madness for responsibility through a disciplinary process and, in governing risk, a 'professional industry' is created. The regulation of statements about people with mental health issues are exposed and related to what can be said and done by professionals. Finally, we look at productive power in relation to observation, and how it is intimately related to resistance. We conclude with 'soft' recommendations for practice discursively produced through the writing of the paper.

Finding solutions through empowerment: a preliminary study of a solution-orientated approach to nursing in acute psychiatric settings

Acute inpatient care is not a therapeutic milieu, perhaps owing to the lack of nursing skills. Solution-focused therapy (SFT) has been successful in US inpatient facilities in relation to both objective and subjective 'measures'. This paper reports a study of SFT in a UK context, with the aim of developing a user-friendly SFT training course and assessing its impact on both nurses and clients, via a multifaceted, triangulated data collection design. Nurses' knowledge and clinical performance were assessed, as was the client's perspective. There was a significant difference in nurses' SFT knowledge after training and strong evidence of the model being used in practice during the course of training, although nursing documentation was not fully completed. Eighty-three per cent of nurses said that they would continue using the model, and clients found the SFT approach helpful. The findings match the US experience of using SFT.

Aqueous-phase disappearance of atrazine, metolachlor, and chlorpyrifos in laboratory aquaria and outdoor macrocosms

Dissipation processes are described for a combination of commonly used pesticides-atrazine (6-chloro-4-ethylamino-6-isopropylamino- s-triazine), metolachlor (2-chloro- N-[2-ethyl-6-methyl-phenyl]- N-[2-methoxy-1-methylethyl] acetamide), and chlorpyrifos ( O-O diethyl O-[3,5,6-trichloro-2-pyridinyl] phosphorothioate)-in a laboratory and outdoor pond systems. Dosing rates and timing were designed to duplicate those common in the mid-Atlantic Coastal Plain, USA. Treatments ranged from 2 and 2.5 mg/L to 0.2 and 0.25 mg/L respectively for atrazine and metolachlor, and chlorpyrifos was added at 1.0 and 0.1 mg/L in the aquaria and at 0.1 mg/L in the outdoor macrocosms. Chlorpyrifos disappearance was rapid in all of the systems and followed a two-phase sequence. Initial half-lives varied from 0.16 day to 0.38 day and showed similar rates in the aquaria and the outdoor systems. The second phase of the chlorpyrifis loss pattern was slower (18-20 days) in all the treatments except for the low herbicide treatment in the outdoor test, where it was 3.4 days. Compared to the outdoor system, herbicide losses were much slower in the aquaria, e.g., 150 days for atrazine and 55 days for metolachlor, and no appreciable loss of herbicide was apparent in the high-treated aquaria. In the outdoor systems, the half-lives for the low herbicide treatment were 27 days and 12 days, respectively, for atrazine and metolachlor, and 48 and 20 days, respectively for the high herbicide-treated pond. Very low levels of CIAT (6-amino-2-chloro-4-iso-propylamino- s-triazine) and CEAT (2-chloro-4-ethylamino-6-ethylamino- s-triazine), degradation products of atrazine, were observed in the outdoor studies.

Judgement days: developing an evaluation for an innovative nursing model

This paper reports on the process and outcomes of the evaluation of an innovative nursing model (the Tidal Model). In relation to process, the study has been used to refine the methodology in terms of defining important variables to take as outcome measures to be analysed both descriptively and inferentially. In relation to outcomes, the pre-post-test design has generated significant findings in relation to improved patient care.

Clinical & genetic analysis of four patients with distal upper limb spinal muscular atrophy

BACKGROUND & OBJECTIVES

Distal upper limb spinal muscular atrophy (SMA) is an uncommon segmental variant of SMA. The condition is usually sporadic, affects males more often than females, and manifests late in the second decade of life, remaining confined to the upper limbs. We examined four patients with this form of SMA in order to determine if they carried homozygous deletion mutations in the survival motor neuron (SMN) or neuronal apoptosis inhibitory protein (NAIP) genes that underlie proximal SMA.

METHODS

The four patients with distal upper limb SMA were analysed clinically, electrophysiologically and biochemically. Genomic DNA from each of the patients was analysed by restriction enzyme digestion of polymerase chain reaction (PCR) amplification products, as well single stranded conformation polymorphism (SSCP), to detect deletion events of selected exons of the SMN and NAIP genes.

RESULTS

The clinical phenotype of the four patients, together with the biochemical and electrophysiological studies, confirmed a diagnosis of distal upper limb SMA. The molecular studies excluded homozygous deletion mutations in these patients as causative of their phenotype.

INTERPRETATION & CONCLUSION

The genetic component underlying distal upper limb SMA appears not to involve mutations that are common in proximal SMA patients. It is possible that genes other than SMN and NAIP may be involved, while somatic mosaicism of SMN gene mutations could be implicated in the segmental nature of distal upper limb SMA.

The long and winding road Obtaining funding for qualitative research proposals

In this article, John Cutcliffe and Chris Stevenson drew on their experience of seeking funding for qualitative studies in order to offer researchers some helpful tips.

Launching the Tidal Model in an adult mental health programme

AIM

To implement a new model of psychiatric nursing that uses person-centred care to empower people with acute mental health problems.

METHOD

A pilot study involved the introduction of the model into two wards in the acute mental health services in Newcastle City Health Trust. This was followed by introduction of the model into all nine adult acute wards in the service. One ward was evaluated for six months before and six months after introducing the model and nurses' perceptions of the model have been assessed using questionnaires.

RESULTS

Preliminary findings of the ward evaluation show that since the model has been implemented, more people have been admitted on an informal basis and fewer have been subject to sections of the Mental Health Act (MHA); the number of admissions has doubled while the length of stay has decreased; violent incidents and episodes of self-harm have decreased; the use of restraint has decreased; and the interval between admission and assessment has decreased. Preliminary analysis of the nursing questionnaires shows positive perceptions of the model.

CONCLUSION

The introduction of this model appears to have had a positive impact on the care being given to patients and the nurses using the model appear to be satisfied with the use of patient-centred care.

Social poetics as research and practice: living in and learning from the process of research

This paper is both a report of research work carried out by one author of the paper with the other involved in a supervisory role, and a reflection on methodology that was an emergent property of the research process. The research question arose when professional preunderstandings about schizophrenia as a biological disturbance were bracketed as a Husserlian form of phenomenology was adopted. The initial study focused on the meanings three individuals attached to being diagnosed with a mental illness and being involved in psychiatric treatment systems. The exploration of meanings led to the researcher being guided by one study participant in relation to a suitable framework for making sense of her lived experience of being entangled in psychiatric systems. This involved an appreciation of the poetics of interpersonal interaction that was simultaneously fuelled by the researcher's reading of social poetics in psychology. Thus, the research became a hermeneutic inquiry, focused upon the text of one participant (Beth)1 and the psychiatric system that she and colleagues encountered. Beth's psychiatric predicament was described by a loss of 'self', psychiatric interrogation, and positive and negative features of immersion in the system. A byproduct of taking a poetic approach was that the participant found the research process therapeutic. Thus, social poetics encouraged a beneficial blurring of the boundaries between research and practice. In both arenas, social poetics can lead to a different level of understanding. This is contradictory to mainstream approaches to research that value objectivity with a strict division between the researcher and the subjects, with the aim of producing scientific knowledge.

Egalitarian consultation meetings: an alternative to received wisdom about clinical supervision in psychiatric nursing practice

Clinical supervision (CS) has become a watchword for psychiatric nursing. Yet, there are contradictions and controversies in academic and professional discourse in relation to the nature of CS, both structure and process, its effectiveness and how this is ascertained, the preparation of supervisor and supervisee, and the quality of the supervisory relationship. The perception of such discord encouraged the authors of this paper to step outside the debate and enact a different kind of CS, which came to be known as egalitarian consultation (EC). Egalitarian consultation meetings (ECMs) were established with the postmodern turn in psychiatric nursing as a reference point. A space was created in which participants could construct their particular version of CS. The authors and six G-grade community psychiatric nurses engaged with each other for six videotaped meetings. The data from the recordings were analysed using a hermeneutic grounded theory approach (Strauss & Corbin 1994), in keeping with the style of the research, which combined the roles of researcher and practitioner for the authors. The aim was to produce local knowledge of CS. The ECMs were characterized by a sense of freedom in relation to existing rules about hierarchy and truth. The participants, each as expert in her/his own case world, produced engrossing narratives about and for practice. The group developed a cohesiveness based in closeness and this encouraged radical talk and action--a questioning of practice systems. However, for some group members, radical equated to dangerous in terms of the watchful organization and a return to 'real' work (case supervision) was observed. Innovation in relation to CS may benefit from a change in institutional culture.

Human calcium-independent phospholipase A2 mediates lymphocyte proliferation

Activation of lymphocytes induces blastogenesis and cell division which is accompanied by membrane lipid metabolism such as increased fatty acid turnover. To date little is known about the enzymatic mechanism(s) regulating this process. Release of fatty acids such as arachidonic acid requires sn-2-deacylation catalyzed by a class of enzymes known as phospholipases A(2) (PLA(2), EC ). Herein, we confirm that human peripheral blood B or T lymphocytes (PBL) do not possess measurable levels of 85-kDa PLA(2) as assessed by Western immunoblot. Low levels of 14-kDa PLA(2) protein and activity were detectable in the particulate fraction of PBL and Jurkat cells. Western immunoblot analysis indicates that PBLs possess the calcium-independent PLA(2) (iPLA(2)) protein. Calcium-independent sn-2-acylhydrolytic activity was measurable in PBL cytosols and could be inhibited by the selective iPLA(2) inhibitor bromoenol lactone. Mitogen activation of PBLs resulted in maintenance of activity levels which remained constant over 72 h suggesting an important role for iPLA(2) in this proliferative process. Indeed, evaluation of iPLA(2) activity in cell cycle-arrested Jurkat T cell fractions revealed the highest iPLA(2) levels occurring at the G(2)/M phase. Addition of the iPLA(2) inhibitors, bromoenol lactone, or arachidonyl trifluoromethyl ketone (AAOCF(3)), inhibited both mitogen-induced PBL as well as Jurkat T cell proliferation. Moreover, specific depletion of iPLA(2) protein by antisense treatment also resulted in marked suppression of cell division. Inhibition of Jurkat cell proliferation was not associated with arrest at a particular phase of the cell cycle nor was it associated with apoptosis as assessed by flow cytometry. These findings provide the first evidence that iPLA(2) plays a key role in the lymphocyte proliferative response.

What do people need psychiatric and mental health nurses for?

The study reported here aimed to describe, by consulting with psychiatric practitioners of different disciplines, what people in contact with mental health services need nurses for, in terms of core nursing activity. Yet, recent trends have also been towards consumer-led definitions of good practice. The views of service and ex-service users can contribute much to an exploration of the role of psychiatric and mental health nurses and these perspectives were incorporated into the study. Given the lack of existing theory, a qualitative, grounded theory methodology was selected. In order to generate data rich enough for the analysis, focus groups of psychiatric nurses, social workers, service users, psychiatrists, carers and professions allied to medicine were sampled (13 groups, n=92) on the basis of the themes emerging from the data. Using critical incident technique (Flanagan 1954), the groups were invited to give examples of effective and ineffective nursing interventions, in relation to specific patient needs. The taped material was transcribed and analysed with the help of a computer package (QSR NUD.IST). This led to the selection of a core category, 'knowing you, knowing me', which described service users' and professionals' expectations that nurses are best placed to second guess the needs of patients and present themselves accordingly. Thus, nurses were expected, moment by moment, to know whether to be the patient's friend, a friendly professional, or take a more distant professional stance. The continuum entails different levels of knowledge and power, different language forms and different approaches to structuring time. Nurses themselves are most likely to prefer a position of friendly professional, from which they can move to a more intimate or distant role. Further study is needed to explore how nurses predict patients' expectations of them using a symbolic interactionist framework.

What are psychiatric nurses needed for? Developing a theory of essential nursing practice

Contemporary developments in health care have encouraged a review of the professional status of psychiatric nursing. However, little study has been made, to date, of the discrete 'need' for psychiatric nursing within a multidisciplinary service. Employing an adapted grounded theory methodology, substantive theory was developed concerning the expressed need for psychiatric nursing, by patients, their carers and mental health professionals, based on six sites from England, Eire and Northern Ireland. The study found some consensus across both recipients and providers of mental health care, that the essential feature of nursing (the core category) involved a complex of relationships: 'knowing you--knowing me'. Within that complex, nurses either elected, or were required, to move--or 'toggle'--between three discrete domains of relating: the Ordinary Me (OM); the Pseudo-ordinary or Engineered Me (POEM); and the Professional Me (PM). Four internal dimensions involving the nurses' depth of knowing, power, use of time and use of translation, distinguished these domains. The emergent theory is discussed within the context of the emergent growth in user (consumer) influence and health care technology.

The need for psychiatric nursing: towards a multidimensional theory of caring

Contemporary developments in health care have encouraged a review of the professional status of psychiatric nursing. Although research has documented psychiatric nursing activity, little study has been made of the 'need' for psychiatric nursing within a multidisciplinary service. Employing adapted grounded theory methodology, substantive theory was developed concerning the expressed need for psychiatric nursing, by patients, their carers and mental health professionals. The study was based on six sites from England, Eire and Northern Ireland. The study found some consensus across both recipients and providers of mental health care, that the essential feature of nursing (the core category) involved a complex of relationships: 'knowing you, knowing me'. Within that complex, nurses either elected, or were required, to move--or 'toggle'--between three discrete domains of relating: the Ordinary Me (OM); the Pseudo-ordinary or Engineered Me (POEM); and the Professional Me (PM). Four internal dimensions involving the nurses' depth of knowing, power, use of time and use of translation distinguished these domains. The emergent theory extends current awareness of the importance of interpersonal relations in nursing. To what extent current health care policy, which emphasizes the promotion of alternative roles for nurses, will challenge this essential focus remains unclear.

Photosensitization of guanine-specific DNA damage by 2-phenylbenzimidazole and the sunscreen agent 2-phenylbenzimidazole-5-sulfonic acid

Gel sequencing experiments with end-labeled synthetic oligodeoxyribonucleotides have established that 2-phenylbenzimidazole (PBZ) and the common sunscreen constituent 2-phenylbenzimidazole-5-sulfonic acid (PBSA) function as efficient photosensitizers of DNA damage when they are exposed to UV-B (290-320 nm) radiation or natural sunlight. Although neither compound binds specifically to DNA, both are active at sub-millimolar concentrations and induce the formation of piperidine-labile cleavage sites that map almost exclusively to the positions of guanine residues. The pattern of attack on single-stranded DNA, where all guanines are modified to a similar extent, is typical of photooxidation by singlet oxygen. The involvement of singlet oxygen is consistent with the effect of quenchers and scavengers on the reaction, and is supported by the demonstration that UV-B irradiation of 2'-deoxyguanosine with PBSA in oxygenated solution generates the diagnostic compound 4, 8-dihydro-4-hydroxy-8-oxo-2'-deoxyguanosine in comparatively high yield. In contrast, the main photoinduced cleavage sites in double-helical DNA are located at the 5'-guanines of GG and (to a lesser degree) GA doublets. This characteristic behavior implies that electron transfer from DNA to the photoexcited sensitizer is the predominant mechanism in this conformation. A similar dichotomy of reactivity toward denatured and native DNA has been reported for riboflavin and certain pterin derivatives which resemble PBZ and PBSA in not binding tightly to DNA. The photosensitizing properties of PBSA could possibly detract from its fitness as a sunscreen agent.