Transforming mental well-being for people with diabetes: research recommendations from Diabetes UK's 2019 Diabetes and Mental Well-Being Workshop

AIMS

To identify key gaps in the research evidence base that could help to improve the mental well-being of people with diabetes, and to provide recommendations to researchers and research funders on how best to address them.

METHODS

A 2-day international research workshop was conducted, bringing together research experts in diabetes and in mental health, people living with diabetes and healthcare professionals.

RESULTS

The following key areas needing increased financial investment in research were identified: understanding the mechanisms underlying depression; understanding the multifactorial impact of social stigma; improving the language used by healthcare professionals; supporting people who find it difficult to engage with their diabetes; supporting significant others; supporting people with diabetes and eating disorders; improving models of care by learning from best practice; the potential benefits of screening and managing diabetes distress in routine diabetes care pathways; primary prevention of mental health issues at the time of diagnosis of diabetes; establishing the effectiveness of diabetes therapies on mood and other mental health issues; and understanding the impact of current diabetes technologies on mental health. Research recommendations as to how to address each of these priority areas were also developed.

CONCLUSIONS

This inaugural position statement outlines recommendations to address the urgent unmet need related to the mental well-being of people living with diabetes, and calls on the research community and funders to develop research programmes and strategies to reduce this need.

Developing a theoretical maintenance model for disordered eating in Type 1 diabetes

BACKGROUND

According to the literature, eating disorders are an increasing problem for more than a quarter of people with Type 1 diabetes and they are associated with accentuated diabetic complications. The clinical outcomes in this group when given standard eating disorder treatments are disappointing. The Medical Research Council guidelines for developing complex interventions suggest that the first step is to develop a theoretical model.

AIM

To review existing literature to build a theoretical maintenance model for disordered eating in people with Type 1 diabetes.

METHOD

The literature in diabetes relating to models of eating disorder (Fairburn's transdiagnostic model and the dual pathway model) and food addiction was examined and assimilated.

RESULTS

The elements common to all eating disorder models include weight/shape concern and problems with mood regulation. The predisposing traits of perfectionism, low self-esteem and low body esteem and the interpersonal difficulties from the transdiagnostic model are also relevant to diabetes. The differences include the use of insulin mismanagement to compensate for breaking eating rules and the consequential wide variations in plasma glucose that may predispose to 'food addiction'. Eating disorder symptoms elicit emotionally driven reactions and behaviours from others close to the individual affected and these are accentuated in the context of diabetes.

CONCLUSION

The next stage is to test the assumptions within the maintenance model with experimental medicine studies to facilitate the development of new technologies aimed at increasing inhibitory processes and moderating environmental triggers.

Electronic discharge summaries in cross-border care in the European Union: How close are we to making it happen?

Introduction

The political drive for cross-border care within the European Union and an increasing focus on integrated care both have implications for electronic health records. The hospital discharge summary is a critical component of systems to ensure quality and continuity of care, and in a cross-border setting would particularly benefit from an electronic version. We have explored the extent to which European Union level policy and practice on electronic health records address issues pertinent to the development and implementation of electronic discharge summaries for patients treated outside their own country.

Methods

We approached the topic by analysing data from two different sources: European Union policy documents on topics relevant to electronic health records and deliverables of European Union-funded electronic health record-focused research and development projects. Elements pertinent to different aspects of interoperability – legal, semantic and technical – were extracted from both sources and their content compared to assess the degree of consistency between policy and implementation targets.

Results

We identified 25 policy documents and 14 European Union-funded projects. Our results show that European legislation is increasingly aligned with projects funded through European Union sources and substantial progress has been accomplished in achieving electronic communication across European health systems. Nevertheless, the achievement of a European level interoperable discharge summary is still a distant goal, while inadequate attention has been paid to the coordination of current discharge summary practices in Member States.

Discussion

If the harmonized European Union patient summary is also to function as an electronic discharge summary, further specific steps are needed that address issues of both content and processes related to communication.

Education and informed consent about increased risk donor kidneys: a national survey of non-physician transplant providers

INTRODUCTION

Transplant providers must understand the definition of increased risk donor (IRD) organs to effectively educate transplant candidates and obtain informed consent. This study surveyed non-physician providers from 20 transplant centers about their educational and informed consent practices of IRD kidneys.

METHODS

An anonymous, web-based survey about the content and timing of education and informed consent for potential recipients of IRD kidneys, providers' knowledge of IRD kidneys, and provider and center characteristics was completed by most (67%; 90 of 135) of those invited to participate; 87 responses were included in analysis.

RESULTS

Most (80%) reported understanding the concept of IRD kidneys. However, few reported sufficient knowledge of the Organ Procurement and Transplantation Network definition of IRDs, risk factors, screening tests, window periods, and infection transmission rates. Most (56%) felt uncomfortable with obtaining specific informed consent for IRD kidneys. Most respondents received informal education about IRD kidneys (78%), and recognized the need for (98%) and were interested in receiving (99%) further education on this topic.

CONCLUSION

Non-physician transplant providers need and are interested in better education about IRD kidneys to effectively educate patients and obtain patients' informed consent.

The Monitor Practice Programme: is non-invasive management of dental caries in private practice cost-effective?

BACKGROUND

The objective of this research was to assess the efficacy and cost-effectiveness of a non-invasive approach to dental caries management in private dental practice.

METHODS

Private dental practices from a variety of locations in New South Wales were randomly allocated to either non-invasive management of caries, or continue with usual care. Patients were followed for three years and caries incidence assessed. A patient-level decision analytic model was constructed to assess the cost-effectiveness of the intervention at two years, three years, and hypothetical lifetime.

RESULTS

Twenty-two dental practices and 920 patients were recruited. Within the clinical trial there was a significant difference in caries increment favouring non-invasive therapy at both two and three years. Efficacy was independent of age, gender, medical concerns, fluoride history, or previous history of dental caries, in a population of patients attending for treatment in private dental practices, in a variety of locations both urban and rural. Cost per DMFT avoided estimate was A$1287.07 (two years), A$1148.91 (three years) decreasing to A$702.52 in (medium) and A$545.93 (high) risk patients (three years).

CONCLUSIONS

A joint preventive and non-invasive therapeutic approach appears to be cost-effective in patients at medium and high risk of developing dental caries when compared to the standard care provided by private dental practice.

Improving the management and referral of patients with transient ischaemic attacks: a change strategy for a health community

PROBLEM

Rapid referral and management of patients with transient ischaemic attacks is a key component in the national strategy for stroke prevention. However, patients with transient ischaemic attacks are poorly identified and undertreated.

DESIGN AND SETTING

Before and after evaluation of quality improvement programme with controlled comparison in three primary care trusts reflecting diverse populations and organisational structures in an urban district in the North of England.

KEY MEASURES FOR IMPROVEMENT

The proportion of patients receiving antiplatelet drugs and safe driving advice on referral to a specialty clinic, and the numbers of referrals, adjusted for age, to the specialist clinic before and after the improvement programme.

STRATEGIES FOR CHANGE

Interviews with patient and professionals to identify gaps and barriers to good practice; development of evidence based guidelines for the management of patients with transient ischaemic attacks; interactive multidisciplinary workshops for each primary care trust with feedback of individual audit results of referral practice; outreach visits to teams who were unable to attend the workshops; referral templates and desktop summaries to provide reminders of the guidelines to clinicians; incorporation of standards into professional contracts.

EFFECTS OF CHANGE

A significant improvement occurred in identification and referral of patients with transient ischaemic attacks to specialist clinics, with a 41% increase in referrals from trained practices compared with control practices. There were also significant improvements in the early treatment and safety advice provided to patients before referral.

LESSONS LEARNT

A strategic approach to effective quality improvement across a diverse health community is feasible and achievable. Careful planning with patient and professional involvement to develop a tailored and multifaceted quality improvement programme to implement evidence based practice can work in very different primary care settings. Key components of the effectiveness of the model include contextual analysis, strong professional support, clear recommendations based on robust evidence, simplicity of adoption, good communication, and use of established networks and opinion leaders.

A cost-utility analysis of clopidogrel in patients with non-ST-segment-elevation acute coronary syndromes in the UK

OBJECTIVE

To assess the long-term cost effectiveness of 1 year's treatment with clopidogrel on top of standard therapy (including aspirin; ASA) compared with standard therapy alone, in patients diagnosed with non-ST-segment-elevation acute coronary syndromes (ACS) in the UK.

DESIGN

Cost utility analysis using a Markov model, incorporating clinical data from CURE (a multicentre randomised controlled trial, involving 12,562 patients) and data from UK observational studies.

SETTING

Health economic evaluation carried out from the perspective of the UK NHS.

PATIENTS

A representative cohort of 1000 UK patients aged 66 years, diagnosed with non-ST-segment-elevation ACS.

INTERVENTIONS

Either a combination of 75 mg/day clopidogrel (300 mg loading dose, within 24 h prior to hospital admission) and standard therapy (including ASA, 75-325 mg/day) for 1 year followed by standard therapy alone for their remaining lifetime, or standard therapy alone (including ASA, 75-325 mg/day) for life.

MAIN OUTCOME MEASURES

Incremental cost per life-year gained and incremental cost per quality-adjusted life-year (QALY) gained.

RESULTS

In the base case, the incremental cost effectiveness of the clopidogrel combination vs standard therapy alone is estimated as pounds 6991 per life-year gained and pounds 7365 per QALY gained. The probability that clopidogrel remains cost effective within the generally accepted pounds 30,000 per QALY threshold is more than 80%. The confidence interval around the relative risk for vascular death was identified as the main parameter affecting the estimated cost effectiveness.

CONCLUSIONS

One year's treatment with clopidogrel is a cost effective intervention compared with standard therapy that should be considered as a routine treatment for patients with non-ST-segment-elevation ACS.

Systematic review and economic evaluation of a long-acting insulin analogue, insulin glargine

OBJECTIVES

To evaluate the use of insulin glargine in its licensed basal-bolus indication in terms of both clinical and cost-effectiveness.

DATA SOURCES

Electronic databases.

REVIEW METHODS

A systematic review of the literature, involving a range of databases, was performed to identify all papers relating to insulin glargine.

RESULTS

Nineteen studies met the inclusion criteria but full reports were available for only six. For type 1 diabetes patients, insulin glargine appears to be more effective than neutral protamine Hagedorn (NPH) in reducing fasting blood glucose (FBG) but not in reducing glycosylated haemoglobin (HbA1c) and there is some evidence that both insulins are as effective as each other in both FBG and HbA1c control. For type 2 patients for whom oral antidiabetic agents provide inadequate glycaemic control, there is no evidence that insulin glargine is more effective than NPH in reducing either FBG or HbA1c and some evidence that both insulins are as effective as each other in both FBG and HbA1c control. Evidence for control of hypoglycaemia is equivocal. In studies where insulin glargine is demonstrated to be superior to NPH in controlling nocturnal hypoglycaemia, this may be only apparent when compared with once-daily NPH and not twice-daily NPH. Further, this superiority of glargine over NPH in the control of nocturnal hypoglycaemia may relate to one formulation of insulin glargine (HOE901[80]) and not another (HOE901[30]). There is no conclusive evidence that insulin glargine is superior to NPH in controlling symptomatic hypoglycaemia and severe hypoglycaemia. Insufficient data are available to conclude whether insulin glargine is different from each of the commonly used NPH dosing regimens: once daily and more than once daily. Given the lack of a published evidence base for the cost-effectiveness of insulin glargine, the economic review concentrates on a review of the industry submission and an amended model. Three economic models are provided in the submission, two relating to type 1 diabetes and one relating to type 2 diabetes. All three models compare the cost--utility of insulin glargine against NPH insulin. In general, the structures of the models are poor and in all three models, mistakes relating to assumptions and calculations have been made. The assessment team believe that the cost per QALY estimates generated by the Aventis model may be an underestimate for several reasons. The cost-effectiveness of insulin glargine in both type 1 and type 2 diabetes is highly sensitive to the amount of utility associated with reducing the fear of hypoglycaemia.

CONCLUSIONS

The evidence suggests that, compared with NPH insulin, insulin glargine is effective in reducing the number of nocturnal hypoglycaemic episodes, especially when compared with once-daily NPH. There appears to be no improvement in long-term glycaemic control and therefore insulin glargine is unlikely to reduce the incidence of the long-term microvascular and cardiovascular complications of diabetes. Further research into insulin glargine is needed that addresses the quality of life issues associated with fear of hypoglycaemia and also the economic impact of balance of HbA1c control and incidence of hypoglycaemia achieved in practice. Studies examining the economic evidence on insulin glargine should be published.

Clinical effectiveness and cost-effectiveness of pioglitazone and rosiglitazone in the treatment of type 2 diabetes: a systematic review and economic evaluation

OBJECTIVES

To evaluate the use of pioglitazone and rosiglitazone, in terms of both clinical and cost-effectiveness in the treatment of type 2 diabetes.

DATA SOURCES

Electronic databases and the reference lists of relevant articles, in addition 14 health services research-related resources were consulted via the Internet.

REVIEW METHODS

A systematic review of the literature, involving a range of databases, was performed to identify all papers relating to the glitazones. The methodological quality of the included randomised controlled trials (RCTs) was assessed using the Jadad method. A generic proforma for the critical appraisal of modelling studies in health economics was used in systematically reviewing the economic assessment studies identified. This was supplemented by a detailed review of the disease-specific factors within the studies. Where possible, key outcomes were compared. Readers should note that information from the sponsor's submission was submitted in confidence to the National Institute for Clinical Excellence (NICE). Such information was made available to the NICE Appraisals Committee, but has been removed from this version of the report.

RESULTS

Of the 1272 studies identified, nine studies met the inclusion criteria. The clinical evidence available showed that glitazones reduce glycosylated haemoglobin by approximately 1%, and are more effective at higher doses than at lower doses. Glitazone treatment is associated with weight gain. No published data were available on the long-term effects of glitazone use. No prospective RCTs were found comparing pioglitazone to rosiglitazone, but the available evidence indicated that the two treatments had similar effects. There are no published economic studies on either pioglitazone or rosiglitazone. Economic evaluations for both glitazones were provided by the manufacturers. Sensitivity analyses undertaken by the assessment team suggest that the cost per quality-adjusted life-year (QALY) of rosiglitazone is most sensitive to dosage and treatment effect, that is, the effect of rosiglitazone on beta-cell function and insulin sensitivity. In the two scenarios where rosiglitazone is compared with metformin and sulfonylurea combination therapy, the cost-effectiveness of rosiglitazone switches from around 10,000 pounds per QALY to being dominated by the comparator strategy. Since the baseline estimate of cost-effectiveness is not robust to changes in the treatment effect and is reliant on the many assumptions included within the metabolic and long-term economic models, caution should be used in interpreting the baseline result.

CONCLUSIONS

The clinical evidence available showed that glitazones can reduce glycosylated haemoglobin; however there were no peer-reviewed data available on the long-term effects of their use or any prospective RCTs found comparing pioglitazone with rosiglitazone. No published economic studies on either pioglitazone or rosiglitazone were found, although sensitivity analyses undertaken by the assessment team suggest that the cost per QALY of rosiglitazone is most sensitive to dosage and treatment effect. It is suggested that research already undertaken in this area should be published, preferably in peer-reviewed journals. Direct head-to-head comparisons of the glitazones in combination with metformin or sulfonylurea would be helpful. The current licence arrangements do not allow for routine use of the glitazones in triple oral combination therapy or in combination with insulin. Evidence is emerging of use of the glitazones within such combinations; therefore, prospective RCTs would be useful. These studies could examine short-term transition strategies and longer term management. The impact of the glitazones in delaying transfer to insulin and the impact on long-term outcomes should also be considered for investigation.

Cost-utility analysis of imatinib mesilate for the treatment of advanced stage chronic myeloid leukaemia

Imatinib mesilate (Glivec), Novartis Pharmaceuticals) is a novel therapy for the treatment of chronic myeloid leukaemia (CML). We evaluated the cost-effectiveness of imatinib (600 mg daily) when used for the treatment of patients in advanced stages of CML (accelerated phase and blast crisis) against conventional therapies of combination chemotherapy (DAT) and palliative care in hospital or at home. A Markov model simulated the transitions of hypothetical patient cohorts and outcomes were modelled for 5 years from the start of treatment. Costs were estimated from the perspective of the UK National Health Service. Over 5 years, a patient in accelerated phase will, on average, accrue an additional 2.09 QALYs with imatinib compared to conventional therapies, while patients in blast crisis will accrue an additional 0.58 quality-adjusted life-years (QALYs) with imatinib compared to conventional therapies. The costs per additional QALY gained from treatment with imatinib compared with conventional therapies were pound 29344 (accelerated phase) and pound 42239 (blast crisis). The results were particularly sensitive to the price of imatinib, improvements in quality of life, and the duration of haematological responses. We conclude that treatment of CML with imatinib confers considerably greater survival and quality of life than conventional treatments but at a cost.

Progression of natural attenuation processes at a crude oil spill site: II. Controls on spatial distribution of microbial populations

A multidisciplinary study of a crude-oil contaminated aquifer shows that the distribution of microbial physiologic types is strongly controlled by the aquifer properties and crude oil location. The microbial populations of four physiologic types were analyzed together with permeability, pore-water chemistry, nonaqueous oil content, and extractable sediment iron. Microbial data from three vertical profiles through the anaerobic portion of the contaminated aquifer clearly show areas that have progressed from iron-reduction to methanogenesis. These locations contain lower numbers of iron reducers, and increased numbers of fermenters with detectable methanogens. Methanogenic conditions exist both in the area contaminated by nonaqueous oil and also below the oil where high hydrocarbon concentrations correspond to local increases in aquifer permeability. The results indicate that high contaminant flux either from local dissolution or by advective transport plays a key role in determining which areas first become methanogenic. Other factors besides flux that are important include the sediment Fe(II) content and proximity to the water table. In locations near a seasonally oscillating water table, methanogenic conditions exist only below the lowest typical water table elevation. During 20 years since the oil spill occurred, a laterally continuous methanogenic zone has developed along a narrow horizon extending from the source area to 50-60 m downgradient. A companion paper [J. Contam. Hydrol. 53, 369-386] documents how the growth of the methanogenic zone results in expansion of the aquifer volume contaminated with the highest concentrations of benzene, toluene, ethylbenzene, and xylenes.

Why do GPs not implement evidence-based guidelines? A descriptive study

BACKGROUND

There is an acknowledged gap between research findings and their implementation in clinical practice despite the existence of effective educational interventions.

OBJECTIVES

Our aim was to identify what is impeding GPs from pursuing currently recognized good practice and implementing evidence-based guidelines in their management of hypertension in the elderly.

METHOD

We carried out a qualitative study using semi-structured interviews conducted during focus group outreach visits to 34 GPs from nine practices in Merseyside involved in an educational programme designed to improve the management of hypertension in the elderly.

RESULTS

Several barriers to the implementation of evidence-based guidelines in the management of hypertension in the elderly were identified. These included: doubts about the applicability of trial data to particular patients; the poor adherence of GPs to practice protocols; ageist attitudes of some GPs; the effect of time pressure and financial considerations making the subject a low priority; the absence of an effective computer system; and the absence of an educational mentor. All participants demonstrated a very positive attitude to practice-based education. They also welcomed external audit data, which compared their performance with that of other practices. Single-handed GPs were particularly enthusiastic about this approach as it provided them with the peer pressure they lacked.

CONCLUSIONS

In order to bridge the gap between research and practice, educators need to address the various 'barriers to change' amongst practitioners.

Experimental microgyri disrupt the barrel field pattern in rat somatosensory cortex

Transcranial freeze lesions in neonatal rat pups produce microgyri and adjacent epileptogenic regions of neocortex that can be used to model human polymicrogyria. The hypothesis that the presence of microgyri is associated with abnormal cortical organization occurring within as well as adjacent to the microgyri was tested by creating microgyri within the face representation of somatosensory cortex. Microgyri were associated with a widespread disruption of the stereotypic whisker barrel field pattern delineated with cytochrome oxidase (CO) staining. CO-stained patches resembling barrel hollows were absent within the microgyrus, and were abnormally shaped and distributed outside of the microgyrus. Adjacent Nissl- or acetylcholinesterase-stained sections demonstrated that both cell clusters and thalamocortical afferents contributed to the abnormally organized paramicrogyral zone identified in CO-stained sections. Field potential recordings showed that this region of heavy CO staining corresponded to the epileptogenic zone adjacent to the microgyrus. Results support our hypothesis that the epileptogenic paramicrogyral zone develops an abnormal organization of cell clusters and thalamocortical projections that could contribute to epileptogenesis in the paramicrogyral zone.

Distribution of Microbial Physiologic Types in an Aquifer Contaminated by Crude Oil

> Abstract We conducted a plume-scale study of the microbial ecology in the anaerobic portion of an aquifer contaminated by crude-oil compounds. The data provide insight into the patterns of ecological succession, microbial nutrient demands, and the relative importance of free-living versus attached microbial populations. The most probable number (MPN) method was used to characterize the spatial distribution of six physiologic types: aerobes, denitrifiers, iron-reducers, heterotrophic fermenters, sulfate-reducers, and methanogens. Both free-living and attached numbers were determined over a broad cross-section of the aquifer extending horizontally from the source of the plume at a nonaqueous oil body to 66 m downgradient, and vertically from above the water table to the base of the plume below the water table. Point samples from widely spaced locations were combined with three closely spaced vertical profiles to create a map of physiologic zones for a cross-section of the plume. Although some estimates suggest that less than 1% of the subsurface microbial population can be grown in laboratory cultures, the MPN results presented here provide a comprehensive qualitative picture of the microbial ecology at the plume scale. Areas in the plume that are evolving from iron-reducing to methanogenic conditions are clearly delineated and generally occupy 25-50% of the plume thickness. Lower microbial numbers below the water table compared to the unsaturated zone suggest that nutrient limitations may be important in limiting growth in the saturated zone. Finally, the data indicate that an average of 15% of the total population is suspended.http://link.springer-ny.com/link/service/journals/00248/bibs/37n4p263.html

Hypertension in the elderly: attitudes of British patients and general practitioners

The perceptions of patients and GPs of the risk of stroke in treated and untreated elderly hypertensives, and their attitudes towards anti-hypertensive therapy were examined. To explore attitudes of patients to the management of hypertension a qualitative approach was used, employing semi-structured interviews, with subsequent thematic analysis of the transcriptions. A questionnaire study of GPs' attitudes to the same subject was also conducted. The elderly (n = 75) greatly overestimate the risks of hypertension and the benefits of treatment. Most would accept anti-hypertensive therapy despite being informed of the true risks, citing confidence in their doctor as the major determinant in their decision. GPs (n = 121) were well informed of the risks and benefits, but less than half adhere to current guidelines. GPs should be aware how much the elderly overestimate the risks of hypertension and the benefits of its treatment. When considering treating hypertension in this group, patient contributions in the treatment decision-making process should be actively encouraged, especially as many elderly hold a deferential attitude towards their doctor. Patients should be informed of the risks of their disease and the benefits of treatment in terms they understand. The use of visual aids helps patients to grasp the difficult concepts of risk and benefit.

Advances in the treatment and prophylaxis of Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia (PCP) is the most common illness associated with the acquired immunodeficiency syndrome (AIDS) in the United States and also occurs in immunocompromised persons not infected with the human immunodeficiency virus.. Several advances have taken place in the treatment and prophylaxis of PCP, with most clinical trials conducted in patients with AIDS. Treatment of choice is trimethoprim-sulfamethoxazole (TMP-SMX). Desensitization regimens are available for those who have a fever or rash associated with the agent. Patients with severe PCP who cannot tolerate TMP-SMX may be treated successfully with pentamidine or trimetrexate. Those with mild to moderate disease may receive dapsone-trimethoprim, clindamycin-primaquine, or atovaquone if they cannot take TMP-SMX. Adjunctive therapy with corticosteroids improves the outcome in patients with AIDS and severe PCP.

The influence of parasympatholytics on the resolution of acute attacks of asthma

PURPOSE

To evaluate the role of parasympatholytics in the resolution of acute attacks of asthma.

METHODS

This study employed a prospective sequential design in which the influence of 0.5 and 1.0 mg of ipratropium bromide on peak expiratory flow rates (PEFR), hospital admissions, and length of stay (LOS) in the emergency department (ED) was evaluated. The parasympatholytic was added to a well-investigated standard therapeutic regimen that was anchored by the use of repetitive doses of albuterol, and employed pretested decision algorithms.

RESULTS

One hundred and thirty-one patients received ipratropium (l) and 123 who did not (NI) served as controls. There were no significant pretreatment between group differences in gender, racial composition clinical signs and symptoms, or PEFR. The presence of ipratropium in the regimen did not influence discharge/admission patterns, LOS, the rate of improvement of the patients, or the level of PEFR achieved.

CONCLUSION

Anticholinergic agents such as ipratropium are not first-line treatments for acute asthma. They do not add any therapeutic benefit to the effects of albuterol given in divided doses over 1 hour, nor do they facilitate recovery in patients whose immediate response to sympathomimetics is impaired.

Clinical and human resource planning for the downsizing of psychiatric hospitals: the British Columbia experience

Riverview Hospital, B.C.'s only and Canada's largest remaining provincial psychiatric hospital began a formal planned "downsizing" process in 1992. This initiative was an important element in the Province's strategic plan to shift to a more community-focused mental health system and to bring tertiary psychiatric services "closer to home" by redeveloping Riverview Hospital on three sites. The paper summarizes the literature pertaining to the "downsizing" of psychiatric hospital services in relation both to clinical and human resource planning. It describes the mental health system in B.C. and the service system context in which this exercise is occurring. It is based on the first three years of experience in identifying the major challenges and the strategies developed to meet these challenges. It draws some conclusions about the effectiveness of these strategies and it speculates about the likely future challenges as the "downsizing" process continues.

Handedness in children at school entry: does the 'Mesker test' provide a valid method for testing writing handedness?

The 'Mesker test', an experiment devised after the psycho-motor dominance test described by the Dutch paediatrician Mesker, was evaluated as a method for testing writing handedness in 145 children at school entry in Crewe Health Authority. Also included in the assessment was if, and how these children know their laterality. Positive outcome was measured as Mesker test result corresponding to spontaneous hand-preference in symbol copying. The correct indication of right arm or leg was evaluated in relation to the outcome by chance. The Mesker test could not confirm hand-preference in children at school entry. There was no significant relation to the child's maturity and no significant consistency in test performance. The sub-group of right-handed writers who confirmed their handedness showed an almost significant level of consistency. No more children who thought they knew the right side indicated the correct limb then could have been arrived at by chance. This was not significantly related to having been taught, writing handedness or maturity. It is concluded therefore, that at school entry age children don't have a good knowledge of their body's laterality. Although the Mesker test does not confirm writing handedness at school entry, it may be useful in older children with inconsistent laterality.

Gorilla class I major histocompatibility complex alleles: comparison to human and chimpanzee class I

14 gorilla class I major histocompatibility complex (MHC) alleles have been isolated, sequenced, and compared to their counterparts in humans and chimpanzees. Gorilla homologues of HLA-A, -B, and -C were readily identified, and four Gogo-A, four Gogo-B, and five Gogo-C alleles were defined. In addition, an unusual Gogo class I gene with features in common with HLA-A and its related pseudogene, HLA-H, is described. None of the gorilla alleles is identical or even closely related to known class I alleles and each encodes a unique antigen recognition site. However, the majority of polymorphic substitutions and sequence motifs of gorilla class I alleles are shared with the human or chimpanzee systems. In particular, elements shared with HLA-A2 and HLA-B27 are found in Gogo-A and -B alleles. Diversity at the Gogo-B locus is less than at the Gogo-A locus, a trend the opposite of that seen for HLA-A and -B. The Gogo-C locus also appears to have limited polymorphism compared to Gogo-A. Two basic Gogo-C motifs were found and they segregate with distinctive sets of HLA-C alleles. HLA-A allels are divided into five families derived from two ancient lineages. All chimpanzee A alleles derived from one of these lineages and all gorilla alleles derive from the other. Unlike chimpanzee Patr-A alleles, the Gogo-A alleles do not clearly partition with one of the HLA-A families but have similarities with two. Overall, gorilla class I diversity appears from this sampling to show more distinctions from class I HLA than found for chimpanzee class I.

Tuberculosis as an endemic and nosocomial infection among the elderly in nursing homes

We studied reactivity to tuberculin skin testing in nearly all nursing home residents in Arkansas. Only 12 per cent of the 12,196 newly admitted residents were tuberculin positive, as compared with 20.8 per cent of the 13,441 residents who were first tested more than a month (mean, 30 months) after admission. The proportion of persons who were positive on initial testing varied greatly with the time spent in the home before testing. Those who were not reactive on initial testing had a 5 per cent rate of conversion for each year spent in a home with a known recent infectious case (within three years) and a 3.5 per cent rate for each year in a home with no recognized recent case. Active tuberculosis developed in only 1 of 534 persons with positive tuberculin tests or previous reactions who were treated with isoniazid, but in 79 (2.4 per cent) of 3270 persons who were not (P less than 0.001). The disease developed in only 1 (0.16 per cent) of 605 persons whose tests converted to positive and who were treated with isoniazid, as compared with 45 (5.9 per cent) of 757 whose tests converted but who were not treated (P less than 0.001). We conclude that new infection with tuberculosis is an important risk for nursing home patients and that greater care should be taken to detect and treat new infections before the disease develops and the infection spreads.

Epidemic tuberculosis in a nursing home: a retrospective cohort study

In a retrospective study, the results of tuberculin skin tests done in a nursing home were examined, where most residents admitted during 1972-1981 were tested using purified protein derivative of tuberculin administered intradermally. Of 514 residents who were tested at least once during the study period, results of the admission skin test were available for 254 and follow-up skin test results were available for 226. On admission, 13 per cent (35/254) were skin-test positive (greater than or equal to 10 mm induration at 48 hours). Skin test positivity for males was 16 per cent, females, 11 per cent, nonwhites, 19 per cent, and whites, 12 per cent. Highest skin test positivity was for persons received as transfers from other nursing homes (24 per cent) and lowest was for those entering from individual homes (8 per cent, P = 0.016, Fisher's Exact Test). On follow-up, 38/226 (17 per cent) residents who had been tuberculin-negative on at least two previous occasions were found to be positive; 24 (63 per cent) of these conversions occurred in a single year (1975) following detection of an infectious patient. The infection rate for persons residing in the nursing home during that year was 28 per cent (28/99) compared with 7.9 per cent (10/127) for persons either discharged before or admitted after 1975 (relative risk = 3.6, P less than 0.001). Ten to 15 per cent of new residents are tuberculin-positive (harbour a dormant tuberculous infection), leaving 85-90 per cent of newly admitted persons who are tuberculin-negative and thus susceptible to infection if exposed. The study shows that tuberculosis must be considered as a potential nosocomial infection in nursing homes.(ABSTRACT TRUNCATED AT 250 WORDS)

Free oxygen radicals are not detectable by chemiluminescence during human natural killer cell cytotoxicity

Mononuclear cells isolated from peripheral blood of normal donors produce free oxygen radicals (FR), detectable by chemiluminescence (CL), when interacting with target cells during natural killer (NK) cell lysis. FR-producing cells were found to have monocyte characteristics and gave a positive CL reaction when mixed at low concentration (0.5%) with purified NK cells. No correlation was found between susceptibility to NK cell lysis and capacity to induce CL with different target cell lines. Using high and low molecular FR scavengers, no NK cell inhibition was seen with superoxide dismutase, cytochrome c, and catalase, whereas some inhibition was seen with 4,5-dihydroxy-m- benzenedisulphonic acid (Tiron) and 2,3-dihydroxybenzoate. These compounds, however, required higher concentrations than used for inhibition of CL, suggesting an alternative action of these compounds. Normal levels of NK cell activity were found in two patients with chronic granulomatous disease, who were genetically incapable of producing detectable amounts of FR. As a result, it is concluded that human NK cells do not produce large amounts of FR during killing and that FR are unlikely to be the lytic end product. Nevertheless, neither a low degree of FR formation in NK cells nor a more subtle signal-transmitting role of FR during NK cell triggering can be excluded.

A simple device to encourage the unwilling child to wear a pressure garment

This brief report describes how, with commendable psychological insight, the father of a child recently treated in our burns unit adopted a very simple device to encourage his youngster to wear a pressure garment to deal with hypertrophic scarring.

Comparison of sodium amylosulfate and sodium polyanetholsulfonate in blood culture media

A comparison between sodium polyanetholsulfonate and sodium amylosulfate in unvented vacuum blood culture bottles containing tryptic soy broth was made with 5,800 sets of blood cultures. No statistically significant differences in isolation rates of bacteria were noted.

Evaluation of blood culture media supplemented with sucrose or with cysteine

A total of 5,883 blood samples from patients with suspected bacteremia were inoculated concurrently into each of three media under vacuum with CO2: tryptic soy broth (TSB) with sodium polyanetholesulfonate (SPS), TSB with SPS and cysteine, and TSB with SPS and sucrose. There were 395 positive cultures, excluding presumed contaminants. No significant differences were noted with the addition of cysteine to TSB with SPS, and no streptococcal mutants requiring thiol groups were isolated. Haemophilus, Staphylococcus aureus, and bacteriodaceae were isolated more frequently (P less than 0.05) in the absence of sucrose. The addition of sucrose to TSB containing SPS did not significantly increase the rate of positivity or the time interval to detection of positivity of any group of bacteria.

Comparison of two liquid blood culture media containing sodium polyanethole sulfonate: tryptic soy and Columbia

In a comparison of tryptic soy broth and Columbia broth, two blood culture media containing sodium polyanetholesulfonate, there were 589 positive cultures (excluding presumed contaminants). The two media were equivalent in performance except for lower detection rates for Staphylococcus aureus (P < 0.01) and Pseudomonas aeruginosa (P = 0.05) and a higher detection rate for Bacillus (P < 0.01) in Columbia broth. No significant differences were noted in time intervals to detection of positivity. Routine subcultures on the 1st and 5th days of incubation provided the initial detection of 18.1% of the positive cultures.

Detection of bacteremia with liquid media containing sodium polyanetholsulfonate

Two liquid blood culture media, Tryptic soy broth (TSB) and Thiol broth, containing sodium polyanetholsulfonate were compared in 8,654 cultures. Pseudomonas and Corynebacterium (including Propionibacterium) were isolated significantly more frequently (P < 0.001) from TSB than from Thiol. Escherichia coli, Haemophilus, and Bacteroidaceae were isolated more frequently in TSB; however, the differences were not statistically significant. In no instance was Thiol superior to TSB in detecting bacteremia. In an additional 2,977 cultures, aerobic and anaerobic Vacutainer culture tubes with supplemented peptone broth were inoculated in parallel with TSB and Thiol. Significantly greater rates of detection (P < 0.01) in TSB or Thiol were noted with Pseudomonas, E. coli, Enterobacter, viridans, and group A streptococci, Bacteroidaceae, and staphylococci.

Stability of barium sulfate turbidity standards

McFarland barium sulfate standards prepared in 1952 were compared spectrophotometrically with freshly and identically prepared standards; the results were nearly identical.

Four-hour microbiological assay of gentamicin in serum

Since the microbiological assay of the antibiotic content of serum generally requires 18 to 24 hr of incubation, results of such procedures may not become available in time to make appropriate adjustments in subsequent dosages of antibiotic. A 4-hr bioassay for determining concentrations of gentamicin in serum has been developed in which Staphylococcus aureus ATCC 6538P is used as the test organism. Poured plates have yielded satisfactory results after storage at 4 C for 5 days. Results of the 4-hr procedure agree closely with those of a conventional 18-hr disc-plate assay performed with the same test organism.