A feasibility study for a clinical decision support system prompting HIV testing

OBJECTIVES

Levels of undiagnosed HIV infection and late presentation remain high globally despite attempts to increase testing. The objective of this study was to evaluate a risk-based prototype application to prompt HIV testing when patients undergo routine blood tests.

METHODS

Two computer physician order entry (CPOE) systems were modified using the application to prompt health care workers (HCWs) to add an HIV test when other tests selected suggested that the patient was at higher risk of HIV infection. The application was applied for a 3-month period in two areas, in a large London hospital and in general practices in Teesside/North Yorkshire. At the end of the evaluation period, HCWs were interviewed to assess the usability and acceptability of the prompt. Numbers of HIV tests ordered in the general practice areas were also compared before and after the prompt's introduction.

RESULTS

The system was found to be both useable and generally acceptable to hospital doctors, general practitioners and nurse practitioners, with little evidence of prompt/alert fatigue. The issue of the prompt appearing late in the patient consultation did lead to some difficulties, particularly around discussion of the test and consent. In the general practices, around 1 in 10 prompts were accepted and there was a 6% increase in testing rates over the 3-month study period (P = 0.169).

CONCLUSIONS

Using a CPOE-based clinical decision support application to prompt HIV testing appears both feasible and acceptable to HCWs. Refining the application to provide more accurate risk stratification is likely to make it more effective.

An economic and environmental evaluation for bamboo-derived bioethanol

The potential to obtain bioethanol from bamboo using three different pretreatment technologies (liquid hot water (LHW), dilute acid (DA) and soaking in aqueous ammonia (SAA)) is assessed via techno-economic and environmental analyses.

High-fat/low-carbohydrate diet reduces insulin-stimulated carbohydrate oxidation but stimulates nonoxidative glucose disposal in humans: An important role for skeletal muscle pyruvate dehydrogenase kinase 4

AIM

The aim of this report was to study the effect of high-fat (HF)/low-carbohydrate (CHO) diet on regulation of substrate metabolism in humans.

METHODS

Ten healthy men consumed either a HF (75% energy as fat) or control (35%) diet for 6 d in random order. On d 7, blood glucose disappearance rate (Rd) was determined before and during a hyperinsulinemic euglycemic clamp. Substrate oxidation was determined by indirect calorimetry. Muscle biopsies were obtained prediet, postdiet, and postclamps.

RESULTS

Rd was similar under basal conditions but slightly elevated (approximately 10%, P < 0.05) during the last 30 min of the clamp after the HF diet. HF diet reduced CHO oxidation under basal (by approximately 40%, P < 0.05) and clamp conditions (by approximately 20%, P < 0.05), increased insulin-mediated whole-body nonoxidative glucose disposal (by 30%, P < 0.05) and muscle glycogen storage (by approximately 25%, P < 0.05). Muscle pyruvate dehydrogenase complex activity was blunted under basal and clamp conditions after HF compared with control (P < 0.05) and was accompanied by an approximately 2-fold increase (P < 0.05) in pyruvate dehydrogenase kinase 4 (PDK4) mRNA and protein expression.

CONCLUSION

Short-term HF/low-CHO dietary intake did not induce whole-body insulin resistance, but caused a shift in im glucose metabolism from oxidation to glycogen storage. Insulin-stimulated CHO oxidation and muscle pyruvate dehydrogenase complex activity were blunted after the HF diet. Up-regulation of muscle PDK4 expression was an early molecular adaptation to these changes, and we showed for the first time in healthy humans, unlike insulin-resistant individuals, that insulin can suppress PDK4 but not PDK2 gene expression in skeletal muscle.

Nutrition in patients with cystic fibrosis: a European Consensus

This document is the result of an European Consensus conference which took place in Artimino, Tuscany, Italy, in March 2001 involving 33 experts on nutrition in patients with cystic fibrosis, organised by the European Cystic Fibrosis Society, and sponsored by Axcan-Scandipharm, Baxter, Dr Falk Pharma, Fresenius, Nutricia, SHS International, Solvay Pharmaceuticals (major sponsor). The purpose of the conference was to develop a consensus document on nutrition in patients with cystic fibrosis based on current evidence.

Primary health care in Saudi Arabia: applying global aspects of health for all, locally

Primary health care in Saudi Arabia: applying global aspects of health for all, locally This paper describes the application of primary health care principles in the Islamic Kingdom of Saudi Arabia. It arose from a doctoral supervisory experience on a joint programme for women students, operating between a British and Saudi Arabian University. The research looked at nutritional advice given by diploma-level nurses to pregnant women attending primary health care centres in Saudi Arabia. The supervisor supported research that drew on internationally recognized trends in nursing research (the reflexive learner) whilst attending to local requirements and conventions of the culture. The student was encouraged explicitly to site the research within the framework of Islamic teaching and Saudi culture. The Qur'an was used as an overarching framework within which the tenets of primary health care were explored. This was seen to be crucial in addressing World Health Organisation and the International Council of Nurses' views on contextualizing nursing for the greatest benefit of the population. This was of particular relevance in Saudi Arabia where research carried out in the community by women is novel, and as yet there are no nurse theorists from within Saudi culture.

A survey of postgraduate education programmes and research interests of GPs in community trusts in an inner city area

Following discussions with medical lecturers in a postgraduate centre, a questionnaire was sent to all the general practitioners (GPs) in three selected Community Trusts in an inner city area. Besides their qualifications and research interests, the GPs were asked for their views on continuing education. The results showed that opportunities for collaborative education with other members of the primary care groups (PCGs) would be possible if it focused on research methods and 'Health of the Nation' targets. The results showed that up to 61% of the GPs who responded had carried out research and had collaborated with nurses on the research projects. There was considerable variation across the Community Trusts in relation to the experience and interests of the GPs. The formation of the PCGs and joint commissioning offered an excellent opportunity for both collaborative educational opportunities and research. As the interests of the GPs is so diverse, some thought about consolidating and harnessing their interests and expertise in order to influence local and national research agendas may be of value.

Anthropology and children's nursing

Children's nurses have become more involved in the provision of culturally sensitive care. There has been a search for a more meaning centred (or hermeneutic) method in exploring children's worlds. The possible relevance of anthropology as an approach to both the culture of children's nursing and the cultures in which children's nurses find themselves is explored.

Against women: are we looking after our general practitioners? GPs' views of the 1990 part-time contract

A postal survey was conducted looking at the roles and experiences of General Practitioners on part-time contracts. This involved their perception of the attitudes of their colleagues and patients to their part-time status, and the consequences of these for their professional development. Of the 130 General Practitioners with part-time contracts in the one Regional Health Authority that was being surveyed 77.7% responded; 74.3% of the respondents were women. Of the women General Practitioners who responded to this particular question, the predominant age-bands were 31-40 years [41.4% (41)] and 41-50 [19.2% (19)], whilst male General Practitioners were more evenly spread across the age bands. The results showed that the majority of General Practitioners took up part-time contracts to enable them to look after their dependants, though a sizeable minority wished for free time or to relieve stress from a full-time contract. Forty percent said that they felt excluded from decision making about continuity of patient care and practice policy. Just under forty percent also stated that their workload was excessive in comparison with their full-time counterparts. Further, many expressed the opinion that they were financially penalised. The cost effective correlation between the increased availability of General Practitioners (particularly women) for patient care, and the costly medical education and training of such General Practitioners not being 'wasted' for several years was also noted together for the need for ongoing (or continual) medical education and training. The findings of this survey suggest there are many unresolved issues involved in satisfactory part-time contracting arrangements for General Practitioners. This particularly affects women General Practitioners. Whilst the RCP policy statement addresses education and training for general practice, the question of not losing out in relation to training opportunities and promotion is not addressed. The unresolved effects of the intra-professional differences in opportunities may affect the inter-professional functioning of the primary health care team and ultimately continuity and quality of care for patients.

Improvement of nebulised antibiotic delivery in cystic fibrosis

AIM

To investigate deposition patterns and to assess the delivery rate of two nebuliser systems in children with cystic fibrosis (CF).

METHODS

Thirty three children with CF on regular treatment with nebulised antibiotics had radioisotope scans performed using technetium-99m labelled aerosol antibiotic generated by a Ventstream nebuliser (median mass diameter (MMD), 3.3 microm; delivery rate, 0. 075 ml/min) under conditions similar to their routine home practice. The inhomogeneity of the images was scored on a 1-10 rating scale (a low score indicating even distribution of the antibiotic), and stomach deposition was measured as a percentage of overall deposition. Twenty patients had a repeat scan using an Optimist nebuliser (MMD, 1.8 microm; delivery rate, 0.02 ml/min).

RESULTS

The mean inhomogeneity scores were 5.4 in the Ventstream group and 3. 5 in the Optimist group. Mean stomach deposition was 17.3% in the 33 patients using the Ventstream nebuliser. There was an inverse relation between height and stomach deposition (r = 0.69). In the 20 patients who had both nebulisers, the mean percentages of stomach deposition for the Ventstream and Optimist nebulisers were 11.8% and 1.6%, respectively. The Ventstream nebuliser delivered antibiotic at an average 2.8 times faster rate than the Optimist nebuliser.

IMPLICATIONS

A smaller particle size results in a more homogenous distribution of the antibiotic in the lungs with decreased stomach deposition. This should not be seen as a recommendation to use the Optimist nebuliser because more antibiotic was delivered to most parts of the lung with the Ventstream because of its increased delivery rate.

Mothers' understanding of their children's bodies

Children under 6 months, brought to the accident and emergency department (A&E) are distressed by problems often related to digestion. Parental knowledge of their children's bodies showed relatively little differentiation between structures. They made clear distinctions between the quality of their baby's crying and the problem. Parents made decisions to seek help on the basis of the quality of their child's crying and thereby its associated disorder. Telephone advice for parents may be the way forward in service provision, and will therefore require more exacting knowledge from the parents. The research approach used in the study--cognitive mapping--appeared to be acceptable to the mothers, as a way of eliciting representations.

Serum cortisol levels are related to moods of elation and dysphoria in new mothers

Serum cortisol levels were measured in 163 women on the third day after childbirth. Significantly elevated levels of cortisol were found to be associated with the "blues," and significantly lower levels characterized women who exhibited mild hypomania (the "highs"). Low levels of cortisol were independently associated with epidural anesthesia, while elevated levels were related to assisted delivery. There was no significant association with breast or bottle feeding. Changes in serum cortisol were thus found to parallel the mild bidirectional changes in affect that frequently follow childbirth.

Postnatal care following premature birth

There is a growing awareness that women who give birth prematurely have a particular need for specialist after-care and support. Jane Littlewood and Lesley Taylor report the findings of a study to examine the differing experiences of postnatal care reported by women following full-term and premature birth.

Understanding the meaning of wounds

Little research has been done to address patients' understanding of wounds and how that might interfere with treatment and healing. This article tackles the issue by examining the meaning of wounds to patients. The origin of the wound and the patients' environment can make a difference to how patients view treatment and healing. The author identifies how this knowledge can be incorporated into nurses' assessment of wounds.

Screening elderly people: a multidisciplinary concern

The Elderly Screening Survey was carried out in 1990 as a follow-up to a similar study completed by the Centre for the Study of Primary Care in 1988. The aim of these two studies was to look at national differences in the types of screening programmes for elderly people and, specifically, to look at who carries out these programmes. The Elderly Screening Studies of 1988 and 1990 can be located within the ongoing debates about screening. In particular, given the implications of the general practitioner contract arrangements, these studies provide information on the discussion about the role and involvement of community nurses in screening older people. The results suggest that screening programmes for this age group had become more tailored to 'age-related need' in 1990 as compared to 1988. In 1990, districts were more likely to employ a wider variety of nursing personnel in carrying out screening schedules. Furthermore, it was evident that more districts were employing district nurses and practice nurses to implement screening assessments than in 1988. Attention is drawn to the lack of guidelines at district level on screening activities. The need to re-assess training provision particularly for practice nurses is highlighted.

Psychosexual functioning after the treatment of cancer of the vulva. A longitudinal study

Ten couples, the women beginning treatment for carcinoma of the vulva, participated in a 2-year longitudinal study on sexual functioning before and after treatment. Sexual functioning was measured on admission and at 6, 12, and 24 months posttreatment. Sexual functioning was made operational in terms of current sexual behavior, sexual motivation, sexual (dis)satisfaction, and the perception of genital sensations of sexual arousal. An age-matched nonpatient control group was added to the study and the impact of physical variables was also evaluated. Within 1 year, all women who were sexually active before the treatment had resumed their sexual activities. At the 6-month assessment an increase in relational sexual dissatisfaction could be detected. Over the remaining observation period the women's satisfaction with sexual interaction with the partner was not found to be different from their pretreatment satisfaction and not different from the satisfaction in the control group, in spite of the physical damage and persisting poor perception of genital symptoms of sexual arousal during lovemaking. Satisfaction with sexual interaction with the partner under these circumstances appears to be more an expression of satisfaction with the intimate aspects of the sexual relationship than of satisfaction with the physiologic arousal aspects of the sexual relationship. It is argued that psychological and social variables are more crucial for sexual rehabilitation than physical variables. Therefore, psychosocial issues constitute the most promising focus for intervention.

Psychiatric morbidity, platelet monoamine oxidase and tribulin output in headache

A significantly higher proportion of patients with headache showed scores in the psychopathological range of the General Health Questionnaire (GHQ) compared with controls, with ratings particularly high on the anxiety and depression subscales. Across the whole group, there was a significant negative correlation between platelet monoamine oxidase (MAO) activity and GHQ score overall, and with the anxiety and depression subscales. There was a significant positive correlation between platelet MAO activity and urinary output of the endogenous MAO inhibitor, tribulin. Within the migraine group, there was a significant negative correlation between tribulin output and GHQ score. These findings suggest that the biochemical nature of the anxiety associated with migraine may differ from that in other conditions such as generalized anxiety disorder where high platelet MAO activity and high tribulin output have been reported.

A model for nursing using anthropological literature

This paper describes the usefulness of the incorporation of medical anthropology into the nursing process. It suggests that in order to plan comprehensive patient care, much more attention needs to be paid to lay concepts of illness and causation of illness. This must take place at the assessment stage. If it does not, the nurse and the patient may be working towards conflicting goals of care which may prevent healing.

Low platelet monoamine oxidase activity in headache: no correlation with phenolsulphotransferase, succinate dehydrogenase, platelet preparation method or smoking

Platelet monoamine oxidase activity in male migrainous and cluster headache patients was significantly lower than in male controls, confirming our previous study. The activity range showed a normal distribution and low mean values could not be attributed to a subgroup with particularly low activity. When Corash 's platelet preparation method was used, with its high platelet yield, specific enzyme activities of a similar order were obtained. Thus, the low values encountered were not due to abnormal recovery within the platelet population. Two other enzyme activities, phenolsulphotransferase M and succinate dehydrogenase, were also measured in the same platelet samples. Although low succinate dehydrogenase activity was identified in the headache groups, it appeared to represent a separate phenomenon and there was no significant correlation between activity of either enzyme and that of monoamine oxidase. This shows that the low activity of platelet monoamine oxidase in headache is not related to a generalised platelet enzyme deficit. It was also shown that the low monoamine oxidase activity in the headache patients could not be attributed to smoking.

Platelet size: no correlation with migraine or monoamine oxidase activity

A Coulter Model "S Plus" counter has been used to study platelets from 39 migrainous patients between attacks, six during attacks, eight with active cluster headache and 26 controls. None of the patient groups showed any abnormality in platelet size profile. There was no correlation between platelet monoamine oxidase activity and mean platelet volume in any of the groups.

Platelet monoamine oxidase: specific activity and turnover number in headache

Monoamine oxidase turnover numbers (molecules of substrate converted to product per minute per active site) have been calculated for the human platelet enzyme using [3H]pargyline. Headache patients with high and low monoamine oxidase specific activities relative to controls were found to have turnover numbers very close to those for controls. This finding suggests that their specific activities vary because of differences in the concentration of active monoamine oxidase molecules, rather than differences in the ability of those enzyme molecules to catalyse the deamination reaction.

Platelet phenolsulphotransferase deficiency in dietary migraine

Patients with dietary migraine were found to have significantly lower levels of platelet phenolsulphotransferase activity than either migrainous patients without a history of dietary provocation or normal controls. Of the two known human variants of this enzyme, the phenol-inactivating P form, for which no endogenous substrate has so far been identified, was more severely involved than the M enzyme, which inactivates monoamines (including tyramine). Such commonly implicated dietary triggering agents as chocolate and cheese may contain as-yet-unidentified phenolic substrates of phenolsulphotransferase P; if the platelet enzyme deficiency were mirrored by low gut activity, abnormally large amounts of potentially toxic substances might gain access to the circulation in consequence.

Platelet monoamine oxidase activity and headache

Mean platelet monoamine oxidase activity was reduced compared with control values in groups of headache-free male (but not female) patients suffering from classical migraine and from tension headache. Mean activity in male cluster patients, headache free, both during acute and quiescent phases of their illness, was also notably reduced. Retesting some migraine subjects after up to four years, showed that low activity may be a persistent feature: the correlation coefficient for repeated assays was 0.91 (p less than 0.01). There was no relationship between platelet monoamine oxidase activity and history of dietary migraine. A subgroup of headache patients with permanently low monoamine oxidase activity values may have been defined.

Small-bowel mucosa in asymptomatic children with celiac disease. Mucosal changes with gluten-free diets

Even though children with celiac disease may appear to be progressing satisfactorily while taking gluten-free diets, dietary lapses and persisting mucosal abnormalities are common. Of 32 children with celiac disease proven by biopsy only ten kept regularly to their diet, and 11 continued to ingest gluten regularly. Despite satisfactory clinical progress, intestinal biopsy specimens obtained after at least one year of a gluten-free diet were markedly abnormal in eight and were normal in only 14 children. Laboratory criteria also failed to detect those with persisting mucosal abnormalities. The only way to ensure that the small-bowel mucosa returns to normal and remains so is by intestinal biopsy.