A comparative review of advanced practice nurse programmes in the Nordic and Baltic countries

BACKGROUND

Advanced practice nurses (APNs) programs are career-development opportunities significant for nursing workforce retention as well as for the quality of patient care. Inconsistency regarding policy, education, titles, scope of practice, skills and competencies have been identified as major challenges in developing advanced practice nursing in Europe. APN roles and education are under development in the Nordic and Baltic countries. However, there is a lack of information on the current state in this region.

OBJECTIVE

The purpose of this paper is to compare APN programs in the Nordic and Baltic countries to identify their commonalities and differences.

DESIGN AND METHODS

This descriptive comparative study reviewed seven master's level APN programs in six Nordic and Baltic countries. Data was extracted from the programme by the expert teachers or leaders of the programmes (N = 9). Competencies recommended in the European Tuning Project (ETP) and the International Council of Nurses (ICN) guidelines on advanced practice nursing, were used to evaluate the programs. The same informants provided additional information on the current state of APN education in the country.

RESULTS

The admission requirements were similar in the six countries but in two, clinical work experience is an entry requirement. There are two commonly identified APN roles: clinical nurse specialist (CNS) and nurse practitioner (NP). Most of the programs included all the EPT and ICN competencies. The main differences regarded prescribing competencies. All programmes included clinical training, but the methods on how it is implemented varies.

CONCLUSION

The findings indicate that APN programs in the Nordic and Baltic countries correspond with the recommendations of the European Tuning Project and ICN guidelines. This is an important message for administrators, policymakers, and politicians, as well as the nursing community, on providing opportunities for APNs to practice to their full potential within each country as well as cross-country.

TWEETABLE ABSTRACT

"APN programmes in the Nordic and Baltic countries correspond with international guidelines. Special attention is needed in future on the clinical training of APNs".

Improvements in the infrastructure for nursing research in universities in Kazakhstan

AIM

This study aimed to describe the status and analyze the improvements made by universities in Kazakhstan to nursing research infrastructure in the following services: library, internationalization, finance, information and communication technology (ICT), and research, development, and innovation (RDI).

BACKGROUND

In higher education institutions (HEIs), a strong research infrastructure is a necessity for academic education and research. In Central Asian countries, nursing is regarded as an assistive field to medicine, affecting nursing research infrastructures.

METHODS

In this descriptive study, following benchmarking and a recommendations report, an interview of nursing faculty members was used to obtain data regarding nursing research infrastructure in ten universities in Kazakhstan. The SQUIRE-EDU was used to ensure the quality of reporting.

RESULTS

The Kazakhstani universities providing nursing education are still in the process of developing their nursing research infrastructure. They have not acquired access to nursing databases, and only one textbook concerning nursing research can be found from their libraries. None of the universities have joined international nursing networks. The participation of the university staff and students in conferences with nursing themes has increased. The universities are investing in staff capacity building, but not yet in nursing research projects.

DISCUSSION AND CONCLUSION

Kazakhstani universities have the autonomy to develop nursing research and its infrastructure. Active measures by the university management, such as financing access to nursing databases, international cooperation, and international projects, are necessary.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Research infrastructures' quality strongly impacts the development of nursing science and practice in any country. It is crucial to increase the volume of research that demonstrates the effectiveness of clinical nursing and its contribution to health outcomes. To enable the faster development of nursing science in Central Asian countries, this development should be supported through international collaboration.

Development of management structures for future nursing services in the Republic of Kazakhstan requires change of organizational culture

Aim

This study's aim was to describe the development of new management structures for nursing services in pilot public healthcare organizations in the Republic of Kazakhstan by focusing on cultural change from the former Soviet system to the modern nursing management system.

Background

Because organizational culture plays an essential role in developing nursing management processes, the challenge in Kazakhstan is to change the deep‐rooted Soviet administration practices, such as top‐down management and the absence of a career structure in nursing, to meet the new public management system's requirements.

Method

Participatory method was used to generate organizational culture change in 31 pilot organizations.

Results

The organizational structures were reorganized with new nursing positions. Changes concerning nurses' job descriptions and educational requirements were introduced to the legislation. Workforce planning and work division between the healthcare professionals were suggested, allowing new operational functions for nurses. The implemented changes facilitate the culture change in the healthcare and nursing service system.

Conclusion

The shift of healthcare organizations towards a modern nursing management system has started in Kazakhstan.

Implications for Nursing Management

Good understanding and competence of cultural issues related to the change processes are critical in countries that are undergoing fundamental reforms in their healthcare systems.

Nursing research priorities based on CINAHL database: A scoping review

Aim

To analyse nursing research based on the CINAHL database to identify research priorities for nursing.

Design

A scoping literature review was conducted. The CINAHL Plus (EBSCO) Full Text was searched between 2012-2018.

Methods

Out of 1522 original publications, 91 fulfilled the inclusion criteria. The Joanna Briggs Institute critical appraisal tools were applied. Data were analysed by a thematic analysis method.

Results

A strong emphasis should be put on development and evaluation of nursing theories and, in addition, randomized controlled trial studies, meta-synthesis, experimental and intervention studies are needed in nursing research. Development of competencies and skills in the nursing profession ought to be studied more extensively and research should be focused on variety fields of nursing practice.

Breast deformation during the course of radiotherapy: The need for an additional outer margin

PURPOSE

The aim of this retrospective study was to investigate and quantify the extent of breast deformation during the course of breast cancer (BC) radiotherapy (RT). The magnitude of breast deformation determines the additional outer margin needed for treatment planning to deliver a full dose to the target volume. This is especially important when using inverse planning techniques.

METHODS

A total of 93 BC patients treated with RT and with daily CBCT image guidance were selected for this study. Patients underwent either only breast-conserving surgery (BCS) (n = 5), BCS with sentinel node biopsy (n = 57) or BCS with radical axillary node dissection (n = 31). The treatment area included the whole breast and chest wall (54%) or also the axillary lymph nodes (46%). 3D-registration was conducted between 1731 CBCT images and the respective planning CT images to assess the difference in breast surface.

RESULTS

The largest maximum breast surface expansion (MBSE) was 15 mm; the average was 2.4 ± 2.1 mm. In 294 fractions (17%), the MBSE was ≥5 mm. An outer margin of 8 mm would have been required to cover the whole breast in 95% of the treated fractions. There was a statistically significant correlation between the MBSE and body mass index (r = 0.38, p = 0.001).

CONCLUSIONS

Significant changes in the breast surface occur during the course of BC RT which should be considered in treatment planning. An additional margin outside the breast surface of at least 8 mm is required to take into account the anatomical changes occurring during BC RT.

A Survey of Coronary Risk Factors and B-Type Natriuretic Peptide Concentrations in Cardiac Nurses from Europe: Do Nurses Still Practice what they Preach?

BACKGROUND

From a previous survey of cardiac nurses attending a scientific conference, we learned that these nurses adopted a healthier lifestyle than the general population.

AIMS

The aim of this study was to determine the overall profile of cardiac risk factors in a similar cohort and determine whether cardiac nurses continue to 'practice what they preach' in this regard. Secondly, we examined the practical value of screening a large cohort of individuals within a short time frame (total of 8 hours screening time) and determined the range of BNP concentrations within a 'healthy' cohort.

METHODS

Data on CHD risk factors were collected with a short self-report questionnaire. The sample consisted of 122 cardiac nurses from 19 countries attending a European cardiac nursing conference held in Stockholm. A venous blood sample was collected into a tube containing potassium ETDA. B-type natriuretic peptide was measured on-site with the use of a portable fluorescence immunoassay kit.

RESULTS

Most participants were female (89%). Participants ranged in age from 23 to 60 years with a mean age of 41 (S.D. 9.4). Eleven percent - all female - reported they were current smokers, 27% (34) had a BMI >25 and 27% of the sample stated they did not exercise regularly. Almost half (48%) of the sample reported a family history of CHD. As expected, all BNP-values were within the normal range. There were significant differences in BNP on the basis of sex (P<0.05) and age (P<0.05) and a trend towards increasing BNP concentrations with progressively higher BMI scores (P=0.06).

CONCLUSION

This study reconfirms the likelihood that many cardiac nurses heed their own advice on lifestyle modification to reduce cardiovascular risk and therefore provide a good role model for the promotion of primary and secondary prevention initiatives.

Pharmacological Treatment and Perceived Health Status During 1-Year Follow Up in Patients Diagnosed with Coronary Artery Disease, But Ineligible for Revascularization: Results from the Euro Heart Survey on Coronary Revascularization

BACKGROUND

It has been recognized that a clinically significant portion of patients with coronary artery disease (CAD) continue to experience anginal and other related symptoms that are refractory to the combination of medical therapy and revascularization. The Euro Heart Survey on Revascularization (EHSCR) provided an opportunity to assess pharmacological treatment and outcome in patients with proven CAD who were ineligible for revascularization.

METHODS

We performed a secondary analysis of EHS-CR data. After excluding patients with ST-elevation myocardial infarction and those in whom revascularization was not indicated, 4409 patients remained in the analyses. We selected two groups: (1) patients in whom revascularization was the preferred treatment option (n = 3777, 86%), and (2) patients who were considered ineligible for revascularization (n = 632, 14%).

RESULTS

Patient ineligible for revascularization had a worse risk profile, more often had a total occlusion (59% vs. 37%, p < 0.001), were treated more often with ACE-inhibitors (65% vs. 55%, p < 0.001) but less likely with aspirin (83% vs. 88%, p < 0.001). Overall, they had higher case-fatality at 1-year (7.0% vs. 3.7%, p < 0.001). Regarding self-perceived health status, measured via the EuroQol 5D (EQ-5D) questionnaire, these same patients reported more problems on all dimensions of the EQ-5D. Furthermore, in the revascularization group we observed an increase between discharge and 1-year follow up (utility score from 0.85 to 1.00) whereas patients ineligible for revascularization did not improve over time (utility score remained 0.80)

CONCLUSION

In this large cohort of European patients with CAD, those considered ineligible for revascularization had more co-morbidities and risk factors, and scored worse on self-perceived health status as compared to revascularized patients in the revascularization group. With the exception of ACE-inhibitors and aspirin, there were no major differences regarding drug treatment between the two groups. Given these clinically significant observations, there appears to be a role for nurse-led, multidisciplinary, rehabilitation teams that target clinically vulnerable patients whose symptoms remain refractory to standard medical care.

Medial malleolar stress fracture in athletes: diagnosis and operative treatment

BACKGROUND AND AIMS

Stress fractures are common overuse injuries in athletes. Medial malleolar stress fractures are rare but they have an important clinical relevance because of their tendency to cause considerable disability and loss of time in sports without proper treatment. The diagnosis of medial malleolar stress fracture is often a challenge and it is therefore often delayed which may cause even further problems in the treatment. The purpose of this study was to increase the awareness of medial malleolar stress fractures as a possible cause for medial ankle pain and to stress the importance of MRI in the diagnostics as well as to evaluate the results of surgical treatment.

PATIENTS AND METHODS

Between 1995 and 2008, a total of ten athletes with a medial malleolar stress fracture were operated at our centre. All operated cases during those years were included in the study. The cases were retrospectively analyzed. Return to pre-injury level of sport was evaluated and considered as an indicator of successful treatment.

RESULTS

Initially all standard radiographs were negative whereas in MRI the fractures were all visible. After operative treatment all medial malleolar stress fractures healed clinically in three to four months and all except one of the athletes were able to return to their pre-injury level of sports.

CONCLUSION

Early MRI is recommended if a medial malleolar stress fracture is suspected. Surgical treatment seems to result in rapid healing of the fracture and return to sports. In our opinion early surgery should be considered especially in athletes.

First online measurements of sulfuric acid gas in modern heavy-duty diesel engine exhaust: implications for nanoparticle formation

To mitigate the diesel particle pollution problem, diesel vehicles are fitted with modern exhaust after-treatment systems (ATS), which efficiently remove engine-generated primary particles (soot and ash) and gaseous hydrocarbons. Unfortunately, ATS can promote formation of low-vapor-pressure gases, which may undergo nucleation and condensation leading to formation of nucleation particles (NUP). The chemical nature and formation mechanism of these particles are only poorly explored. Using a novel mass spectrometric method, online measurements of low-vapor-pressure gases were performed for exhaust of a modern heavy-duty diesel engine operated with modern ATS and combusting low and ultralow sulfur fuels and also biofuel. It was observed that the gaseous sulfuric acid (GSA) concentration varied strongly, although engine operation was stable. However, the exhaust GSA was observed to be affected by fuel sulfur level, exhaust after-treatment, and driving conditions. Significant GSA concentrations were measured also when biofuel was used, indicating that GSA can be originated also from lubricant oil sulfur. Furthermore, accompanying NUP measurements and NUP model simulations were performed. We found that the exhaust GSA promotes NUP formation, but also organic (acidic) precursor gases can have a role. The model results indicate that that the measured GSA concentration alone is not high enough to grow the particles to the detected sizes.

Sphingosine kinase as an oncogene: autocrine sphingosine 1-phosphate modulates ML-1 thyroid carcinoma cell migration by a mechanism dependent on protein kinase C-alpha and ERK1/2

Sphingosine 1-phosphate (S1P) induces migration of the human thyroid follicular carcinoma cell line ML-1 by activation of S1P(1) and S1P(3) receptors, G(i) proteins, and the phosphatidylinositol 3-kinase-Akt pathway. Because sphingosine kinase isoform 1 (SK) recently has been implicated as an oncogene in various cancer cell systems, we investigated the functions of SK in the migration, proliferation and adhesion of the ML-1 cell line. SK overexpressing ML-1 cells show an enhanced secretion of S1P, which can be attenuated, by inhibiting SK activity and a multidrug-resistant transport protein (ATP-binding cassette transporter). Furthermore, overexpression of SK enhances serum-induced migration of ML-1 cells, which can be attenuated by blocking ATP-binding cassette transporter and SK, suggesting that the migration is mediated by autocrine signaling through secretion of S1P. Inhibition of protein kinase C alpha, with both small interfering RNA (siRNA) and small molecular inhibitors attenuates migration in SK overexpressing cells. In addition, SK-overexpressing cells show an impaired adhesion, slower cell growth, and an up-regulation of ERK1/2 phosphorylation, as compared with cells expressing a dominant-negative SK. Taken together, we present evidence suggesting that SK enhances migration of ML-1 cells by an autocrine mechanism and that the S1P-evoked migration is dependent on protein kinase C alpha, ERK1/2, and SK.

Thallium scintigraphy in prediction of occlusion of bypass grafts in asymptomatic and symptomatic patients

To evaluate thallium scintigraphy in predicting coronary artery bypass graft patency, exercise thallium scintigraphy and selective graft and native vessel angiograms were performed in 22 asymptomatic and 29 symptomatic consecutive patients three months after coronary artery bypass grafting (CABG). Twelve out of 22 asymptomatic patients (55%) had reversible thallium defects on postoperative images; in 10 patients the postoperative scans were normal. The graft patency was significantly lower in asymptomatic patients with abnormal thallium perfusion compared to those with normal perfusion after CABG (68% vs. 91%, p less than 0.05). The rate of graft patency in symptomatic patients was 66/87 (76%). Thallium scintigraphy was 77% sensitive and 78% specific in detecting one or more stenosed or occluded bypass grafts in patients without angina (accuracy 77%). When data from exercise electrocardiography were combined with scintigraphy, all but one patient with incomplete revascularization could be detected (positive predictive accuracy 92%). In symptomatic patients, thallium scintigraphy accurately predicted the presence or absence of graft occlusion in 24/29 (83%) cases. Thus, abnormal myocardial perfusion due to stenosis or occlusion of bypass grafts is common in both asymptomatic and symptomatic patients after CABG. Thallium scintigraphy together with exercise electrocardiography appear to be useful non-invasive methods in detecting painless myocardial ischemia and in predicting bypass graft occlusion after CABG.

Influenza A1 myocarditis in conscripts

The incidence of viral myocarditis was studied prospectively at the Central Military Hospital 1 in Finland in connection with an A1 virus influenza epidemic in Jan. 1978. Of 104 conscripts taken consecutively to hospital because of a sudden respiratory infection, 41 had serologically confirmed influenza A, 37 were serologically negative, while in 26 it was not possible to carry out complete virological analyses. Six of the serologically confirmed influenza patients had acute myocarditis on the basis of serial electrocardiographic ST segment and/or T wave changes, unresponsive to beta-blockade. The incidence of the influenza A myocarditis was thus 9% of the 67 verified and suspected cases of influenza taken together. Multidirectional echocardiography revealed regional myocardial dysfunction in all the influenza patients with myocarditis; the MB-CK isoenzyme was elevated in 3 of them. The ECG changes found in connection with influenza thus commonly indicate the presence of myocardial involvement, usually a mild one.

Accuracy and usefulness of echoventriculography in acute myocardial infarction

Echoventriculography is a noninvasive and three-dimensional ultrasonic technique capable to assess in detail the regional performance of the left ventricle. Therefore the mechanical performance of the left ventricle after myocardial infarction is informatively assessed by the composite contributions made by infarcted and noninfarcted segments. Its reliability has been confirmed by direct cineangiographic and autopsy correlations. In clinical decision making such direct information is of great value both for diagnosis and therapeutic selection. In the coronary care unit echoventriculography provides most information obtained by the less feasible invasive cineangiographic examinations.

Usefulness of multiaxis echocardiography in assessment of the left ventricle in ischemic heart disease. A review

Echoventriculography, a multiaxis M-mode echocardiographic technique, was developed to examine in detail the regional wall motions of the left ventricle. The basic technical aspects and limitations are described, and experience is reviewed on 263 healthy subjects or patients with ischaemic heart disease. The reliability in detecting site and size of asynergic segments was excellent as related to electrocardiographic and thallium scintigraphic sites of acute infarction, and with left ventricular cineangiograms in chronic coronary heart disease. The correlation with pathologic anatomic size of infarct in 24 consecutive patients was r = 0.88 (p less than 0.001) when expressed by a percentage of the left ventricular horizontal circumference. 94% of 111 infarcted segments were correctly detected by echo; only the posteroseptal and the most lateral regions remain out of the methodological range. The method separated old infarct scars from fresh necrosis. Decreasing echo contraction index correlated with increasing severity of coronary obstructions in 43 patients studied for coronary artery surgery. In 15 infarct patients the M-mode technique was more sensitive than two-dimensional echocardiography in recording asynergic segments or endocardial echoes. The multiple segmental echoventriculographic index decreased parallel with clinical severity of acute infarction (r = -0.79, p less than 0.001; 30 patients). There was a 88% (p less than 0.01) concordance between the reduction of the ST segments (-30%) and the recovery of the mechanical function in the ischaemic myocardial segments (+26%) after beta blockade with pindolol in 22 patients with acute infarction. Methylprednisolone showed no improvement. With dopamine the left ventricular size decreased markedly (p less than 0.0005). Echoventriculography thus seems to be very informative in evaluation of chronic or acute left ventricular dysfunction, despite the rather demanding nature of the technique in practice.

Etiology of mild acute infectious myocarditis. Relation to clinical features

The etiology of mild myocarditis, diagnosed on the basis of serial ECG changes during an acute infection, was studied in 126 consecutive conscripts. A fourfold rise in the antibody titers in the paired serum samples was required for a positive etiologic diagnosis. An etiologic diagnosis was made probable in 47% of the patients. Adenovirus was incriminated in 19 patients, vaccinia in 12, influenza A in eight, beta-hemolytic Streptococcus in six, mononucleosis in five and Mycoplasma in three. Chlamydia, influenza B and Coxsackie B4 were each found in two patients; parainfluenza, mumps and adult Still's disease were each found in one patient. The incidence of vaccinia myocarditis was 1/10000 smallpox vaccinations. Clear-cut myopericarditis was usually noted during vaccinia, mononucleosis, Mycoplasma, Chlamydia and Coxsackie B4 infections. Adenovirus and influenza A myocarditis was most often subclinical, being mostly detected only because of ECG screening of patients without cardiac symptoms. Frequent recent ventricular extrasystoles were most often triggered by a beta-hemolytic Streptococcus infection. The etiology of infectious myocarditis seems to reflect the overall profile of viruses and other infective agents in the study population at that particular time. Cardiotrophic viruses such as Coxsackie B only rarely cause myocarditis outside epidemics.

Family dynamics in families of severe COPD patients

AIM AND OBJECTIVES

The purpose of this study was to describe family dynamics in families with severe chronic obstructive pulmonary disease (COPD) on the basis of Barnhill's framework for healthy family systems. The sample consisted of 35 severe COPD patients and 30 family members at Tampere University Hospital, Finland or in the neighbouring regions.

BACKGROUND

Chronic obstructive pulmonary disease is a public health problem worldwide. It is a slowly progressive airway disease, producing a decline in lung function which is not fully reversible.

DESIGN

The sample included the families of patients without oxygen therapy and the families of patients who had long-term oxygen therapy (LTOT). The data were collected using the Family Dynamics Measure 2 (FDM2) and the Family Dynamics Questionnaire (FDQ).

METHOD

A quantitative research method was employed in the study. Frequency and percentage distributions, as well as cross-tabulations, were used to describe the data. Mean values and standard deviations were calculated for the sum variables of six dimensions of the FDM2.

RESULTS

In the dimensions of individuation, mutuality and flexibility, dynamics in the families of patients with LTOT was significantly better than of the patients without oxygen therapy. Especially in the dimension of mutuality, the families of LTOT patients functioned very well, while in the dimensions of communication and roles, family dynamics in these families was notably worse, although still good.

CONCLUSION

Poor self-identity--enmeshment, isolation from others and lack of flexibility to varying conditions--in families with severe COPD can weaken the ability of the families to manage in everyday life.

RELEVANCE TO CLINICAL PRACTICE

Families need family nursing to adapt to alterations occurring when a family member has severe COPD. Nurses can give support and help for these families for their roles of patient and caregiver, as well as opportunities to speak with someone about their situation.

Cardiovascular risk estimation by professionally active cardiovascular nurses: results from the Basel 2005 Nurses Cohort

BACKGROUND

Nurses play a key role in the prevention of cardiovascular disease (CVD) and one would, therefore, expect them to have a heightened awareness of the need for systematic screening and their own CVD risk profile. The aim of this study was to examine personal awareness of CVD risk among a cohort of cardiovascular nurses attending a European conference.

METHODS

Of the 340 delegates attending the 5th annual Spring Meeting on Cardiovascular Nursing (Basel, Switzerland, 2005), 287 (83%) completed a self-report questionnaire to assess their own risk factors for CVD. Delegates were also asked to give an estimation of their absolute total risk of experiencing a fatal CVD event in the next 10 years. Level of agreement between self-reported CVD risk estimation and their actual risk according to the SCORE risk assessment system was compared by calculating weighted Kappa (kappa(w)).

RESULTS

Overall, 109 responders (38%) self-reported having either pre-existing CVD (only 2%), one or more markedly raised CVD risk factors, a high total risk of fatal CVD (> or =5% in 10 years) or a strong family history of CVD. About half of this cohort (53%) did not know their own total cholesterol level. Less than half (45%) reported having a 10-year risk of fatal CVD of <1%, while 13% reported having a risk > or =5%. Based on the SCORE risk function, the estimated 10-year risk of a fatal CVD event was <1% for 96% of responders: only 2% had a > or =5% risk of such an event. Overall, less than half (46%) of this cohort's self-reported CVD risk corresponded with that calculated using the SCORE risk function (kappa(w)=0.27).

CONCLUSION

Most cardiovascular nurses attending a European conference in 2005 poorly understood their own CVD risk profile, and the agreement between their self-reported 10-year risk of a fatal CVD and their CVD risk using SCORE was only fair. Given the specialist nature of this conference, our findings clearly demonstrate a need to improve overall nursing awareness of the role and importance of systematic CVD risk assessment.

Surgical treatment of partial tears of the proximal origin of the hamstring muscles

BACKGROUND

Hamstring injuries are common especially in athletes. Partial and complete tears of the proximal origin may cause pain and functional loss.

OBJECTIVE

To evaluate the results of surgical treatment for partial proximal hamstring tears.

METHODS

Between 1994 and 2005, 47 athletes (48 cases, 1 bilateral) with partial proximal hamstring tears were operated on. The cases were retrospectively analysed. Before surgery, 42 of the patients had undergone conservative treatment with unsatisfactory results, whereas in five patients the operation was performed within four weeks of the injury.

RESULTS

The mean length of the follow up was 36 months (range 6-72). The result of the operation was rated excellent in 33 cases, good in nine, fair in four, and poor in two. Forty one patients were able to return to their former level of sport after an average of five months (range 1-12).

CONCLUSION

In most cases, excellent or good results can be expected after surgical repair of partial proximal hamstring tears even after conservative treatment has failed.

Cooperative activation of transcription by autoimmune regulator AIRE and CBP

Autoimmune regulator (AIRE) is a transcriptional regulator that is believed to control the expression of tissue-specific genes in the thymus. Mutated AIRE is responsible for onset of the hereditary autoimmune disease APECED. AIRE is able to form nuclear bodies (NBs) and interacts with the ubiquitous transcriptional coactivator CBP. In this paper, we show that CBP and AIRE synergistically activate transcription on different promoter reporters whereas AIRE gene mutation R257X, found in APECED patients, interferes with this coactivation effect. Furthermore, the overexpression of AIRE and CBP collaboratively enhance endogenous IFNbeta mRNA expression. The immunohistochemical studies suggest that CBP, depending on the balance of nuclear proteins, is a component of AIRE NBs. We also show that AIRE NBs are devoid of active chromatin and, therefore, not sites of transcription. In addition, we demonstrate by 3D analyses that AIRE and CBP, when colocalizing, are located spatially differently within AIRE NBs. In conclusion, our data suggest that AIRE activates transcription of the target genes, i.e., autoantigens in collaboration with CBP and that this activation occurs outside of AIRE NBs.

Treatment of Experimental Autoimmune Encephalomyelitis with a Neurotropic Alphavirus Vector Expressing Tissue Inhibitor of Metalloproteinase-2

Prompted by our recent observations of increased MMP-8 and MMP-9 with simultaneous downregulation of tissue inhibitor of metalloproteinase-2 (TIMP-2) and TIMP-3 mRNA levels in the central nervous system (CNS) of mice with severe experimental autoimmune encephalomyelitis (EAE), we used Semliki Forest virus (SFV) to transfer and express recombinant murine TIMP-1-3 genes in the CNS. TIMP-1, TIMP-2 and TIMP-3 expression was confirmed in cultured cells and in the CNS of infected mice. Following intraperitoneal infection with 10(6) plaque-forming units (PFU) of SFV-TIMP, focal TIMP protein expression was achieved throughout the brain. Although already treatment with empty vector inhibited development of EAE to some extent, the expression of TIMP-2 by the virus significantly enhanced the inhibition. TIMP-3-administered mice also had lower disease grade, but the inhibition was not statistically significant. In contrast, SFV-TIMP-1 had no effect, similar to co-infection with TIMP-2 and TIMP-3. We found TIMP-2 expression also by non-infected CNS-resident cells surrounding the virus-positive areas, suggesting a bystander TIMP-2 induction. These data strengthen the view that matrix metalloproteinases are involved in the pathogenesis of EAE and provide clear evidence that virus-mediated delivery of their protein inhibitors can be effective in preventing the clinical disease. TIMPs might be candidates for novel treatment regimens in CNS autoimmune disorders, such as multiple sclerosis.

Psychodynamic personality profile in first-episode severe mental disorders

OBJECTIVE

The aim of this study was to relate measures of psychoanalytically derived personality traits to descriptive diagnosis and psychopathology in severe mental disorders.

METHOD

Sixty-one consecutive first-episode patients with schizophrenia, bipolar disorder and severe major depression were interviewed. Personality traits were assessed with the Karolinska Psychodynamic Profile (KAPP) and compared with the DSM-IV diagnosis and symptom clusters derived from the BPRS.

RESULTS

There were no marked differences in personality traits between the three diagnostic groups, between schizophrenia and affective disorders or between psychotic and non-psychotic illness. However, personality traits had significant associations with symptoms, especially with the emotional retardation cluster.

CONCLUSION

Our findings do not support the hypothesis that severe mental disorders would differ from each other in terms of long-standing psychodynamic personality profiles. Certain dysfunctional personality traits may predict especially negative emotional symptoms and possibly also predispose a person to them.

Acute traumatic extension deficit of the knee

The purpose of this study was to evaluate the events leading to acute traumatic extension deficit of the knee and the arthroscopic findings in these patients. A total of 78 consecutive patients treated in the Turku university hospital during the years 1994-1996 were included. The mean annual incidence of acute traumatic extension deficits of the knee in our study was 1.1 per 10 000 inhabitants. The single most common (33%) event causing the extension deficit was non-sports related twisting of the knee. Various sports related activities accounted for 42% of the extension deficits, and soccer was the most common sport in this group. In conclusion, acute traumatic extension deficit of the knee is usually a sign of serious intra-articular damage, and the most likely finding (in 82% of the patients in our study) is either a meniscal rupture, an anterior cruciate ligament (ACL) rupture, a patellar dislocation, or a combination of these. The lesions in these knees require prompt evaluation by an orthopaedic surgeon mainly because of the high number of bucket-handle and menisco-capsular insertion ruptures of the menisci, which are possibly suitable for repair.

Acute traumatic hemarthrosis of the knee. Is routine arthroscopic examination necessary? A study of 320 consecutive patients

BACKGROUND AND AIMS

Distortions and contusions of the knee are common. Fairly often they will result in hemarthrosis. The purpose of this study was to evaluate the findings in patients with acute traumatic hemarthrosis of the knee and based on these findings estimate the necessity of acute arthroscopic examination.

MATERIAL AND METHODS

A total of 320 patients were examined arthroscopically between the years 1994 to 96 in the Turku University Hospital. Patients with other than chondral or osteochondral fractures were excluded.

RESULTS

The most common arthroscopic findings were rupture of the ACL (45%), dislocation of the patella (23%) and meniscal tear (21%). In only 113 (35%) cases an immediate therapeutic procedure was performed in addition to the arthroscopic examination.

CONCLUSIONS

Based on our findings we believe that routine arthroscopic examination is not necessary in patients with acute traumatic hemarthrosis of the knee. In our opinion the patient should be examined and followed by an orthopedic surgeon and if a lesion requiring operative treatment is diagnosed or suspected, an arthroscopic examination should be scheduled. The timing of the procedure should be such that all possible lesions encountered can be treated in the same operation.

Intraoperative imaging in a comprehensive neuronavigation environment for minimally invasive brain tumour surgery

BACKGROUND

Development of an image-guided operation theatre offering multimodal information for mini-invasive neurosurgical brain tumour operations.

METHODS

A multi-purpose resistive low-field MR scanner with on-off capability, was installed in a radio frequency-shielded operating room with in-room control panel and display. Intraoperative ultrasound imaging with Doppler mode as needed is used to provide check-up image data between intraoperative MR-imaging sessions. Cortical stimulation and registration are performed during awake craniotomies. The neuronavigation systems are customised arm-based and passive optical. The navigation systems show the positions of the ultrasound probe, cortical stimulation electrode, biopsy needles, endoscope and other instruments on the intraoperative MR-images.

FINDINGS

Since 1999, 70 patients (mean age 47, range 3-88 years) have been operated with intraoperative MR-guidance (including 10 tumour biopsies, 56 resections). Twenty-one patients (mean age 46, range 16-67 years) underwent awake craniotomy and tumour resection secured with cortical stimulation and usually preoperative fMR-imaging. The present operating environment offered useful multimodal information for surgery of brain tumours in critical locations. Surgical mortality was 0%, morbidity included 3 (4.3%) infections and 2 (2.9%) permanent hemiparesis. Further removal of tumour was continued in 17 cases (57%) out of the 30 cases where intraoperative MR imaging was used for controlling completeness of the resection.

Staurosporine induces a neuronal phenotype in SH-SY5Y human neuroblastoma cells that resembles that induced by the phorbol ester 12-O-tetradecanoyl phorbol-13 acetate TPA)

Treatment of SH-SY5Y human neuroblastoma cells with the protein kinase inhibitor staurosporine, induced both morphological and functional differentiation in these cells. The effects of staurosporine were comparable to those induced by the protein kinase C (PKC) activator, 12-O-tetradecanoyl phorbol 13-acetate (TPA), with respect to induction of neuronal differentiation, i.e. neurite outgrowth, inhibition of DNA synthesis, induction and down-regulation of c-myc protein expression, induction of mRNA for both neuropeptide Y (NPY) and growth associated protein 43 (GAP-43) and stimulation of tyrosine hydroxylase expression. Staurosporine failed to translocate PKC to the membrane fraction or to stimulate phosphorylation of the endogenous PKC substrate M(r) 80,000 (p80). Instead, staurosporine inhibited TPA-induced phosphorylation of p80.

Magnesium potentiation of the function of native and recombinant GABA(A) receptors

Mg2+ decreased basal and GABA-inhibited t-butylbicyclophosphoro[35S]thionate binding to GABAA receptor ion channels in rat brain sections up to 1 mM, but increased the binding at 10 mM. The Mg2+-effect was detectable in the presence of a specific GABA site competitive antagonist. Two-electrode voltage clamp recordings of recombinant alpha1beta2gamma2S, alpha1beta2, alpha2beta2gamma2S and alpha2beta2 GABAA receptors revealed a potentiation by 0.1-1 mM Mg2+ of EC20 GABA-evoked ion currents. At 10 mM, Mg2+ decreased the currents. In the absence of GABA, Mg2+ did not evoke any currents. The results show that physiologically relevant Mg2+ concentrations affect the GABA responses on GABAA receptors in native and the main recombinant receptor subtypes, suggesting putative Mg2+ binding sites on the receptor complex.

The relationship of handedness to asymmetry in the occlusal morphology of first permanent molars

Handedness has been shown to be related to a number of systematic asymmetries in body dimensions, dermatoglyphic patterns and cerebral morphology. The aim here was to compare linear and angular tooth crown asymmetries of the permanent molars in healthy right-handed and left-handed subjects. The material comprised 27 children with recorded concordant left-side dominance of hand, eye and foot. The controls were an age- and sex-matched group with right side dominance. The material is based on the Collaborative Perinatal Project where detailed medical records and the dentitions, including accurate dental impressions, of over two thousand American children were examined in the USA in the sixties. Machine vision technique was used to obtain accurate three-dimensional information from the occlusal surfaces of the first permanent upper and lower molars. The directional asymmetry values of angular measurements of mandibular first molars showed evidence of asymmetry of opposite direction between the two examined groups. The results indicate that occlusal morphology of first permanent molars may be affected by handedness, and this tendency is most evident in the angular measurements of the mandibular molars. Fluctuating asymmetry did not differ significantly between the examined groups.

Predictors of social relations in persons with schizophrenia living in the community: a Nordic multicentre study

BACKGROUND

Deinstitutionalisation has led to persons with serious mental illness spending most of their time outside psychiatric institutions. Not much is known about their social life. The paper presents the results of structured interviews with non-institutionalised persons with schizophrenia about treatment, care and social network. The network data are analysed from three perspectives: finding predictors of the number and of the quality of social contacts, and establishing the respective variables that characterise persons with high, and those with low, scores on both the quantity and quality dimensions of social integration.

METHODS

Random samples of persons with schizophrenia receiving outpatient services in ten psychiatric centres in the four Nordic countries were interviewed. The following instruments were used: Interview Schedule for Social Interaction (ISSI), Camberwell Assessment of Needs, Lancashire Quality of Life Profile, General Assessment of Functioning (GAF) and Brief Psychiatric Rating Scale (BPRS), in addition to a checklist covering the utilisation of different services. The ISSI provided the main data for this paper. A restricted number of possible predictors were used in General Linear Model (GLM) factorial analysis and discriminant analysis.

RESULTS

A total of 418 persons took part in the study. The overall participation rate was 55%. Social integration in terms of number of contacts was related to a high GAF score, few BPRS negative and hostility symptoms, having contact with user organisations and living in urban (in contrast to rural) areas. Availability of emotional relations was predicted by female sex, low scores on the BPRS hostility dimension, high GAF score, having contact with one's family more than once a month, and living in urban areas. Work, adequate leisure activities and GAF score discriminated between the best and worst integrated groups.

CONCLUSIONS

Living in urban areas, being female, having a high GAF score and low scores on hostility predicted better integration in terms of number of contacts and emotional relations.

Enhanced locomotor stimulation by NMDA receptor antagonists in alcohol-sensitive ANT rats

The ability of the antagonists for the N-methyl-D-aspartate (NMDA) type of glutamate receptor to modulate locomotor activity were compared in alcohol-sensitive (or alcohol-nontolerant, ANT) and alcohol-insensitive (or alcohol-tolerant, AT) rat lines. Both rat lines showed altered locomotor activity after acute injections of a competitive antagonist (LY235959), a glycine-site antagonist (L-701,324), or noncompetitive antagonists [MK-801, phencyclidine (PCP), and ketamine] of the NMDA receptor. MK-801 at 0.5 mg/kg caused a strong increase in horizontal activity in both rat lines, the effect being significantly greater in the ANT rats. There was a subpopulation among AT rats that was almost completely unresponsive to MK-801. This insensitivity to MK-801 correlated with the lack of c-fos induction in the retrosplenial and cingulate cortices. Fos immunoreactive cells in these brain regions after MK-801 treatment were more numerous in ANT than AT rats, although c-fos induction in the inferior olivary nucleus was similar in all animals after MK-801. The ANT rats showed greater locomotor stimulation also after ketamine and LY235959, while stimulation induced by PCP and depression induced by L-701,324 did not differ between the rat lines. The data suggest that altered NMDA receptor-mediated processes may correlate with differences in innate alcohol sensitivity in the ANT/AT rat model.

Elevated hypothalamic/midbrain serotonin (monoamine) transporter availability in depressive drug-naive children and adolescents

Cumulative data suggest depression in adulthood being connected to reduced availability of brain serotonin while the role of dopamine remains less specific. Prospective studies have shown a continuity of depressive episodes from childhood to adulthood, combined with poor social function and excess mortality. The object of this study was to examine whether alterations in brain serotonin and/or dopamine transporter levels are already present in depressive children and adolescents. We examined 41 drug-naive patients (aged 7-17) by single photon emission tomography (SPET) using iodine-123-labelled 23-carbomethoxy-3P3(iodophenyl) tropane [123I]beta-CIT as a tracer for monoamine transporters. In addition to the ordinary clinical examination, the patients were given a structured interview and information was gathered from teachers and parents with questionnaires. The diagnoses were established by consensus evaluation between three child psychiatrists. To test the serotonin hypothesis and the dopamine hypothesis regarding depression in children and adolescents, the series was divided into groups with depression present (31) and no depression present (10). In this study, the depressive child and adolescent patients had significantly higher serotonin transporter availability (P < 0.02) in the hypothalamic/midbrain area. Age did not correlate to the hypothalamic/midbrain serotonin transporter binding ratio. No significant difference in dopamine transporter availability in striatum was found between the depressive and the nondepressive children and adolescents.

Effect of aging time of sol on structure and in vitro calcium phosphate formation of sol-gel-derived titania films

Titanium and its alloys have been used successfully in the manufacture of orthopedic and dental implants to replace damaged bone tissue. In this study, different sol-gel-derived TiO(2) coatings were produced on titanium substrates using different aging times (5, 10, 24, or 48 h) of the sol before dipping the coatings and varying numbers (one, three, or five) of coating layers. The influence of the aging time of the sol on the structure of the titania coatings with respect to in vitro bioactivity was investigated. The in vitro bioactivity tests were done in a simulated body fluid (SBF). The sol properties were monitored using a capillary viscometer and dynamic light scattering to determine the viscosity and particle size, respectively. The topography of the films was characterized using atomic force microscopy. The various sol aging times and numbers of layers produced differences in the topography of the titania films. For the coatings with one and three layers, the aging of the sols had an influence on the height of the peaks (lower with longer aging times) although the peak distance was about the same. The number of coating layers had a stronger influence. The distribution of the peak distances became narrower with an increasing number of coating layers. The coating with three layers (top coating prepared after 24 h of sol aging) and the coatings with five layers had a similar distribution of peak distances (15-50 nm), which was favorable for calcium phosphate formation. On these substrates, calcium phosphate formation started within 3-6 days of immersion in SBF. The aging time of the titania sol and the number of coating layers were found to have a strong influence on the surface topography in the nanometer scale of the titania films. The results indicate that the topography of the outermost surface is of importance for in vitro bioactivity.

Stereospecific modulation of GABA(A) receptor function by urocanic acid isomers

A deamination product of histidine, urocanic acid, accumulates in the skin of mammals as trans-urocanic acid. Ultraviolet (UV) irradition converts it to the cis-isomer that is an important mediator in UV-induced immunosuppression. We have recently shown that urocanic acid interferes with the agonist binding to GABA(A) receptors. We now report that the effects of urocanic acid on binding of a convulsant ligand (t-butylbicyclo[35S]phosphorothionate) to GABA(A) receptors in brain membrane homogenates are dependent on pH of the incubation medium, the agonistic actions being enhanced at the normal pH of the skin (5.5). Using Xenopus laevis oocytes expressing recombinant rat alpha1beta1gamma2S GABA(A) receptors, the low pH potentiated the direct agonistic action of trans-urocanic acid under two-electrode voltage-clamp, whereas cis-urocanic acid retained its low efficacy both at pH 5.5 and 7.4. The results thus indicate clear differences between urocanic acid isomers in functional activity at one putative receptor site of immunosuppression, the GABA(A) receptor, the presence of which in the skin remains to be demonstrated.

Long-range interactions in neuronal gene expression: evidence from gene targeting in the GABA(A) receptor beta2-alpha6-alpha1-gamma2 subunit gene cluster

Clustering of GABA(A) receptor alpha1, alpha6, beta2, and gamma2 subunit genes on mouse chromosome 11/human chromosome 5 may have functional significance for coordinating expression patterns, but until now there has been no evidence for cross-talk between the genes. However, altering the structure of the alpha6 gene, specifically expressed in the cerebellum, with neomycin gene insertions in two different experiments unexpectedly reduced the expression of the widespread alpha1 and beta2 genes in the forebrain. There were corresponding reductions in the levels of alpha1 and beta2 subunit proteins and in autoradiographic ligand binding densities to GABA(A) receptors in the forebrain of alpha6-/- mice. The gamma2 mRNA level was not changed, nor were beta3 and delta mRNAs. The data suggest that elements in the neo gene may have an influence over long distances in the GABA(A) subunit gene complex on as yet undefined structures coordinating the expression of the alpha1 and beta2 genes.