IntraperitonealInsulin: A Protocol for Administration during CAPD and Review of Published Protocols

For many diabetics in end-stage renal failure, the initial therapy they receive will be continuous ambulatory peritoneal dialysis (CAPD) together with i.p. insulin. To date, all published protocols rely on empirical dosages based upon predialysis insulin requirements. A practical regimen for the institution of i.p. insulin administration during CAPD is described. The only endpoints used to determine insulin dosage were fasting plasma glucose 5 to 10 mmol/L and 2 h postprandial plasma glucose 8 to 15 mmol/L. An initial protocol related to body weight, dextrose content, volume, and timing of dialysate was based on a retrospective analysis of the results in our first 10 patients. Subsequently, a prospective assessment in an additional 22 patients confirmed the effectiveness of the regimen. The following protocol is recommended for the institution of i.p. insulin therapy in patients undergoing CAPD: Preprandial exchanges 1.36% dextrose-0.175 U/L dialysate/kg body weight 3.86% dextrose-0.25 U/L/kg Overnight exchanges 1.36% dextrose-0.1 U/L/kg 3.86% dextrose-0.15 U/L/kg Further adjustment of insulin dosage is then made on the basis of four hourly plasma glucose profiles. Self-monitoring of capillary blood glucose is recommended.

"This is a question we have to ask everyone": asking young people about self-harm and suicide

WHAT IS KNOWN ON THE SUBJECT?: An essential part of the mental health assessment is to evaluate the risk of harm to self. Fundamentally this involves asking directly about self-harming behaviour and suicidal thoughts or urges, but practitioners often find it difficult to open up these conversations. This evaluation of risk is particularly important as self-harm and suicidal thoughts are frequently found in young people who attend mental health services. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Young people are not always routinely asked directly about self-harm or suicidal thoughts when they are assessed. There are two ways that mental health practitioners introduce this topic: first, by building up to it by initially asking about general feelings, and second by stating that it is a requirement to ask everyone. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These questions should not be avoided by mental health practitioners just because they are difficult. We offer suggestions as to how to ask questions about self-harm and suicide based on real-world practice.

ABSTRACT

Introduction Questions about self-harm and suicide are essential in risk assessments with children and young people, yet little is known about how mental health practitioners do this. Aim The core aim was to examine how questions about self-harm and suicidal ideation are asked in real-world practice. Method A qualitative design was employed to analyse 28 video-recorded naturally occurring mental health assessments in a child and adolescent mental health service. Data were analysed using conversation analysis (CA). Results In 13 cases young people were asked about self-harm and suicide, but 15 were not. Analysis revealed how practitioners asked these questions. Two main styles were revealed. First was an incremental approach, beginning with inquiries about emotions and behaviours, building to asking about self-harm and suicidal intent. Second was to externalize the question as being required by outside agencies. Discussion The study concluded that the design of risk questions to young people had implications for how open they were to engaging with the practitioner. Implications for practice The study has implications for training and practice for psychiatric nurses and other mental health practitioners in feeling more confident in communicating with young people about self-harm and suicidal ideation.

'They're not witches. …' Young children and their parents' perceptions and experiences of Child and Adolescent Mental Health Services

BACKGROUND

Recent initiatives have emphasized the ongoing need to include children in healthcare research, which is relevant to the development of both paediatric and mental healthcare services. Our aim was to contribute children and their parents' perceptions and experiences of Child and Adolescent Mental Health Services (CAMHS), with the objective of providing guidance for those wishing to improve inclusivity and empowerment.

METHOD

We performed a thematic analysis of interview data taken from 11 children (9 boys, 2 girls, aged 8-12) and their parents (12 mothers, 2 fathers), who had recently been referred to CAMHS for mental health and educational problems.

RESULTS

Three core themes emerged from the data. Fear of the unknown refers to emotional apprehension due to uncertainty of what happens in CAMHS. However children also provided useful reassurances for future service users. Therapeutic engagement refers to the importance of being listened to and building up good relationships with professionals. Finally making services acceptable was discussed in terms of issues of accessibility, session tolerances and suggestions for the development of child-centred services.

CONCLUSIONS

Children were able to provide potentially useful opinions of CAMHS. In a time of limited resources it is imperative that the voices of children and their parents are acknowledged in order to improve accessibility and experiences within CAMHS.

Diagnosing autistic spectrum disorder in the age of austerity

BACKGROUND

Diagnosing autistic spectrum disorder is a challenge, typically involving myriad professionals. In the current climate we explore how diagnosis is managed in the real world by professionals.

METHODS

Using semi-structured interviews we thematically analyse data from psychiatrists, paediatricians and educational psychologists.

RESULTS

While there is some consistency across and within these groups there are also a number of variances, and several important issues are highlighted. These include the problem of time and resources, the issue of location for diagnosis, the value of diagnostic tools and schedules, the need for supporting information, the difficulty of multi-agency working, the relevance of a physical examination and the eventual diagnostic label.

CONCLUSIONS

In the current economic climate and considering changes in guidelines there is a need to evaluate current service provision and enhance services. However, attention needs to be paid to the practical and realistic application of the suggested guidance.

Patterns of differentiated thyroid cancer in Baluchistan Province of Pakistan: some initial observations

The incidence of thyroid cancer is increasing in several countries. The main objective of this retrospective study was to find and describe province-specific estimates of incidence in males and females by age groups for differentiated thyroid cancer (DTC). This study reports on 87 cases of DTC from Baluchistan province of Pakistan treated with post operative radioiodine at the Center for Nuclear Medicine and Radiotherapy (CENAR) Quetta from January 2003 to December 2009. The patient data has been collected from CENAR Quetta. Patients with DTC were confirmed by clinical examination, thyroid scintigraphy (Thyroid scan), blood tests (T3, T4, TSH) and histopathalogy tests and then treated with radioiodine. The Median age of the patients was 35.5 years (Range 12-70 years). The final histological diagnosis was papillary carcinoma in 71 (81.6 %) cases, follicular carcinoma in 6 (6.9%) cases while 10 (11.5%) cases presented with mixed papillary and follicular carcinoma. About 53 % cases were found in females with age 21-40 years. No strike predominance was observed in any age group for males. Four patients presented with recurrence while six patients showed metastasis in cervical lymph nodes. The small annual incidence did not follow any definite pattern. DTC has a small incidence in Baluchistan due to lack of education and health care facilities. The incidence of DTC is higher in females when compared with males as per this study. This preliminary study will provide an insight to incidence of DTC, its treatment facilities and future planning strategies in Baluchistan, Pakistan.

Measurement of Conformational Changes in the Structure of Transglutaminase on Binding Calcium Ions Using Optical Evanescent Dual Polarisation Interferometry

The conformational changes occurring when the protein transglutaminase binds calcium ions have been studied using the optical evanescent technique of dual polarization interferometry (DPI) implemented via a dual slab waveguide structure. Immobilized transglutaminase layers of 4-5 nm in thickness were obtained, which when challenged with calcium ions underwent a contraction of approximately 0.5 nm (depending on the concentration of calcium) and an increase in refractive index of approximately 1 x 10-2. The affinity constant for the calcium binding was found to be in the range of 0.95 +/- 0.2 mM. The results reported are in good agreement with those found in the literature obtained by other techniques. It has also been shown that the structural changes occurring during the binding event are considerably larger than the mass changes that take place; thus, DPI offers a potentially valuable method to study real-time structural changes occurring to proteins when they bind metal ions.

Displacement imprinted polymer receptor analysis (DIPRA) for chlorophenolic contaminants in drinking water and packaging materials

The preparation of a molecularly imprinted polymer (MIP) for pentachlorophenol is described together with two alternative reporter derivatives for use in a displacement imprinted polymer receptor analysis (DIPRA) format procedure. In this procedure, alternative reporter molecules were rebound to the synthetic receptor sites and their displacement by the target analyte was employed as the basis of a simple procedure for the measurement of chlorophenols in water and packaging material samples. Water samples were extracted using the standard procedure (EPA 528) and a detection limit of 0.5 microg l(-1) was achieved using the DIPRA detection method, with good agreement between the displacement technique and GC-ECD analysis. A variety of packaging materials, extracted using a buffered detergent solution were also analysed using the DIPRA procedure and showed good agreement with GC results. In addition, investigation of the cross-reactivity of a range of pesticides and materials commonly encountered in environmental analysis indicated the procedure gave good discrimination between pesticides bearing a chlorophenolic moiety and other materials. The procedure is considered highly suitable for use as a rapid field-test method or for incorporation into a test kit device.

Flow pattern visualization in a mimic anaerobic digester: experimental and computational studies

Advanced non-invasive experiments like computer automated radioactive particle tracking and computed tomography along with computational fluid dynamics (CFD) simulations were performed in mimic anaerobic digesters to visualize their flow pattern and obtain hydrodynamic parameters. The mixing in the digester was provided by sparging gas at three different flow rates. The simulation results in terms of overall flow pattern, location of circulation cells and stagnant regions, trends of liquid velocity profiles, and volume of dead zones agree reasonably well with the experimental data. CFD simulations were also performed on different digester configurations. The effects of changing draft tube size, clearance, and shape of the tank bottoms were calculated to evaluate the effect of digester design on its flow pattern. Changing the draft tube clearance and height had no influence on the flow pattern or dead regions volume. However increasing the draft tube diameter or incorporating a conical bottom design helped in reducing the volume of the dead zones as compared to a flat bottom digester. The simulations showed that the gas flow rate sparged by a single point (0.5 cm diameter) sparger does not have appreciable effect on the flow pattern of the digesters.

Biosorption of nitrophenols on anaerobic granular sludge

The sorption and desorption of 2-nitrophenol (2-NP), 4-nitrophenol (4-NP) and 2,4-dinitrophenol (2,4-DNP) on live anaerobic granular sludge was studied at five different sorbate (nitrophenols) concentrations between 10 x 10(3) - 90 x 10(3) microg l(-1). Experiments were conducted at room temperature (29 +/- 2 degrees C) and at an initial pH of 7.5. The maximum uptake capacity of live anaerobic granular sludge was found to b e 1,427, 1,511 and 1,865 microg g(-1) VSS for 2-NP, 4-NP and 2,4-DNP, respectively. The equilibrium data of three nitrophenols obeyed both Freundlich and linear isotherm models. Sorption was observed to be partially reversible. About 20-89%, 36-90% and 29-80% desorption was observed for 10 x 10(3) - 90 x 10(3) microg l(-1) sorbate concentrations of 2-NP, 4-NP and 2,4-DNP, respectively.

"Bite-and-Switch" approach using computationally designed molecularly imprinted polymers for sensing of creatinine

A method for the selective detection of creatinine is reported, which is based on the reaction between polymerised hemithioacetal, formed by allyl mercaptan, o-phthalic aldehyde, and primary amine leading to the formation of fluorescent isoindole complex. This method has been demonstrated previously for the detection of creatine using creatine-imprinted molecularly imprinted polymers (MIPs) Since MIPs created using traditional methods were unable to differentiate between creatine and creatinine, a new approach to the rational design of a molecularly imprinted polymer (MIP) selective for creatinine was developed using computer simulation. A virtual library of functional monomers was assigned and screened against the target molecule, creatinine, using molecular modelling software. The monomers giving the highest binding score were further tested using simulated annealing in order to mimic the complexation of the functional monomers with template in the monomer mixture. The result of this simulation gave an optimised MIP composition. The computationally designed polymer demonstrated superior selectivity in comparison to the polymer prepared using traditional approach, a detection limit of 25 microM and good stability. The "Bite-and-Switch" approach combined with molecular imprinting can be used for the design of assays and sensors, selective for amino containing substances.

Substitution of antibodies and receptors with molecularly imprinted polymers in enzyme-linked and fluorescent assays

A new technique for coating microtitre plates with molecularly imprinted polymers (MIP), specific for low-molecular weight analytes (epinephrine, atrazine) and proteins is presented. Oxidative polymerization was performed in the presence of template; monomers: 3-aminophenylboronic acid (APBA), 3-thiopheneboronic acid (TBA) and aniline were polymerized in water and the polymers were grafted onto the polystyrene surface of the microplates. It was found that this process results in the creation of synthetic materials with antibody-like binding properties. It was shown that the MIP-coated microplates are particularly useful for assay development. The high stability of the polymers and good reproducibility of the measurements make MIP coating an attractive alternative to conventional antibodies or receptors used in enzyme linked immunosorbent assay (ELISA).

Biotransformation of nitrophenols in upflow anaerobic sludge blanket reactors

Four identical bench-scale upflow anaerobic sludge blanket (UASB) reactors, R1, R2, R3 and R4, were used to assess nitrophenols degradation at four different hydraulic retention times (HRT). Reactor R1 was used as control, whereas R2, R3, and R4 were fed with 2-nitrophenol (2-NP), 4-nitrophenol (4-NP), and 2,4-dinitrophenol (2,4-DNP), respectively. The concentration of each nitrophenol was gradually varied from 2 to 30 mg/l during acclimation. After acclimation reactors were operated under steady-state conditions at four different HRTs--30, 24, 18, and 12 h, to study its effect on the removal of nitrophenols. Overall removal of 2-NP and 4-NP was always more than 99% but 2,4-DNP removal decreased from 96% to 89.7% as HRT was lowered from 30 to 12 h. 2-Aminophenol (2-AP), 4-aminophenol (4-AP) and 2-amino,4-nitrophenol (2-A,4-NP) were found to be the major intermediates during the degradation of 2-NP, 4-NP and 2,4-DNP, respectively. Out of the total input of nitrophenolic concentration (30 mg/l), on molar basis, about 41.248.4% of 2-NP, 59.4-68% of 4-NP, 30-26.6% of 2,4-DNP was recovered in the form of their respective amino derivatives at 30-12 h HRT. COD removal was 98-89%, 97-56%, 97-52%, and 94-46% at 30-12 h HRT for R1, R2, R3 and R4, respectively. Average cell growth was observed to be 0.15 g volatile suspended solid (VSS) per g COD consumed. Methanogenic inhibition was observed at lower HRTs (18 and 12 h), however denitrification was always more than 99% with non-detectable level of nitrite. The granules developed inside the reactors were black in color and their average size varied between 1.9 and 2.1 mm.

Assessing the strengths and weaknesses of action research

BACKGROUND

Proponents of action research claim that it is not just for researchers, but helps to empower research participants to make changes in practice. This literature review examines some of the evidence for and against a research methodology that might still be unfamiliar to many nurses.

CONCLUSION

Action research often lends itself to small-scale studies and is time-consuming. The value of such a methodology is that it provides a powerful means of improving and enhancing practice.

[Risk factors for surgical wound infection in digestive surgery. Retrospective study of 3,000 surgical wounds]

A retrospective consecutive study was made of 3000 surgical wounds. All wounds were examined for ten days after operation. The overall infection rate of surgical wound infection (SWI) was 3.53%. SWI lengthened significantly duration of hospital stay (12 days vs 4 days, p < 10-6). Monovariate analysis had shown as significantly risk factors: diabetes (12.26% vs 5.49%, p < 10-6), emergency operation (5.64% vs 2.43%, p < 10-3), acute appendicitis (24.53% vs 13.06%, p < 10-3), biliary emergencies (10.37% vs 4.73%, p < 10-3), operations achieved by young surgeons (5.55% vs 2.83%, p < 10-3), choledochotomy (10.38% vs 5.46%, p < 0.05), colorectal resection (8.50% vs 4.14%, p < 0.05), open laparotomy versus laparoscopy (19.81% vs 1.89%, p < 0.05) and operating time (148 mn vs 104 mn, p < 0.05). Logistic regression showed that diabetes (p = 0.00488), biliary emergencies (p = 0.0016), seniority of surgeon (p = 0.0023), type of skin incision (p = 0.0196) and operating time (p = 0.0005) were the independent risk factors for surgical wound infection.

Nonwhite ethnicity and the provision of specialist palliative care services: factors affecting doctors' referral patterns

The aim of this paper was to examine the use of palliative care services by members of black/minority ethnic communities. Referral patterns of hospital consultants and general practitioners (GPs) to Birmingham St Mary's Hospice were examined. Semistructured interviews were carried out to explore doctors' perceptions of the benefits and limitations of hospice services for their black/minority ethnic patients and to identify potential barriers to referral. In total, 27 doctors were interviewed: 15 hospital consultants and 12 GP. The GPs were selected according to size of practice within areas of Birmingham with significant black/minority ethnic populations. Referrals received by the hospice for the period April 1996 to November 1997 were collected from the Hospice's computerized database. Results show that, compared to white Europeans, there was an underutilization of day care and inpatient hospice services by members of black/minority ethnic communities. Doctors did, however, refer their black/minority ethnic patients for hospice home-care services: 8.5% of referrals received by the hospice were for nonwhite patients. This referral rate increased to 19.3% in specific postcode areas known to have significant black/minority ethnic communities. Further research is needed to establish levels of awareness, explore attitudes towards palliative care services and assess the demand for specific services within various black/minority ethnic communities.

Conducting research involving palliative patients

AIM

The objective of this study was to outline some of the reasons why palliative care patients are seen to be vulnerable as research participants.

METHOD

The author conducted a literature review to ascertain whether or not palliative care patients should be involved in research.

RESULTS

The author found that the case for involving patients who are receiving palliative care in research is overwhelming, but that the protection of these patients must be an integral part of the research.

CONCLUSION

The research design should essentially incorporate the same aims as the palliative care philosophy: patient autonomy, open awareness, holism, respect and collaboration.

Chemical grafting of molecularly imprinted homopolymers to the surface of microplates. Application of artificial adrenergic receptor in enzyme-linked assay for beta-agonists determination

A technique for coating of microplate wells with a molecularly imprinted polymer (MIP), specific for epinephrine, is presented. 3-Aminophenylboronic acid was polymerized in the presence of epinephrine using oxidation of the monomer by ammonium persulfate. This process resulted in the grafting of a thin polymer layer onto the polystyrene surface of the microplates. The polymer affinity was determined by an enzyme-linked assay using a conjugate of horseradish peroxidase and norepinephrine (HRP-N). It was found that imprinting resulted in increased affinity of the polymer toward HRP-N and epinephrine. Influence of the buffer pH and concentration on the polymer affinity was analyzed. It was shown that the MIP-coated microplates could be used for assay development and drug screening. The high stability of the polymers and good reproducibility of the measurements make MIP coating an attractive alternative to traditional antibodies or receptors, used in ELISA.

Vasoseal hemostasis following coronary interventions with abciximab

Femoral arteriotomy management using a collagen vascular hemostasis device (VasoSeal, Datascope Corporation, Montvale, New Jersey) was studied in 50 consecutive patients following interventional coronary procedures performed with abciximab (ReoPro, Eli Lilly and Company, Indianapolis, Indiana). Low-dose weight-adjusted or no heparin was employed. The first 25 patients were permitted to sit up after 6 hours with ambulation the following day. The second 25 patients were allowed to sit up after 1 hour and ambulate after 6 hours. Despite early activity and ambulation, there were no hemorrhagic complications including hematoma, pseudoaneurysm, blood transfusion, or surgical repair. Hemoglobin and platelet counts remained stable overnight prior to discharge. This pilot study demonstrates the potential efficacy of VasoSeal in achieving early sheath removal and ambulation in patients undergoing interventional procedures using ReoPro.

Vasoseal hemostasis following coronary interventions with Abciximab

Femoral arteriotomy management using a collagen vascular hemostasis device (VasoSeal) was studied in 50 consecutive patients following interventional coronary procedures performed with Abciximab (ReoPro). Low dose weight adjusted or no heparin was employed. The first 25 patients were permitted to sit up after 6 hours with ambulation the following day. The second 25 patients were allowed to sit up after 1 hour and ambulate after 6 hours. Despite early activity and ambulation, there were no hemorrhagic complications including hematoma, pseudoaneurysm, blood transfusion, or surgical repair. Hemoglobin and platelet counts remained stable overnight prior to discharge. This pilot study demonstrates the potential efficacy of VasoSeal in achieving early sheath removal and ambulation in patients undergoing interventional procedures using ReoPro.

Drugs acting at central benzodiazepine receptors attenuate ethanol-induced gastric lesions in rats

The characteristics of the receptors involved in the protective action of benzodiazepines against ethanol-induced gastric lesions were investigated by studying the effect of benzodiazepine ligands on such lesions in both intact and unilaterally vagotomized rats. Clonazepam [5-(2-chlorophenyl)-1,3-dihydro-7-nitro-2H-1,4-benzodiazepine-2-one] a specific central-type receptor agonist (0.625-2.5 mg/kg p.o. or i.p.) and CGS 9896 [2-(4-chlorophenyl)-2,5-dihydropyrazolo(4,3-c)quinoline-3(3H)-one] a non-sedative partial agonist with anxiolytic properties (2.5-10 mg/kg p.o.) significantly reduced the gastric damage induced by ethanol (10 ml/kg of a 50% solution v/v p.o.) in non-vagotomized rats but Ro 5-4864 [7-chloro-5-(4-chlorophenyl)-1,3-dihydro-1-methyl-2H-1,4-benzodiazepine- 2 -one] a pure peripheral-type receptor agonist (5-20 mg/kg p.o.) failed to affect this damage. The protective action of clonazepam and CGS 9896 against ethanol-induced gastric lesions was blocked, dose dependently, by the central-type receptor antagonist, flumazenil [ethyl 8-fluoro-5,6-5-methyl-6-oxo-4H-imidazo(1,4)f1p4odiazepine-3-carbox ylate] (1.25-20 mg/kg i.p.). In the unilaterally vagotomized rat, ethanol produced lesions in the right (vagotomized) and the left (non-vagotomized) halves of the gastric mucosa to nearly the same extent, while clonazepam and CGS 9896 uniformly decreased the lesions in both halves. It is concluded that central-type benzodiazepine receptors located in the stomach, specifically those mediating the anxiolytic effect of benzodiazepines, are involved in the protective action of benzodiazepines against ethanol-induced gastric lesions.

Challenging beliefs about tuberculosis

Tuberculosis (TB) is still prevalent in the UK, and current prevention strategies are largely reactive. This article describes a study of TB patterns in the Dudley area, the preliminary findings of which suggest that some commonly-held stereotypes about TB should be challenged. The author believes that if TB is to be eliminated from the UK, prevention strategies need to be proactive and based on locally determined needs. The clinical nurse specialist (TB) is ideally placed to lead this work.

The effect of halothane on neonatal ciliary beat frequency

The effect of a commonly used anaesthetic agent, halothane, on neonatal cilial function was determined. A nasal cilial sample was taken from 13 healthy, term, newborn infants. For 1 h, half of each sample was exposed to halothane and half to air. Cilial function was assessed by measuring beat frequency with a modified light transmission method. Cilial beat frequency was significantly slower in the cilia exposed to halothane, 9(s.d. 2.5)Hz, than to air, 12.9(s.d. 1.5)Hz. Decreased mucociliary clearance following halothane anaesthesia is due, at least in part, to a directly depressant effect of halothane on ciliated cells.

Appreciation for even-handed overage

I would like to congratulate Nursing Standard for its even-handedness in giving candidates for the forthcoming United Kingdom Central Council elections free space to publicise their manifestos.

Converting the faithful

As many enrolled nurses know only too well, conversion course places are as scarce as water in the desert. There are plenty of courses available now, but with the imposed tutor/student ratio of 1:10, and the high number of people wanting to do the course, places are very rare indeed.