Four-Way Wada: SEEG-based mapping with electrical stimulation, high frequency activity, and phase amplitude coupling to complement traditional Wada and functional MRI prior to epilepsy surgery.

Presurgical evaluation of refractory epilepsy involves functional investigations to minimize postoperative deficit. Assessing language and memory is conventionally undertaken using Wada and fMRI, and occasionally supplemented by data from invasive intracranial electroencephalography, such as electrical stimulation, corticortical evoked potentials, mapping of high frequency activity and phase amplitude coupling. We describe the comparative and complementary role of these methods to inform surgical decision-making and functional prognostication. We used Wada paradigm to standardize testing across all modalities. Postoperative neuropsychological testing confirmed deficit predicted based on these methods.

Quantifying the accretion of hyperphosphorylated tau in the locus coeruleus and dorsal raphe nucleus: the pathological building blocks of early Alzheimer's disease.

AIMS: Hyperphosphorylated tau neuronal cytoplasmic inclusions (ht-NCI) are the best protein correlate of clinical decline in Alzheimer's disease (AD). Qualitative evidence identifies ht-NCI accumulating in the isodendritic core before the entorhinal cortex. Here, we used unbiased stereology to quantify ht-NCI burden in the locus coeruleus (LC) and dorsal raphe nucleus (DRN), aiming to characterize the impact of AD pathology in these nuclei with a focus on early stages. METHODS: We utilized unbiased stereology in a sample of 48 well-characterized subjects enriched for controls and early AD stages. ht-NCI counts were estimated in 60-µm-thick sections immunostained for p-tau throughout LC and DRN. Data were integrated with unbiased estimates of LC and DRN neuronal population for a subset of cases. RESULTS: In Braak stage 0, 7.9% and 2.6% of neurons in LC and DRN, respectively, harbour ht-NCIs. Although the number of ht-NCI+ neurons significantly increased by about 1.9× between Braak stages 0 to I in LC (P = 0.02), we failed to detect any significant difference between Braak stage I and II. Also, the number of ht-NCI+ neurons remained stable in DRN between all stages 0 and II. Finally, the differential susceptibility to tau inclusions among nuclear subdivisions was more notable in LC than in DRN. CONCLUSIONS: LC and DRN neurons exhibited ht-NCI during AD precortical stages. The ht-NCI increases along AD progression on both nuclei, but quantitative changes in LC precede DRN changes.

Peripheral venous catheter related complications are common among paediatric and neonatal patients.

AIM: The aims of this study were to describe the characteristics of peripheral venous catheters (PVCs), including dwell time and reasons for removal, and explore predictors for PVC-related complications. METHODS: We included PVCs in 2032 children - 484 neonatal and 1548 paediatric - from 12 inpatient units. Data were retrieved from the patient record system, and predictors for complications were explored using logistic regression analyses. RESULTS: Just over one-third (35.4%) of the PVCs were removed due to complications, in particular infiltration and occlusion (51.9 and 48.4/1000 PVC days, respectively). PVC survival time was shorter in neonatal than paediatric patients (4 versus 5 days), and infiltration was more frequent in neonatal patients (92.8 versus 38.7/1000 PVC days). Infiltration was associated with younger age (odds ratio 0.97) for neonatal patients and with younger age (OR 0.96), insertion in the bend of the arm (OR 1.48) or ankle (OR 2.81) for paediatric patients. Occlusion was, both for neonatal and paediatric patients, associated with longer dwell time (OR 1.32 and 1.22 respectively), insertion in the ankle (OR 5.00 and 3.51) or foot (OR 3.47 and 1.99). CONCLUSION: PVC-related complications, particularly infiltration and occlusion, were more common in hospitalised children but decreased with the child's age.

An evaluation of the usability of a computerized decision support system for nursing homes.

BACKGROUND: Computerized decision support systems (CDSSs) have the potential to significantly improve the quality of nursing care of older people by enhancing the decision making of nursing personnel. Despite this potential, health care organizations have been slow to incorporate CDSSs into nursing home practices. OBJECTIVE: This study describes facilitators and barriers that impact the ability of nursing personnel to effectively use a clinical CDSS for planning and treating pressure ulcers (PUs) and malnutrition and for following the suggested risk assessment guidelines for the care of nursing home residents. METHODS: We employed a qualitative descriptive design using varied methods, including structured group interviews, cognitive walkthrough observations and a graphical user interface (GUI) usability evaluation. Group interviews were conducted with 25 nursing personnel from four nursing homes in southern Norway. Five nursing personnel participated in cognitive walkthrough observations and the GUI usability evaluation. Text transcripts were analyzed using qualitative content analysis. RESULTS: Group interview participants reported that ease of use, usefulness and a supportive work environment were key facilitators of CDSS use. The barriers identified were lack of training, resistance to using computers and limited integration of the CDSS with the facility's electronic health record (EHR) system. Key findings from the usability evaluation also identified the difficulty of using the CDSS within the EHR and the poorly designed GUI integration as barriers. CONCLUSION: Overall, we found disconnect between two types of nursing personnel. Those who were comfortable with computer technology reported positive feedback about the CDSS, while others expressed resistance to using the CDSS for various reasons. This study revealed that organizations must invest more resources in educating nursing personnel on the seriousness of PUs and poor nutrition in the elderly, providing specialized CDSS training and ensuring that nursing personnel have time in the workday to use the CDSS.

Accuracy in the recording of pressure ulcers and prevention after implementing an electronic health record in hospital care.

OBJECTIVE: To compare the accuracy in recording of pressure-ulcer prevalence and prevention before and after implementing an electronic health record (EHR) with templates for pressure-ulcer assessment. METHODS: All inpatients at the departments of surgery, medicine and geriatrics were inspected for the presence of pressure ulcers, according to the European Pressure Ulcer Advisory Panel-methodology, during 1 day in 2002 (n = 357) and repeated in 2006 (n = 343). The corresponding patient records were audited retrospectively for the presence of documentation on pressure ulcers. RESULTS: In 2002, the prevalence of pressure ulcers obtained by auditing paper-based patient records (n = 413) was 14.3%, compared with 33.3% in physical inspection (n = 357). The largest difference was seen in the geriatric department, where records revealed 22.9% pressure ulcers and skin inspection 59.3%. Four years later, after the implementation of the EHR, there were 20.7% recorded pressure ulcers and 30.0% found by physical examination of patients. The accuracy of the prevalence data had improved most in the geriatric department, where the EHR showed 48.1% and physical examination 43.2% pressure ulcers. Corresponding figures in the surgical department were 22.2% and 14.1%, and in the medical department 29.9% and 10.2%, respectively. The patients received pressure-reducing equipment to a higher degree (51.6%) than documented in the patient record (7.9%) in 2006. CONCLUSIONS: The accuracy in pressure-ulcer recording improved in the EHR compared with the paper-based health record. However, there were still deficiencies, which mean that patient records did not serve as a valid source of information on pressure-ulcer prevalence and prevention.

Free radical transfer, fluctuating structure and reaction cycle of ribonucleotide reductase.

Our understanding of the nature and functional importance of protein dynamics is based on experimental and theoretical work on rather 'simple' systems. Here, the principles of the fluctuating structure of a protein is applied to the complex enzyme ribonucleotide reductase (RNR). This enzyme contains a stable tyrosyl radical, which is a strong oxidant. The radical initiates the enzymatic reaction by oxidizing the ribose moeity of the substrate, bound at a distance of ca. 35 A away from the tyrosine harboring the radical. The transfer of the oxidation equivalent, the electron hole, requires a chain of overlapping electronic orbitals along the route, and is made energetically possible by the simultaneous switching of a series of H-bonds, making the transfer charge neutral. Only a fraction of the enormous number of accessible protein substates support this transfer. The probability of an enzyme molecule to obtain such a substate by thermal fluctuations is negligible, except for the case of a complete enzyme with bound substrate. When the radical has been transferred to the ribose, its 2'-OH is immediately reduced to 2'-H by the enzyme, and the electron hole goes back via the chains of orbital overlaps and H-bonds. This model is capable to explain all known kinetic properties of the wild type enzyme and its mutated forms. The analogy between this model of how the fluctuating protein structure controls and makes the radical transfer possible in RNR and recent ideas about the mechanism of the anomalously fast proton conduction in liquid water is considered.

Amniotic fluid microflora in asymptomatic women at mid-gestation.

The presence and composition of amniotic fluid (AF) microflora, as well as AF glucose concentration and white blood cell (WBC) count, were investigated in 22 consecutive asymptomatic women with intact membranes at mid-gestation. AF was retrieved by trans-abdominal amniocentesis. Three of the 22 women (13.6%) had microorganisms in their AF: Chlamydia trachomatis in 2 and both Corynebacterium group absolute nonfermenter (ANF) group and Propionibacterium spp. in 1. No differences were found in clinical characteristics, glucose concentration or WBC count in patients with and without microorganisms in their AF.

Auditing nursing content in patient records.

The objective of this paper is twofold: (a) to explore different approaches in reviewing records based on a literature review of studies of audits of patient records and (b) to apply these approaches on a sample of records to illuminate consequences of their application. The method used was a literature review of papers on recording of nursing care (n = 56). Based on our findings, an audit of a stratified sample of records (n = 298) from Swedish community health care and nursing homes was performed, applying the different approaches for auditing previously described in the literature. The review showed that audits of patient records were performed using four different approaches with varying aims. The focus of the four approaches can be described as formal structure, process comprehensiveness, knowledge-based and concordance with actual care. The results of this study suggest that audits of patient records should not be solely limited to encompass the formal structure of recording. To avoid a superficial picture or a false sense of high quality and to obtain a more complete and reliable portrait of the quality of recording, we suggest the process comprehensiveness approach in combination with a critical review of the knowledge base for the assessment, diagnosis and interventions of patient records.

The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses' and patients' descriptions.

The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses' and patients' descriptions. Data from patient records will increasingly be used for care planning, quality assessment, research, health planning and allocation of resources. Knowledge about the accuracy of such secondary data, however, is limited and only a few studies have been conducted on the accuracy of nursing recording. The aim of this study was to analyse the concordance between the nursing documentation in nursing homes and descriptions of some specific problems of nurses and patients. Comparisons were made between wards where nurses had received training in structured recording based on the nursing process (study group) and wards where no intervention had taken place (reference group). Data were collected from the patient records of randomly selected nursing home residents (n=85). The methods used were audits of patient records and structured interviews with residents and nurses. The study revealed considerable deficiencies in the accuracy of the patient records when the records were compared with the reports from nurses and residents. The overall agreement between the interview data from nurses and from the patient records was low. Concordance was better in the study group as compared with the reference group in which the recorded data were structured only following chronological order. The study unequivocally demonstrates that there are major limitations in using records as a data source for the evaluation, planning and development of care.

Patient problems, needs, and nursing diagnoses in Swedish nursing home records.

PURPOSE: To describe the main problems, needs, risks, and nursing diagnoses and to examine the descriptions of some common and serious patient problems in nursing home records. METHODS: A retrospective audit of a stratified, random sample (N = 12O) of patient records from eight nursing homes in six Swedish municipalities. FINDINGS: Results showed major deficiencies in nursing documentation in the patient records. Only one record contained a comprehensive description of one patient problem that corresponded to the requirements of Swedish laws and regulations. No record was found that contained a systematic and comprehensive assessment of any of the selected problems based on established criteria or the use of an assessment instrument. CONCLUSIONS: Nursing documentation in patient records does not reflect the use of systematic assessment and research-based instruments for determining patient care needs. Nurses need skills in assessment in the care of the elderly to be able to set priorities in care and deliver adequate care.

Patient records in nursing homes. Effects of training on content and comprehensiveness.

The purpose of this study was to describe the effects on the contents and comprehensiveness of the nursing-care documentation in the patient records at nursing homes following an educational intervention. A review was made of records (n = 120) from nursing homes in six Swedish municipalities, allocated to a study group and a reference group. All the nursing home nurses in three municipalities received education concerning the nursing process and how to document according to the VIPS model. A retrospective audit of all nursing notes in the records from the nursing homes was made before and after the intervention. Improvements were found in the contents of the records in the study group. The number of notes on nursing history more than doubled. The occurrence of the recording of nursing diagnoses, goals and discharge notes increased. No corresponding changes were observed in the reference group. In the study group, an increase in the number of acceptable notes with contents on nursing history, status, nursing diagnosis, planned and implemented interventions, and nursing discharge notes was found. This increase was significant. The comprehensiveness in the documentation of single nursing problems was only slightly improved in the study group. No record met the requirements of the national regulations on nursing documentation or followed the nursing process thoroughly.

EPR study of the mixed-valent diiron sites in mouse and herpes simplex virus ribonucleotide reductases. Effect of the tyrosyl radical on structure and reactivity of the diferric center.

Reduction of ribonucleotide reductase (EC 1.17.4.1) R2 proteins in a frozen glycerol-buffer solution at 77 K by mobile electrons generated by gamma-irradiation produces EPR-detectable iron sites in mixed-valent Fe(II)/Fe(III) states. The primary EPR signals give information about the ligand arrangement of the diferric form of the iron site, whereas secondary signals observed after annealing of the sample show the effects of structural relaxation. In recombinant metR2 proteins (without free radical) from mouse and herpes virus type 1, the mixed-valent sites trapped at 77 K give rise to axial S = 1/2 EPR spectra with g values in the range 1.79-1.94, observable at temperatures up to 110 K. The spectra are assigned to mu-oxo-bridged dinuclear iron sites. In mouse metR2, the primary EPR spectrum is a mixture of two components. Annealing the R2 samples to 160-170 K transforms the primary EPR signals into rhombic spectra, characterized by gav < 1.8, and observable only below 25 K. These spectra are assigned to partially relaxed forms with a mu-hydroxo bridge, formed by protonation of the oxo bridge. Further annealing at 220 K produces new rhombic EPR spectra, which are closely similar with those observed and found to be stable after chemical reduction at room temperature. The EPR signal of the primary mixed-valent iron site in active mouse R2 protein with a tyrosyl radical also has two components. Both are different from those observed in metR2. In herpes simplex virus type 1 protein R2, one primary mixed-valent component was observed for the met protein. The dose-yield curve for the mixed-valent state in active mouse R2 is sigmoidal in shape, indicating that the tyrosyl radical is reduced by mobile electrons before the iron site. Kinetic experiments on the reduction by dithionite on mouse R2 without and with radical show a significantly enhanced rate for reduction of the iron site in the protein without radical. The results suggest that in active mouse R2 only complete diferric sites with neighboring radicals give rise to the mixed-valent spectra, and that these sites may exist in two structurally distinct forms. The results on the mouse R2 proteins confirm and extend previous results obtained on the Escherichia coli protein R2 showing that the presence of the tyrosyl radical significantly affects not only the structure but also the reactivity of the iron site.

Non-medical prevention of pre-eclampsia.

Daily supplementation with 1.5-2 g calcium is the only known effective method of non-medical prevention of pre-eclampsia. Data concerning the role of bed rest for prevention of this condition are still controversial. Fish oil and magnesium supplements have proved ineffective in clinical trials. Dietary salt restriction is not acceptable in view of its possible adverse effects.

The VIPS model--implementation and validity in different areas of nursing care.

The development of common concepts and terms for nursing practice is crucial for the effective use of nursing-information systems. In Sweden, the VIPS model has been developed to support the systematic and common documentation of nursing care in patient records. The model has been widely used in different areas of nursing practice. This literature review was conducted as a part of a larger project to study the validity and reliability of the VIPS model, as well as its dissemination into the Swedish health-care system. The findings showed in general good reliability and content validity for the keywords in the VIPS model. The implications for the further development of the model are discussed.

Nursing documentation in patient records: experience of the use of the VIPS model.

The VIPS model for the documentation of nursing care in patient records was scientifically developed and published in 1991, with the aim of supporting the systematic documentation of nursing care and promoting individualized care. As the model seemed to be accepted and used in many parts of Sweden, a study was conducted in order to gather further information on the validity of the model, to describe the clinical and educational experience of its use and to refine it. Experience of the use of the model was gathered from a review of the scientific papers and other reports on it, from questionnaires addressed to nurses (n = 514), from comments by key informants, and from interviews with faculty members at all the nursing schools in the country. The findings showed that an intense process of change and development was occurring regarding nursing documentation. However, there were limitations in the use of the entire nursing process, especially in the specification of patient problems and the formulation of nursing diagnoses and nursing interventions. The keywords (Swedish spelling) of the VIPS model had good content validity in different areas of nursing care. The findings also indicated the need for further elaboration and revision of some of the keywords. A revised version of the VIPS model based on these findings is presented.

Effect of the tyrosyl radical on the reduction and structure of the Escherichia coli ribonucleotide reductase protein R2 diferric site as probed by EPR on the mixed-valent state.

It was recently shown by EPR that high yields of a sterically constrained mixed-valent species may be formed in radical free protein metR2 of Escherichia coli ribonucleotide reductase by gamma-irradiation at 77 K [Davydov, R., Kuprin, S., Gräslund, A., & Ehrenberg, A. (1994) J. Am. Chem. Soc. 116, 11120]. This species, with S = 1/2, essentially retains the ligand geometry of the original diferric center and should be a sensitive probe for structural changes in the diferric centers. Here we apply this probe and demonstrate that there is a structural difference between the diferric iron center of the complete site of protein R2, with a tyrosyl radical, and that of metR2, without radical. The EPR spectrum of the mixed-valent species of metR2 shows pure axial symmetry, while complete sites show rhombic distortion and a shifted high-field turning point. Differences also remain in the EPR of the first S = 9/2 species obtained by annealing at 165 K, but disappear after relaxation at 200 K. In addition, the diferric center of a complete site is not reduced radiolytically until the associated tyrosyl radical has been reduced, indicating that an electron first reaching the iron center may be transferred to the radical. This route of electron transfer and the influence of the radical on the structure of the iron center are likely to have functional roles for the formation of the proposed substrate radical and regulation of redox processes within the enzyme. The sensitivity of the structure of the iron site to the structure of the Tyr-122 site is also demonstrated by the strong influence the mutation Y122F has on the EPR spectra of the corresponding mixed-valent species.

Spectral-Density Mapping of 13Calpha-1Halpha Vector Dynamics Using Dipolar Relaxation Rates Measured at Several Magnetic Fields

The spectral-density mapping of a 13Calpha-1Halpha vector of Leu10 in the 22-residue peptide hormone motilin [P. Allard, J. Jarvet, A. Ehrenberg, and A. Graslund, J. Biomol. NMR 5, 133-146 (1995)] is extended in this paper to three polarizing fields 9.4, 11.7, and 14.1 T in order to improve the accuracy of the calculated spectral-density function J(omega) and to extend the sampling range up to 750 MHz. The problem with a usually large relative error in J(omegaH) is eliminated since the generally more precise J(omegaH - omegaC) and J(omegaH + omegaC) determined at other fields appear at nearly the same frequencies. The fitting of dynamic models to the points of spectral density was made with error weighting, and the influence of J(omegaH) was found to be negligible. Therefore, the high-frequency part of the spectral-density function is determined essentially without influence from the two transverse-type relaxation rates. In the case of a carbon-proton vector, the relaxation is mainly determined by dipolar interaction and is only weakly influenced by other relaxation mechanisms, which makes it particularly suitable for the spectral-density mapping technique. The measured relaxation rates in the time domain are transformed into the frequency domain by spectral-density mapping, and the slopes in different frequency regions are important parameters when comparing experimental data with theoretical models of motion. Using an adjustable internuclear distance reff, combined with the model-free approach, it is possible to obtain a reasonable fit to measured spectral-density points at J(0) and around J(omegaC). At the same time, however, the high-frequency slope of the spectral-density function defined by J(omegaH - omegaC) and J(omegaH + omegaC) could not be reproduced.

Nonideality of water-hexafluoropropanol mixtures as studied by X-ray small angle scattering.

Strong temperature dependent low angle X-ray scattering by trifluoroethanol- and hexafluoro-2-propanol-water mixtures was observed in conditions commonly used in NMR work on peptides. At least two types of molecular effects may contribute to the observed scattering: formation of clathrate hydrate-like aggregates of alcohol with water as have been proposed for the similar system tert-butanol-water (Iwasaki, K. and Fujiyama, T. (1976) J. Phys. Chem. 81, 1908-1912) and a further heterogeneity of the solution resulting from immiscibility of the two components.

NMR studies of binding of 5-FdUDP and dCDP to ribonucleoside-diphosphate reductase from Escherichia coli.

5-Fluoro-2'-deoxyuridine-5'-diphosphate (5-FdUDP) has been synthesised using an original route, previously applied to the synthesis of natural nucleoside diphosphates. The interaction between 5-FdUDP and the enzyme ribonucleoside-diphosphate reductase (EC 1.17.4.1) has been studied with 19F-NMR. The product analogue is shown to be in fast exchange with substrate binding sites on protein subunit 1 (R1) of ribonucleoside-diphosphate (NDP) reductase. The number of binding sites is reduced to half when the complete holoenzyme R1R2 is formed. The temperature dependence of the line broadening of 5-FdUDP was studied using 19F-NMR, and of dCDP and dUDP using 1H-NMR. The temperature dependences are complex and a molecular model in which R1 is in a temperature dependent equilibrium between at least two conformations is suggested in order to explain the observed behaviour. Binding of a ligand to the substrate binding sites affects the conformational equilibrium in a ligand specific way. Formation of the holoenzyme R1R2 also affects the equilibrium.