The nursing care of stroke patients in nursing homes. Nurses' descriptions and experiences relating to cognition and mood.

Registered nurses working in nursing homes often care for stroke patients with impaired cognition and mood disorders. Understanding the behaviour of these patients often puts great demands on nurses. This study illuminates registered nurses' descriptions and experiences of stroke patients and the nursing care given in nursing homes, with a focus on cognition and mood. Registered nurses responsible for the care of stroke patients in nursing homes were asked to describe the individual patient's state of health and the nursing care given. Patients' cognition and mood have been selected for this article. A qualitative content analysis was used to group the text into categories. Registered nurses' descriptions showed great complexity and variation in patients' disabilities, as well as uncertainty about understanding these patients and the appropriate nursing care. Registered nurses described the need for further education in stroke care, and adequate resources for patient activity training, as well as meeting patients' psychosocial and communicative needs.

Stroke patients ready for discharge from acute care--a multi-dimensional assessment of functions and further care.

PURPOSE: The aim of this study was to describe actual functions, performance of activities and needs of further care in patients with stroke in acute care wards at the time the physicians decided that the patients were ready for discharge, in relation to placement after discharge and the motives for the decision. METHOD: Thus 114 stroke patients in Stockholm County were assessed with the Resident Assessment Instrument, and the motives for further care were reviewed in the patients' case records. RESULTS: The results showed that the oldest, most severely impaired stroke patients had the shortest mean length of stay before the physician considered the patients ready for discharge to nursing homes, where resources for long-term rehabilitation and stroke care vary. CONCLUSION: It is important to secure continuing adequate care and rehabilitation for elderly severely impaired stroke patients being discharged early from acute care hospitals.

Pharmacokinetics and distribution of liposomal busulfan in the rat: a new formulation for intravenous administration.

The plasma pharmacokinetics and tissue distribution of busulfan (Bu) were investigated after intravenous injection of free Bu (D-Bu) and freshly prepared liposomal Bu (L-Bu). Liposomal Bu was prepared using L-alpha-phosphatidylcholine, 1,2-dioleolyl-sn-glycero-3-phosphate, and cholesterol. The liposomes formed were unilamellar vesicles measuring 220 +/- 14 nm in diameter and containing a Bu concentration of 0.31 +/- 0.03 mg/ml. The half-life of Bu in the present formulation was determined to be 8.7 +/- 2.7 days at 4 degrees C. The liposomes in the new formulation were stable for 20 days at 4 degrees C. After the intravenous administration of L-Bu or D-Bu (dissolved in a mixture of DMSO, ethanol, and propylene glycol) to the rats a higher bone marrow exposure to Bu as expressed in AUC marrow/AUC blood was achieved using L-Bu as compared with D-Bu (1.59 and 0.83, respectively). A higher distribution volume was observed for L-Bu as compared with D-Bu (1.39 versus 0.67 l/kg, respectively). The elimination half-lives were significantly longer in both blood and marrow after the administration of L-Bu as compared with D-Bu (2.52 and 3.08 versus 1.53 and 1.75 h, respectively). The new liposomal Bu showed linear pharmacokinetics within the range of 0.5-3.5 mg/kg, which is comparable with that obtained for D-Bu. A slight difference was observed in systemic exposure to L-Bu as compared with D-Bu as expressed in AUC (9.93 and 11.82 microg h ml(-1), respectively). The distribution study using 14C-labeled Bu showed that the radioactivity was significantly higher over 18 h in the bone marrow (3-fold) and spleen (2-fold; P < 0.01) in a comparison of L-Bu with D-Bu. However in the brain, lungs, and heart the distribution of radioactivity after the administration of L-Bu was significantly lower (P < 0.05) than that obtained using D-Bu. On the basis of the present study, the new formulation of liposomal Bu seems to be a promising preparation for clinical trials, since it appears to target bone marrow and spleen with no accumulation in the liver or other organs known for Bu toxicity.

Busulphan kinetics and limited sampling model in children with leukemia and inherited disorders.

Busulphan pharmacokinetics were investigated in 20 children, who underwent bone marrow transplantation for either leukemia or inherited disorders. Busulphan (1.90-6.02 mg/kg/day) was administered orally as a single dose or twice daily. Busulphan kinetics were found to be linear within the studied range. Children with inherited disorders eliminated busulphan significantly faster after the first and the last dose with half-lives (t1/2) of 1.93 and 1.71 h, respectively compared to children with leukemia (3.16 and 2.70 h, respectively). The area under plasma concentration curves (AUCs, corrected for mg/kg) as an expression for the systemic exposure of busulphan were significantly higher in children with leukemia, 22.4 and 19.04 mumol/l.h (5527 and 4690 ng.h.ml-1) after the first and the last dose, respectively, compared to 11.2 and 8.2 mumol/l.h (2768 and 2029 ng.h.ml-1) found in children with inherited disorders. The present results confirm those reported by others, ie busulphan pharmacokinetics can be influenced by the underlying disease and its status. Our population pharmacokinetic analysis showed a negative correlation between the weight corrected clearance and the age in both groups of children. However, clearance was about 42% higher in children with inherited disorders compared to those with leukemia. To estimate AUC for the first dose, we evaluated a limited sampling model based on three concentrations (1, 3 and 6 h). A high correlation (r = 0.998, P < 0.0001, n = 40) between the estimated and the determined AUC was found. The present model is reliable and adequate for studying more patients, with a long-term follow-up combined with drug monitoring in correlation with drug efficacy and toxicity to define the optimal busulphan dosage required.

Retrospective Immunodiagnosis of Malaria in Nonimmune Travelers Returning From the Tropics.

Background: Since travelers are now frequently advised to carry emergency self medication for the treatment of suspected malaria, the issue of retrospective diagnosis of malaria in nonimmune patients has recently gained more importance. Reliable methods for evaluating the frequency and justifying the use of self medication in clinically suspected malaria are warranted. Methods: One hundred and eighty-five sera from 132 nonimmune travelers returning to a nonendemic area, and with a microscopically confirmed diagnosis of malaria, were investigated for the presence of antibodies against blood stages of Plasmodium falciparum or Plasmodium vivax, by the indirect fluorescence antibody test (IFAT). Eighty-eight patients suffered from infection with P. falciparum and 44 from the infection with P. vivax. In falciparum malaria, 97.1% of patients had positive reactions during a period of 15-60 days after onset of symptoms. During the same period after onset of symptoms, significant titers were demonstrated in 88.2% of patients with vivax malaria. Extended cross-reactions between the antigens used and a wide range of interindividual differences in antibody titers were observed. One hundred sera from Germans recovering from nonmalarial febrile illnesses were used as negative control group in the investigation, of which none resulted in a positive IFAT. Conclusions: We conclude from these results that the IFAT is a specific and sensitive tool for the retrospective confirmation of malaria in the differential diagnosis of fever imported from endemic areas by nonimmune travelers. Nevertheless, when dealing with the individual patient, a careful interpretation, with inclusion of all available clinical data, is mandatory. However, by using blood stage antigens, the IFAT can be considered a sensitive tool in epidemiologic surveys. The tool can be used with a high degree of reliability, even without access to additional clinical data.

Imported rickettsioses in German travelers.

Twenty-two cases of rickettsiosis imported to Germany (13 men, nine women, average age 42 years) in a 5-year period were analyzed retrospectively regarding the travel histories, symptoms and clinical findings, laboratory features and course of the disease. The two primary rickettsial diseases were boutonneuse fever (18 patients) and scrub typhus (three patients). One patient had murine typhus. The main symptom was fever in 91% followed by headache (64%), myalgia (40%), arthralgia (50%) and diarrhea (36%). The most frequent clinical finding was lymphadenopathy in 65%. Eschar was detectable in 55% of patients with Rickettsia conori infection and in one patient with Rickettsia tsutsugamushi infection. All patients with R. tsutsugamushi infection as well as 33% of the patients with R. conori infection had a macular exanthema. One patient with scrub typhus had pleural and pericardial effusions. Seventy-three percent had an increased ESR. Three patients had leucocytosis, three increased transaminases and two normochromic anemia. The incubation period for R. conori infection was 5 to 28 days (average 14 days), for R. tsutsugamushi infection 7 to 21 days (average 16 days). Twenty-one patients were treated with tetracycline or doxycycline, one with erythromycin. All patients were cured. One patient had a relapse. Due to the fact that the symptoms are often not characteristic and that the routine laboratory findings are of only marginal help, the diagnosis of rickettsial diseases is often not easy. A detailed travel history sometimes gives an important hint for diagnosis.

Permethrin-impregnated curtains in malaria control.

The impact of permethrin-impregnated curtains on the incidence of malaria episodes, parasitaemia and splenomegaly was assessed during a 22 month period in 2 groups of children aged 0.5-6 years. One group lived in houses where permethrin-impregnated curtains had been installed, the other group lived in houses without curtains. A significant reduction of incidence of malaria episodes, mean parasite density, parasite prevalence and splenomegaly was consistently observed in the intervention group towards the end of the period of moderate transmission, whereas no clear-cut impact could be demonstrated during the high transmission period. The influence of malaria pressure and community utilization on the protective efficiency of curtains is discussed. Because of their acceptability and the ease of reimpregnation, curtains proved to be a suitable technique for integration into primary health care.

[Impact of utilization of permethrin impregnated curtains on malaria in a rural zone of high transmission in Burkina Faso]. / Impact de l'utilisation des rideaux imprégnés de perméthrine sur le paludisme dans une zone rurale de haute transmission au Burkina Faso.

The efficacy of permethrin impregnated curtains as a malaria control measure was evaluated in a rice field area nearby Ouagadougou (BF). Two groups of children aged 1-5 years matched for age, sex and malaria exposure, were followed through the rainy season of 1987 for illness and febrile episodes. One group of 118 children lived in houses protected with impregnated curtains, the other in houses without curtains. All children were examined for parasitaemia spleen index packed cell volume (PCV) and antisporozoites antibodies at the beginning and the end of the rainy season. During rainy season no difference could be found in the number of clinical episode between the two groups. A reduction in the prevalence of splenomegaly and parasitaemia and an increase in the PCV was observed during the dry season.

Preliminary data on the genetic differentiation of Onchocerca volvulus in Africa (Nematoda: Filarioidea).

Data are reported on the genetic structure of three Onchocerca volvulus populations, respectively from Mali (savanna), Ivory Coast (forest), and Zaire (forest gallery in savanna). Electrophoretic analysis, carried out on 25 gene-enzyme systems, has shown a remarkable genetic heterogeneity existing within O.volvulus. Zaire and West Africa populations appear chiefly differentiated at Mdh-1 and 6Pgdh loci, their average Nei's genetic distance being 0.11. In West Africa Nei's D found between the savanna and forest samples is 0.04. The savanna population from Zaire is more similar to the savanna one from Mali (D = 0.09) than to the forest one from Ivory Coast (D = 0.13). This appears mainly due to the loci Ldh and Hbdh (possibly linked), some alleles of which seem to be selected for in forest populations (Ldh110, Hbdh108), while others in the savanna ones (Ldh100, Hbdh100). The hypothesis that the discrepant epidemiological patterns of human onchocerciasis are related to intrinsic differences in the parasite seems supported by the obtained data. The differences in allele frequencies found at the reported loci appear strong enough to allow biochemical identification of O. volvulus populations from different geographic regions and different habitats.