Recognition of physical deterioration in patients with mental health problems: the role of simulation in knowledge and skill development.

Recognition of physical deterioration in patients with mental health problems has been recognized as a significant problem. Areas of particular concern include rapid tranquilization, physical restraint, the consumption of alcohol and illicit drugs have the potential to result in sudden and catastrophic patient deterioration. Simulation sessions, using patient mannequins, are widely used to support the education of nurses but its use in mental health has been somewhat restricted. The aim of this study was to design and deliver simulation scenarios to develop the skills and knowledge of mental health nursing students in the recognition and management of physical deterioration. A series of three scenarios were developed and delivered to a group of final-year nursing students. Evaluation of the sessions was undertaken using analysis of video footage from the sessions and through two focus groups. The results show that simulation is a useful catalyst for discrepancy creation which in turn leads to the student focusing their future learning towards addressing any identified deficits in skills and knowledge identified. Authenticity of the simulation sessions also plays a role in ensuring student engagement and faculty support during sessions is vital to support the students in managing unfamiliar situations.

Predictive value of digital rectal examination for prostate cancer detection is modified by obesity.

The American Cancer Society's updated screening guidelines for prostate cancer (CaP) render digital rectal examination (DRE) optional. We investigated the impact of DRE on CaP detection among obese men. Data from 2794 men undergoing initial prostate biopsy at three centers were analyzed to assess CaP risk attributed to abnormal DRE across body mass index (BMI) categories. Predictive accuracies of a combination of PSA, age, race, center and biopsy year including or excluding DRE findings were compared by areas under the receiver-operating characteristics curves. In all cohorts, obese men were less likely to have abnormal DREs diagnosed than non-obese men. As BMI category increased, abnormal DREs became stronger predictors for overall CaP in individual (P-trends ≤ 0.05) and combined (P-trend<0.001) cohorts, and for high-grade CaP in the Italian (P-trend=0.03) and combined (P-trend=0.03) cohorts. DRE inclusion improved the predictive accuracy for overall and high-grade CaP detection among all obese men (P ≤ 0.032) but not normal-weight men (P ≥ 0.198). DRE inclusion also near-significantly improved overall CaP detection in obese men with PSA<4 ng ml(-1) (P=0.081). In conclusion, the predictive value of DRE is dependent on obesity and is significantly higher among obese men than normal-weight men.

The effect of improving the thermal quality of cold housing on blood pressure and general health: a research note.

OBJECTIVE: To examine the effect of improving the thermal quality of housing on blood pressure (BP) and general health. DESIGN: A before and after study comparing the changes of the intervention with controls. SETTING: Four blocks of flats in the Easthall area of Easterhouse in Glasgow. PARTICIPANTS: Residents of the four blocks who agreed to participate. INTERVENTION: Two blocks of flats were upgraded from being cold, damp and mouldy to being comfortably warm, dry and mould free throughout. MAIN OUTCOME MEASURES: Changes in BP, general health and financial status. RESULTS: In the intervention subjects, systolic and diastolic blood pressures fell very significantly (p<0.000). There was also an improvement in general health as reported subjectively, and as indicated by a reduction in the use of medication and in hospital admissions. In addition, there was a markedly reduced expenditure on heating costs and other previous expenses. There were no changes in the control subjects in any of these measures. CONCLUSION: Improving the thermal quality of housing to eliminate damp and mould and produce a comfortable temperature throughout the house has a major impact on the health of the residents. There are also financial benefits for the residents, and indirectly for the NHS.

Tensile properties of engineered cartilage formed from chondrocyte- and MSC-laden hydrogels.

OBJECTIVE: The objective of this study was to determine the capacity of chondrocyte- and mesenchymal stem cell (MSC)-laden hydrogel constructs to achieve native tissue tensile properties when cultured in a chemically defined medium supplemented with transforming growth factor-beta3 (TGF-beta3). DESIGN: Cell-laden agarose hydrogel constructs (seeded with bovine chondrocytes or MSCs) were formed as prismatic strips and cultured in a chemically defined serum-free medium in the presence or absence of TGF-beta3. The effects of seeding density (10 vs 30 million cells/mL) and cell type (chondrocyte vs MSC) were evaluated over a 56-day period. Biochemical content, collagenous matrix deposition and localization, and tensile properties (ramp modulus, ultimate strain, and toughness) were assessed biweekly. RESULTS: Results show that the tensile properties of cell-seeded agarose constructs increase with time in culture. However, tensile properties (modulus, ultimate strain, and toughness) achieved on day 56 were not dependent on either the initial seeding density or the cell type employed. When cultured in medium supplemented with TGF-beta3, tensile modulus increased and plateaued at a level of 300-400 kPa for each cell type and starting cell concentration. Ultimate strain and toughness also increased relative to starting values. Collagen deposition increased in constructs seeded with both cell types and at both seeding densities, with exposure to TGF-beta3 resulting in a clear shift toward type II collagen deposition as determined by immunohistochemical staining. CONCLUSIONS: These findings demonstrate that the tensile properties, an important and often overlooked metric of cartilage development, increase with time in culture in engineered hydrogel-based cartilage constructs. Under the free-swelling conditions employed in the present study, tensile moduli and toughness did not match that of the native tissue, though significant time-dependent increases were observed with the inclusion of TGF-beta3. Of note, MSC-seeded constructs achieved tensile properties that were comparable to chondrocyte-seeded constructs, confirming the utility of this alternative cell source in cartilage tissue engineering. Further work, including both modulation of the chemical and mechanical culture environment, is required to optimize the deposition of collagen and its remodeling to achieve tensile properties in engineered constructs matching the native tissue.

Racial differences in occupational status and income in South Africa, 1980 and 1991.

Using data on employed men from the 1980 and 1991 South African Censuses, we analyze the determinants of occupational status and income. Whites are found to have much higher occupational status, and especially income, than members of other racial groups. Most of the racial differentials in occupational status con be explained by racial differences in the personal assets that determine occupational attainment (especially education), but only a much smaller fraction of the White/non-White income differential can be so explained. Despite a modest reduction between 1980 and 1991 in the role of race in socioeconomic attainment, the overall picture shows more stability than change.

Beta-NAP, a cerebellar degeneration antigen, is a neuron-specific vesicle coat protein.

We have identified a target antigen in autoimmune cerebellar degeneration, beta-NAP, that is closely related to the beta-adaptin and beta-COP coat proteins. Beta-NAP is a nonclathrin-associated phosphoprotein expressed exclusively in neurons, from E12 through adulthood. Beta-NAP is present in the neuronal soma and nerve terminal as soluble and membrane-bound pools and is associated with a discrete set of nerve-terminal vesicles. These results establish beta-NAP as a neuron-specific vesicle coat protein. We propose a model in which beta-NAP mediates vesicle transport between the soma and the axon terminus and suggest that beta-NAP may represent a general class of coat proteins that mediates apical transport in polarized cells.

Demonstration of hypomethylation of proteins in the brain of pigs (but not in rats) associated with chronic vitamin B12 inactivation.

1. Pigs treated with nitrous oxide for periods of 1, 2 and 4 months demonstrated markedly reduced levels of methionine synthase and concomitant reduction in the ratio of S-adenosylmethionine to S-adenosylhomocysteine, the methylation ratio, at all time intervals. 2. Both 'O' and 'N' methylations were significantly reduced in pigs after 4 months in nitrous oxide but not after shorter periods. 3. Hypomethylation correlated with the development of clinical ataxia, but was absent when the pigs were clinically normal. It also only occurred when the S-adenosylmethionine level fell. 4. Rats maintained in nitrous oxide for 4 months showed a marked reduction of methionine synthase but no reduction in the methylation ratio or in brain hypomethylation. None of the rats became clinically ataxic. 5. Using an exogenous protein as a methyl group acceptor, it was demonstrated in an in vitro assay that the methyltransferase enzymes responsible for brain 'O' and 'N' methylation were not affected per se by nitrous oxide treatment. 6. It is concluded that reduction of the methylation ratio in the brain of pigs as a consequence of methionine synthase inhibition leads to brain hypomethylation. This hypomethylation could affect critical components of nerve tissue, inducing the vacuolar myelopathic changes seen in the spinal cord of these animals, which mimic those of subacute combined degeneration in man.

An abnormal methylation ratio induces hypomethylation in vitro in the brain of pig and man, but not in rat.

1. The ratio of the methyl donor, S-adenosylmethionine, to the co-product, S-adenosylhomocysteine (the methylation ratio) is known to control the activity of methyltransferases in tissues. Inactivation of the vitamin B12-dependent enzyme, methionine synthase, reduces the methylation ratio in rats and pigs in vivo. 2. We have determined the effect that such alterations have on neural protein 'O' and 'N' methyltransferases using an in vitro assay in rats, pigs and humans in the presence of the normal methylation ratio and the abnormal methylation ratios found experimentally in vivo in rats and pigs. 3. The methylation ratio found in the neural tissues of vitamin B12-inactivated pigs significantly inhibits the protein methyltransferases of pigs and humans. 4. By contrast, the altered methylation ratio found in vitamin B12-inactivated rats only marginally inhibits the equivalent rat methyltransferases. 5. This is consistent with the induction of a myelopathy by such treatment in pigs and humans, but not in the rat. 6. Dietary supplements of methionine given to vitamin B12-inactivated pigs have been shown to prevent the myelopathy in vivo by both elevating the neural S-adenosylmethionine level and resetting the methylation ratio. We find in our in vitro assay that these events reinstate the methyltransferase activity to near normal levels, thus explaining its protective effect in vivo.

Betaine-homocysteine methyltransferase: organ distribution in man, pig and rat and subcellular distribution in the rat.

1. Conflicting reports exist as to the organ distribution of betaine-homocysteine methyltransferase (EC 2.1.1.5). It is important to establish its presence or absence in brain, since its substrate, betaine, has recently become established in the treatment of certain diseases involving this organ. 2. It remains unclear whether the reported success of this treatment results from the use of betaine to methylate homocysteine and produce methionine in situ in neural tissue, or whether the effect is secondary to these same reductions happening in other organs, such as the liver. The former would require the presence of betaine-homocysteine methyltransferase in neural tissue. 3. This study demonstrates the complete absence of any activity for this enzyme in the brain of the three species examined. The enzyme was found to be present in both the liver and kidney of man and pig, but only in the liver of the rat. 4. The only source of betaine in cells is via the oxidation of choline. Since the enzymes involved in this conversion have never been shown to exist anywhere other than the mitochondria, it has been assumed that the methyltransferase is also mitochondrial. In this study, it is demonstrated that the enzyme exists only in the cytoplasm of rat liver cells.

An investigation of recognized incontinence within a health authority.

Incontinence affects a very large proportion of the population bringing with it considerable physical, social, psychological and often financial implications for the sufferer. Hence, it poses a considerable challenge to the providers of health care in relation to service provision and appropriate treatment of the problem. This descriptive study focused on the service provided by one health authority to sufferers of incontinence. The service in operation prior to the study had mushroomed with little thought being given to its organization or management, with the result that little was known about the people receiving the service. The study was commissioned to establish the number of people receiving assistance and the nature of the assistance given. Data were collected using pre-existing records, by questionnaire and by interview. A total of 847 people were found to receive assistance from the health authority, the majority of these being female and over the age of 65. Less than half of the study population were in regular contact with the community nursing service with regard to their incontinence. Of the remainder, inadequate incontinence products were found to be supplied without prior assessment of the problem to a proportion of the study population. Some strategies used by this group to manage their incontinence, disclosed during interview, were considered to be detrimental to the general health and well-being of the individuals practising them. These include non-compliance with prescribed diuretics and self-restriction of fluids. The service provided was considered to be a basic one providing assistance to 0.47% of the population of the study area. The implications of the service provided, highlighted by the findings, are wide-reaching in terms of the resultant underprovision which led to increased misery for some sufferers and the employment of inappropriate coping strategies.

Absence seizures in children: clinical and electroencephalographic features.

The clinical and electroencephalographic (EEG) features of absence seizures in children were evaluated using EEG frequency modulation radiotelemetry and videotape monitoring. The only seizures evaluated were those with a spike-and-wave or multiple spike-and-wave duration lasting at least 3 seconds. A total of 926 absence seizures (426 typical, 500 atypical) were reviewed in 54 patients. Abnormal interictal EEGs, multiple seizure types, mental retardation, or developmental delay were more likely in patients with atypical absence seizures than in patients with typical absence seizures. Both types of absence seizures usually had a clear onset and cessation. Atypical absence seizures lasted significantly longer than did typical absence seizures. Automatisms occurred more frequently in typical absence seizures than in atypical ones, while decreases in postural tone or tonic activity occurred more frequently in atypical absence seizures. Receptive and expressive speech were retained in some patients during both types of seizures. This study demonstrates that typical and atypical absence seizures are not discrete entities but rather form a continuum. No single clinical feature can adequately distinguish the two seizure types.

Speech abnormalities in seizures: a comparison of absence and partial complex seizures.

In order to determine whether speech changes are useful in differentiating seizure types, a study was done in which speech abnormalities during two distinct seizure types, partial complex and absence seizures, were compared. Speech changes noted during prolonged electroencephalographic and video monitoring were compared in 16 patients with 47 partial complex seizures and 19 patients with 95 absence seizures. Speech changes were common during both seizure types. Although some significant differences in speech patterns were noted in the two seizure types, the degree of overlap was such to preclude using speech changes alone as the sole clinical criteria in differentiating the seizures.

Abnormal behavior or epilepsy? Use of long-term EEG and video monitoring with severely to profoundly mentally retarded patients with seizures.

Prolonged electroencephalographic frequency modulated radio telemetry and video-tape monitoring (TEEG-VR) is widely used as a diagnostic aid in the evaluation of patients with suspected epilepsy. Use of this technique with 38 severely to profoundly mentally retarded patients to differentiate epileptic from nonepileptic behavior was reviewed. For only 2 patients was the behavior in question not recorded. Although all patients studied had abnormal EEGs and 90 percent had histories of epileptic seizures, only 38 percent of the behavior in question recorded during TEEG-VR was epileptic seizures. Criteria used for nonretarded patients to differentiate epileptic seizures from nonepileptic behavior was not helpful for this group of patients.

Prolonged EEG and videotape monitoring in children.

Prolonged frequency modulation (FM) radiotelemetry EEG and videotape monitoring (TEEG-VR) have been used together extensively to study patients with epileptic seizures. This technique was used to differentiate epileptic seizures from other episodic behavior in 45 children referred to our epilepsy center in whom the diagnosis could not be made by history, standard EEGs, or observation alone, in 40 children, the behavior in question was recorded during TEEG-VR. In 15 patients, this behavior was found to represent epileptic seizures. Although not indicated in all children with suspected epileptic seizures, TEEG-VR can be a useful diagnostic test in selected children.

Epileptiform activity in aphasia of childhood: an epiphenomenon?

Isolated aphasia with associated EEG epileptiform activity is a recognized syndrome in children. The relationship of the EEG abnormality and the type and severity of the speech impairment has not been well described. This relationship was studied in two children with severe expressive and receptive aphasia with generalized spike-wave discharges on EEG using prolonged EEG FM radiotelemetry and video recording (TEEG-VR). Speech was compared with 10 children with absence seizures with similar EEG abnormalities also evaluated using TEEG-VR. In addition, 43 cases of aphasia with epileptiform activity on the EEG reported in the English literature were reviewed. Speech abnormalities in absence seizures consisted of speech arrest, decreased speed of speech, and brief periods of partial or complete receptive and expressive aphasia, always directly associated with a spike-wave ictus. Speech abnormalities in acquired or congenital aphasia were not related to epileptiform activity and were characterized by severe articulation difficulties, syntactic transformation, paraphasia, and receptive and expressive aphasia. Anticonvulsants did not alter speech. Based on these two cases and the 43 others reviewed in the literature, it is proposed that epileptiform activity in this syndrome is an epiphenomenon reflecting underlying abnormalities of speech areas rather than the cause of the aphasia.