Integrating an evidence-based intervention into clinical practice: 'transitional relationship model'.

The transitional relationship model (TRM) facilitates the discharge process by providing peer support and hospital staff involvement until a therapeutic relationship has been established with a community care provider. A quasi-experimental, action-oriented research design was employed in which psychiatric wards at six hospital sites implemented the model in three waves. Helpful strategies were identified by each wave of wards for consideration by subsequent wards. Using an ethnographic approach, qualitative data were examined to uncover experiences and perceptions of TRM implementation and to help identify key issues that were supporting or hampering implementation. Specific strategies that facilitate the implementation of TRM include: (1) the use of educational modules for on-ward hospital staff training and peer training; (2) presence of on-site champions; and (3) supportive documentation systems. Issues identified as barriers to implementation included: (1) feeling drowned, swamped and overwhelmed; (2) death by process; (3) team dynamics; and (4) changes in champions. Staged large-scale implementation of the TRM allowed for iterative improvements to the model leading to positive outcomes. This study highlights the need to address work environment issues, particularly interprofessional teams.

Consumer input into standards revision: changing practice.

As part of ongoing quality improvement initiatives, the Canadian Standards for Psychiatric-Mental Health Nursing were recently revised. For the first time since the standards were published in 1995, the input of consumers of mental health services was sought. Thirty-one consumers from across Canada participated in focus groups, and answered questions related to the domains of practice as identified in the standards document. Through this input, consumers were able to inform the committee regarding areas of satisfaction and dissatisfaction from their unique perspective. Through this article, the process of consumer collaboration is illustrated in relation to how it shaped Standards revision, and finally how it affected the practitioners involved.

Pulmonary infection in mild variant cystic fibrosis: implications for care.

BACKGROUND: Disease phenotype in cystic fibrosis (CF) shows considerable heterogeneity. Atypical or mild mutations in the CFTR gene have been linked to late-onset pulmonary disease; however, few reports document the condition of the airway in infants and young children with apparent "mild" disease. Prognosis is uncertain in this group of patients and this, in turn, has led to inconsistency in management. Our initial experience of pulmonary infection in children with mild variant CF prompted a more detailed review of clinical outcome. METHODS: A retrospective cohort study was carried out comparing frequency of bacterial isolates and clinical outcomes in eleven compound heterozygotes for DeltaF508 and a second mild mutation, mainly R117H, with a matched group of DeltaF508 homozygotes. RESULTS: Staphylococcus aureus was isolated in 8 of the 11 patients with mild variant disease and Pseudomonas aeruginosa found in 7 (64%), although the frequency of positive cultures was significantly less (2.8/year) than the DeltaF508 homozygotes (6.1/year, p<0.05). Shwachman scores (median+range) were significantly higher in patients with mild mutations - 94, 74-92 vs. 88, 77-91; p<0.005); there was also a small but significant difference in chest radiograph (Chrispin-Norman) scores (median+range) (mild 5.1, 4-9, vs. severe 5.8, 3-10; p 0.04). There was little difference in lung function in terms of FEV1 (median+range) between the two groups (% predicted, mild 86.5, 68-87 vs. severe 76.0, 65-88; p 0.5). CONCLUSIONS: Most patients with mild variant CF will have bacterial isolates from airway cultures requiring antibiotic therapy three to four times a year. Infection with both S. aureus and P. aeruginosa is common. Anti-staphylococcal prophylaxis for the first two years should be considered.

[Cowpox virus infection in a child]. / Infection à cowpox virus chez l'enfant.

UNLABELLED: Although human cowpox virus infection is rare nowadays, an animal reservoir of this virus still exists. The general course of cowpox virus infections is usually benign but the diagnosis is difficult and often late. CASE REPORT: An 11-year-old boy, owner of two cats, presented with an infected sacral wound lesion associated with fever and lymph nodes. The wound became necrotic and other cutaneous and mucous membrane lesions developed secondarily. Blood tests did not show hyperleukocytosis or a systemic inflammatory response. Concurrently one of the cats was examined by a veterinary because of multifocal cutaneous lesions. Evocative skin biopsy specimens from the animal and, secondarily from the patient, allowed the identification of orthopoxvirus. Evolution was slowly favourable under symptomatic treatment. CONCLUSION: Poxviruses are responsible for many animal and human diseases, the most famous of them being smallpox which today is considered eradicated. Vaccination against smallpox is no longer performed since 1977. Whether the arrest of vaccinations against smallpox may induce the apparition of other poxviruses infections or alter their clinical expression is an open question.

[Trismus and tetanus vaccine]. / Trismus et vaccination antitétanique.

BACKGROUND: Tetanus immunization, mandatory in France before the age of 18 months, is usually well tolerated. Fever and local reaction at the site of injection are the most common side effects. We report a case of trismus associated with tetanus immunization. CASE REPORT: A 12-year-old boy was hospitalized for a trimus which occurred 22 h after a booster dose of tetanus polio vaccine. The spasm of masticator muscles was so severe that the patient had difficulties in elocution and feeding. A moderate fever and a hypertonia of the lower limbs were associated. The trismus resolved itself within about 5 min after diazepam intravenous infusion. After examination of the buccal cavity, a local cause was discarded. The outcome was favorable and the clinical status of the boy was still normal six months later. DISCUSSION: Although no similar cases have been published, 13 other comparable adverse events associated with four vaccines containing tetanus toxoid were reported to the manufacturer within a period of 12 years. During the same period, more than 66 millions doses of vaccines containing tetanus toxoid were distributed. Trisms appeared to be more likely reported in adults after booster doses. Onset of the symptoms was between a few hours to 15 days. Outcome was always favorable. CONCLUSION: Although trimus associated to tetanus toxoid immunization is rare and remains unexplained, physicians should be aware of this adverse event.

The constitution of community: how individuals diagnosed with schizophrenia and their friends achieved community.

This article describes a qualitative research project, based on a grounded theory design, that addressed the processes involved in how individuals with schizophrenia were able to use their own abilities to form a self-authored community. The article offers a perspective on community integration that takes into account the importance of relationships, and in the case of individuals with schizophrenia, the importance of day-to-day relationships. The assumption is that the constitution of community is an outcome of the processes involved in learning and practicing being social (Cohen 1985, p. 15). These relationships do not necessarily have to be strong or numerous in order for community integration to be realized. In this article it is argued that an element in the establishment of such relationships for individuals with schizophrenia is the ready availability of others on a day-to-day basis. Relationships and friendships grew for individuals diagnosed with schizophrenia when such access occurred in a place where the context of what was likely to happen in an interaction was relatively well understood.

Transcriptional repressor ERF is a Ras/mitogen-activated protein kinase target that regulates cellular proliferation.

A limited number of transcription factors have been suggested to be regulated directly by Erks within the Ras/mitogen-activated protein kinase signaling pathway. In this paper we demonstrate that ERF, a ubiquitously expressed transcriptional repressor that belongs to the Ets family, is physically associated with and phosphorylated in vitro and in vivo by Erks. This phosphorylation determines the ERF subcellular localization. Upon mitogenic stimulation, ERF is immediately phosphorylated and exported to the cytoplasm. The export is blocked by specific Erk inhibitors and is abolished when residues undergoing phosphorylation are mutated to alanine. Upon growth factor deprivation, ERF is rapidly dephosphorylated and transported back into the nucleus. Phosphorylation-defective ERF mutations suppress Ras-induced tumorigenicity and arrest the cells at the G0/G1 phase of the cell cycle. Our findings strongly suggest that ERF may be important in the control of cellular proliferation during the G0/G1 transition and that it may be one of the effectors in the mammalian Ras signaling pathway.

[The creation of partnerships: perspectives and possibilities]. / La création de partenariats: perspectives et possibilités.

This article re-examines access to treatment and care in the current context of fiscal restriction and change in locus of care. Taking the position that the development of partnerships with all parties who work in the mental health area is an important process, this article argues that such processes are infrequently discussed. Further, creating a partnered relationship with the person with mental disorder is also neglected. The authors examine mechanisms of relationship change as care moved from large, total-care institutions to general hospitals and finally, to the community. How professionals, individuals with mental disorder and their families have been affected by this change in terms of how alliances are constituted and maintained is discussed. The authors conclude with two case examples which illustrate the reconciliation and non-reconciliation of differing points of view between all partners which likely affected clinical outcomes.

[Severe parvovirus B19 infection in an immunocompetent child with hemophilia A]. / Infection sévère à parvovirus B19 chez un enfant hémophile A immunocompétent.

BACKGROUND: B19 parvovirus is a widespread virus whose typical manifestations in immunocompetent children are erythema infectiosum, acute erythroblastopenia and fetal anemia. CASE REPORT: An 11 year-old immunocompetent patient with hemophilia A was referred for an hemorrhagic syndrome. Forty days after a pasteurized coagulation factor concentrates treatment, and after 12 days of treatment with solvent/detergent factor VIII concentrates, he developed fever, consciousness disorders, pancytopenia, liver cytolysis and probably minor haemophagocytic syndrome, associated with human parvovirus B19 infection. His clinical state returned to normal within 15 days. A retrospective study revealed that the patient had received every day for 12 days, one parvovirus B19 polymerase chain reaction positive batch before the occurrence of symptoms. CONCLUSION: This case highlights the possibility of severe parvovirus B19 infection transmitted by clotting factors prepared from large pools of plasma. The use of recombinant factors would allow to reduce human virus contamination, even if immune risk has to be more accurately assessed.

ERF: an ETS domain protein with strong transcriptional repressor activity, can suppress ets-associated tumorigenesis and is regulated by phosphorylation during cell cycle and mitogenic stimulation.

ERF (ETS2 Repressor Factor) is a novel member of the ets family of genes, which was isolated by virtue of its interaction with the ets binding site (EBS) within the ETS2 promoter. The 2.7 kb ubiquitously expressed ERF mRNA encodes a 548 amino acid phosphoprotein that exhibits strong transcriptional repressor activity on promoters that contain an EBS. The localization of the DNA-binding domain of the protein at the N-terminus and th repression domain at the C-terminus is reminiscent of the organization of ELK1-like members of the ets family; however, there is no significant homology between ERF and ELK1 or any other ets member outside the DNA-binding domain. The repressor activity of ERF can antagonize the activity of other ets genes that are known transcriptional activators. Furthermore, ERF can suppress the ets-dependent transforming activity of the gag-myb-ets fusion oncogene of ME26 virus. Although ERF protein levels remain constant throughout the cell cycle, the phosphorylation level of the protein is altered as a function of the cell cycle and after mitogenic stimulation. The ERF protein is also hyperphosphorylated in cells transformed by the activated Ha-ras and v-src genes and the transcription repressor activity of ERF is decreased after co-transfection with activated Ha-ras or the kinase domain of the c-Raf-1 gene, indicating that ERF activity is probably regulated by the ras/MAPK pathway. Consistent with the in vivo phosphorylation and inactivation by ras, ERF is efficiently phosphorylated in vitro by Erk2 and cdc2/cyclin B kinases, at sites similar to those detected in vivo. Furthermore, a single mutation at position 526 results in the loss of a specific phosphopeptide both in in vivo and in vitro (by Erk2) labeling. Substitution of Thr526 for glutamic acid also decreases the repression ability of ERF. Our data suggest a model in which modulation of ERF activity is involved in the transcriptional regulation of genes activated during entry into G1 phase. Obstruction of the ERF repressor function by the transactivating members of the ets family of genes (i.e.gag-myb-ets) may be essential for the control of genes involved in cell proliferation and may also underlie their tumorigenic effects.

Defining target sequences of DNA-binding proteins by random selection and PCR: determination of the GCN4 binding sequence repertoire.

We developed a simple and accurate method to define the sequence recognition properties of DNA-binding proteins. The method employs polymerase chain reaction (PCR) amplification of sequences selected from a mixture of random oligonucleotides by the gel mobility-shift assay. We used this method to define the sequence requirement of the binding domain of the yeast transcriptional activator GCN4. Using a total of 200 ng of purified protein and four cycles of binding and subsequent amplification, we identified the TGA-(C/G)TCA sequence as the binding consensus of GCN4, which is consistent with the previously reported recognition sequence. In addition, our data indicate that GCN4 can bind with lower affinity to sequences that differ from the optimal sequence in one or even two positions. The most common variation was the C to A at position +2. The majority of the substitutions that still allowed binding were 3' to the central C residue indicating that the two sides of the palindromic recognition sequence are not equivalent.

[Transcutaneous trinitrine. Calling into question the efficacy and innocousness of its use in facilitating venous approach]. / La trinitrine transcutanée. Mise en cause de son efficacité et de son innocuité dans son emploi pour faciliter l'abord veineux.

Seven infants aged 6 days to 9 months were tested for the use by rubbing of a pomade containing 1 mg trinitrine. The study was interrupted because of high blood passage of trinitrine. The authors emphasize the difficulty of any comparison with the use of this drug in adults. They indicate that there was no clinically appreciable side-effect but they advise to delay, until further studies, the use of this technique, with the only objective of improving the technique of intravenous injections or sampling.

[Septic arthritis due to a nontoxigenic diphtheria bacillus]. / Arthrite purulente à bacille diphtérique atoxinogene.

Septic arthritis of the hip in a 2 year old child is described. A nontoxigenic diphtheria bacillus was isolated in large numbers from the articular fluid. The same organism was isolated from excoriated skin lesions of the toes. The bacteriology, epidemiology and pathology of the infection are discussed.