Mental Health Signs Relevant for an Assessment Tool Suitable for Student and Novice Nurses: A Document Analysis.

Novice nurses' mental health assessment practice is characterised by lack of consistency, despite mental health assessment being a core issue in professional nursing and patient safety across health services. This study aimed to identify mental health signs relevant for an assessment tool suitable for student and novice nurses. A document analysis approach was applied, and content analysis was used to analyse data extracted from carefully selected documents. Four main categories of mental health issues were identified: risk issues, symptom issues, psychological issues and self-care issues. Mental health signs were thereafter grouped in ten sub-categories characterising mental health concerns. These were: risk concerns, psychotic concerns, mood, affect and energy concerns, substance use concerns, somatic concerns, perception concerns, communication concerns, cognitive concerns, anxiety concerns and self-care concerns. The identified signs are considered relevant for student and novice nurses to learn and can be further developed into a clinical assessment tool for use in nursing education to strengthen mental health assessment competence in nursing education.

Thiopurine withdrawal during sustained clinical remission in inflammatory bowel disease: relapse and recapture rates, with predictive factors in 237 patients.

BACKGROUND: Thiopurines (azathioprine and mercaptopurine) remain integral to most medical strategies for maintaining remission in Crohn's disease (CD) and ulcerative colitis (UC). Indefinite use of these drugs is tempered by long-term risks. While clinical relapse is noted frequently following drug withdrawal, there are few published data on predictive factors. AIM: To investigate the success of planned thiopurine withdrawal in patients in sustained clinical remission to identify rates and predictors of relapse. METHODS: This was a multicentre retrospective cohort study from 11 centres across the UK. Patients included had a definitive diagnosis of IBD, continuous thiopurine use ≥3 years and withdrawal when in sustained clinical remission. All patients had a minimum of 12 months follow-up post drug withdrawal. Primary and secondary end points were relapse at 12 and 24 months respectively. RESULTS: 237 patients were included in the study (129 CD; 108 UC). Median duration of thiopurine use prior to withdrawal was 6.0 years (interquartile range 4.4-8.4). At follow-up, moderate/severe relapse was observed in 23% CD and 12% UC patients at 12 months, 39% CD and 26% UC at 24 months. Relapse rate at 12 months was significantly higher in CD than UC (P = 0.035). Elevated CRP at withdrawal was associated with higher relapse rates at 12 months for CD (P = 0.005), while an elevated white cell count was predictive at 12 months for UC (P = 0.007). CONCLUSION: Thiopurine withdrawal in the context of sustained remission is associated with a 1-year moderate-to-severe relapse rate of 23% in Crohn's disease and 12% in ulcerative colitis.

Community mental health teams for people with severe mental illnesses and disordered personality.

BACKGROUND: Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favor of providing care in a variety of nonhospital settings, underpins the rationale behind care in the community. A major thrust toward community care has been the development of community mental health teams.

Overexpression of p101 activates PI3Kgamma signaling in T cells and contributes to cell survival.

p101, the regulatory subunit of phosphatidylinositol-3-kinase-gamma (PI3Kgamma), was recently reported as a common site of retroviral insertion in T-cell lymphomas induced in mice by MoFe2-MuLV, a unique recombinant gammaretrovirus. The common interruption of p101 by retroviral integration suggests that the locus encodes an oncogene whose altered expression is related to the induction of T-cell malignancy. To examine a possible role in the malignant process, p101 was overexpressed in human T-cell lines Molt-4 and Jurkat. Transient overexpression of p101 induced apoptosis in recipient cells; however, stable expression could be established in cells that expressed moderate levels of p101. Constitutive p101 overexpression in those cells conferred significant protection against ultraviolet-induced apoptosis. Protection against apoptotic induction was attributed to p101-mediated activation of the Akt pathway. Constitutive overexpression of p101 enhanced the activity of p110gamma and further sensitized it to activation upon stimulation of G protein-coupled receptor. These findings are the first to implicate altered expression of p101 in malignancy, specifically in T-cell lymphoma. The findings further provide insight into the regulation of p110gamma, indicating that the stoichiometry of p110gamma and p101 are important in regulating PI3Kgamma signaling.

Amputation for acute ischaemia is associated with increased comorbidity and higher amputation level.

BACKGROUND: There is some evidence that the early outcome of major amputation is worse after failed thromboembolectomy, but the risk factors and results of amputation done for acute ischaemia have never been compared with those for chronic ischaemia in a large series of patients. METHOD: Retrospective review of 30 day outcome for all 322 primary amputations done for arterial disease during 1992-8. There were 286 patients (163 male; median age 76 years) who had 270 amputations for chronic ischaemia and 52 for acute ischaemia. RESULTS: The acute group had higher prevalences of cardiac disease (48% versus 29%-p<0.02), limiting pulmonary disease (27% versus 13%-p<0.02) and ASA grades 4 and 5 (27% versus 14%-p<0.05). Amputation below the knee was less common after acute ischaemia (31% versus 60%-p<0.001). There were trends towards more revisions (19% versus 11%) and higher mortality (25% versus 19%) in the acute group but neither reached statistical significance. CONCLUSION: Patients having major amputations for acute ischaemia have higher levels of pre-existing comorbidity than those with chronic ischaemia and are twice as likely to require amputation above the knee. They should be managed as a particularly high risk group.

C-kit mutation screening in patients with acute myeloid leukaemia: adaptation of a Giemsa-stained bone-marrow smear DNA extraction technique.

The scarcity of viable tissue samples for leukaemia research is widely recognised and currently restrictive. Archival bone-marrow smears present a valuable resource that can be exploited easily for mutational analysis. Here, a modified technique to extract DNA is described, and used subsequently for mutation/polymorphism screening of the stem-cell factor receptor proto-oncogene c-kit in 23 patients with acute myeloid leukaemia (AML). The selected method was straightforward and used bone-marrow material scraped from periodic acid-Schiff, sudan black B and May-Grünwald/Giemsa-stained preparations, and treated initially with proteinase K prepared in digestion buffer to digest all proteinaceous matter. Following incubation, saturated sodium chloride was added and DNA extracted from the supernatant by phenol/chloroform/isoamyl alcohol treatment. Retrieved DNA was precipitated with ethanol at -20 degrees C overnight, washed with 95% ethanol, air-dried, resuspended using purite water and stored at -20 degrees C prior to use in mutational analysis. The extraction method described was compared with a commercial reagent for combined DNA, RNA and protein isolation using cryopreserved cells from 20 patients with AML. The quality of extracted DNA isolated by the two methods was comparable by polymerase chain reaction (PCR) and single-strand conformation polymorphism (SSCP) techniques. Bone-marrow biopsies are performed regularly on each AML patient to monitor the disease; therefore, an extraction method using this resource could liberate a valuable source of DNA for study (e.g. molecular investigations, including mutation/polymorphism screening etc.). This would allow fresh and programme-frozen cells to be reserved for those investigations requiring intact, viable cells. The use of archived bone-marrow smears would permit vast increase in the scope for retrospective testing and large-scale analyses.

Accelerated G(1) phase progression induced by the human T cell leukemia virus type I (HTLV-I) Tax oncoprotein.

Tax, the human T cell leukemia virus type I oncoprotein, plays a crucial role in viral transformation and the development of the virally associated disease adult T cell leukemia. Because oncogenesis involves alterations in cell growth, it is important to examine the effects of Tax on cell cycle progression. Using a synchronized cell system, we have found that Tax expression accelerates G(1) phase progression and S phase entry with concomitant DNA replication. This accelerated progression is accompanied by an earlier onset of cdk2 kinase activity. In contrast to the shortening of G(1) phase, the length of S phase is unaffected by Tax expression. As a result of a more rapid cell cycle progression, cells expressing Tax exhibit faster growth kinetics and display an altered cell cycle distribution. Additionally, the decreased time allowed for growth in the presence of Tax results in a decreased cell size. Tax-associated acceleration of cell cycle progression may play a role in the ability of this viral oncoprotein to mediate cellular transformation and promote the development of human T cell leukemia virus type I-associated diseases.

Community mental health team management in severe mental illness: a systematic review.

BACKGROUND: Community mental health teams are now generally recommended for the management of severe mental illness but a comparative evaluation of their effectiveness is lacking. AIMS: To assess the benefits of community mental health team management in severe mental illness. METHOD: A systematic review was conducted of community mental health team management compared with other standard approaches. RESULTS: Community mental health team management is associated with fewer deaths by suicide and in suspicious circumstances (odds ratio=0.32, 95% Cl 0.09-1.12), less dissatisfaction with care (odds ratio=0.34, 95% Cl 0.2-0.59) and fewer drop-outs (odds ratio=0.61, 95% Cl 0.45-0.83). Duration of in-patient psychiatric treatment is shorter with community team management and costs of care are less, but there are no gains in clinical symptomatology or social functioning. CONCLUSIONS: Community mental health team management is superior to standard care in promoting greater acceptance of treatment, and may also reduce hospital admission and avoid deaths by suicide. This model of care is effective and deserves encouragement.

Identification of an initiator-like element within the HTLV-I promoter.

Using the 5' long terminal repeat (LTR) as its only promoter, the HTLV-1 provirus generates a single RNA transcript that undergoes differential splicing to express the various viral proteins. Examination of sequence near the transcription start site revealed an element resembling a transcriptional initiator (Inr) at position -8 to -15 in addition to the canonical TATA box at -25. To elucidate basal control of HTLV-I gene expression, functional traits of this element were examined. It specifically bound a protein complex, the mobility of which was altered by antibody to serum response factor, and independently mediated reporter gene expression. Mutating the Inr in a minimal construct reduced basal transcription, whereas mutation of the element within the context of the complete LTR left basal transcription unaffected. Presence of the element influenced transcription start site choices. Exhibiting many characteristics of an Inr, this element may play an important role in regulating HTLV-I gene expression in vivo, particularly during the long clinical latency period prior to development of HTLV-I-induced disease.

Factors influencing the early outcome of major lower limb amputation for vascular disease.

A consecutive series of 349 primary lower limb amputations for vascular disease, done during 1992-1998, were reviewed for amputation level, revision, complications and death, seeking associations with the American Society of Anesthesiology (ASA) grade and pre-operative co-morbidities of patients. Attempted revascularisation, and seniority of surgeon supervising the amputation were also examined for their possible influence on outcome. There were 312 patients (163 male) aged 39-92 years (median, 76 years). The majority of patients were ASA 3 or 4 (76%), and ASA 4 was associated with increased mortality (P < 0.01). Limiting heart problems (P < 0.01) and 'general frailty' (P < 0.001) also carried significantly higher risks of death, but limiting chest problems, dementia, and diabetes mellitus did not. There was no significant association between attempts at revascularisation at any time before amputation, and amputation level or the need for revision. There were no differences between consultants, registrars, and senior house officers (most senior surgeon) for any outcome measure. This study documents the medical status of amputees more clearly than usual, and demonstrates the effect of co-morbidity on the substantial mortality of these patients. The results support an aggressive policy of attempted revascularisation, and show that properly trained junior surgeons obtain satisfactory results.

Transcriptional activity of HTLV-I Tax influences the expression of marker genes associated with cellular transformation.

Human T cell leukemia virus type I (HTLV-I) has been identified as the etiologic agent of adult T cell leukemia (ATL). HTLV-I encodes a transcriptional regulatory protein, Tax, which also functions as the viral transforming protein. Through interactions with a number of cellular transcription factors Tax can modulate cellular gene expression. Since the majority of Tax-responsive cellular genes are important regulators of cellular proliferation, the transactivating functions of Tax appear to be necessary for cellular transformation by HTLV-I. Gaining a complete understanding of the broad range of genes regulated by Tax, the temporal pattern of their expression, and their effects on cell function may identify early markers of disease progression mediated by this virus.

p53-independent induction of apoptosis by the HTLV-I tax protein following UV irradiation.

Human T cell leukemia virus type 1 (HTLV-1) encodes a transforming protein, Tax. Tax is a promiscuous viral transactivator involved in both cell growth and death control. We have previously shown that Tax sensitizes cells to apoptosis induced by DNA-damaging agents and this report further characterizes the Tax-mediated apoptosis pathway. We found that Tax-mediated apoptosis in response to UV irradiation was inhibited by Bcl-2 and Bcl-X(L) overexpression and by treatment with the caspase inhibitor z-VAd-FMK. Since Tax has been shown to functionally inactivate the apoptosis regulator p53, the effect of Tax on apoptosis in the absence of p53 was examined. In these studies, Tax sensitized p53-negative cells to apoptose, suggesting that Tax can mediate a p53-independent form of apoptosis. In addition, cells expressing both Tax and p53 displayed higher levels of apoptosis than cells expressing either protein alone, suggesting that the apoptosis-inducing activities of Tax and p53 are not completely overlapping. These observations demonstrate that Tax can utilize a p53-independent mechanism to induce apoptotic cell death following UV irradiation.

Suppression of DNA repair by HTLV type 1 Tax correlates with Tax trans-activation of proliferating cell nuclear antigen gene expression.

The human T cell leukemia virus type 1 (HTLV-1) viral oncoprotein Tax acts as a transcriptional trans-activator affecting viral as well as cellular gene expression. To understand how Tax induces transformation, the consequences of its ability to alter expression of cellular genes must be examined. We have previously demonstrated that Tax activates expression of the cellular gene, proliferating cell nuclear antigen (PCNA), and that Tax suppresses DNA repair. In this study we tested the ability of previously described Tax mutants to activate PCNA gene expression and their ability to interfere with DNA repair. The results revealed a strong correlation between Tax trans-activation of PCNA gene expression and its ability to inhibit DNA repair via the nucleotide excision repair (NER) pathway. Thus, a consequence of activated PCNA gene expression appears to be reduced DNA repair capacity. These effects of Tax are likely to play important roles in its transforming activity.

Anaesthesia and analgesia for major lower limb amputation.

This study describes the methods of anaesthesia and analgesia used in 349 major lower limb amputations for vascular disease over a seven year period (1992-8). The main type of anaesthesia was general in 55%, spinal in 29%, and epidural in 14%: there were no significant differences for ASA grade, age, or amputation level, nor any statistical differences in mortality for each method of anaesthesia. The main methods of analgesia in the first 48 hours changed between 1992 and 1998, with decreasing intramuscular and oral opioids (from 38% to 7%, and from 23% to 2% respectively) while epidurals became the commonest method (4% in 1992 and 63% in 1998). Thirty seven percent of patients were prescribed carbamazepine for phantom pain. There have been substantial changes in postoperative analgesia following amputation, and epidurals are now common practice, despite the controversy about their role in preventing phantom pain.

Suppression of DNA repair by human T cell leukemia virus type 1 Tax is rescued by a functional p53 signaling pathway.

The Tax protein of human T cell leukemia virus type 1 is a viral transactivator and transforming protein. Tax is known to suppress cellular nucleotide excision repair (NER), and this activity has been proposed to play an important role in Tax transformation. In this study we have investigated the mechanism by which Tax suppresses NER with specific focus on the previously characterized ability of Tax to inhibit p53 function. Suppression of NER by Tax was rescued by overexpression of wild-type p53; however, a p53 transactivation-incompetent mutant did not restore NER activity. The cyclin-dependent kinase inhibitor p21, a major transcriptional target of p53, plays an important role in regulating DNA replication and repair. Overexpression of p21 reversed Tax-induced suppression of NER; however, a p21 C-terminal mutant that lacks the proliferating cell nuclear antigen binding domain did not restore NER activity. Thus, p53 and its downstream effector p21 can inhibit Tax-mediated suppression of DNA repair. These results imply that the inactivation of p53 function by Tax contributes to Tax suppression of DNA repair.

What do trainees think about advanced trauma life support (ATLS)?

Advanced trauma life support (ATLS) has become a desirable or even essential part of training for many surgeons and anaesthetists, but aspects of the ATLS course have attracted criticism. In the absence of published data on the views of trainees, this study sought their opinions in a structured questionnaire, which was completed by trainees in accident and emergency (A & E) (26), anaesthetic (82), general surgical (26), orthopaedic (42) and other (5) posts in different hospitals (response rate 66%). Of the trainees, 78% had done an ATLS course and, of these, 83% considered ATLS a 'major advantage' or 'essential' for practising their proposed specialty--100% for A & E, 94% for orthopaedics, 92% for general surgery, and 75% for anaesthetics. ATLS was considered a major curriculum vitae (CV) advantage by 94%, 85%, 50%, and 45%, respectively. Over 90% had positive attitudes towards ATLS, and 74% selected 'genuine improvement of management of trauma patients' as the most important reason for doing the course: 93% thought ATLS saved lives. Of the respondents, 83% thought that all existing consultants dealing with trauma patients should have done the course, and 41% thought it offered major advantages to doctors not involved in trauma. Funding problems for ATLS courses had been experienced by 14% trainees. This survey has shown that most trainees view ATLS positively. They believe that it provides genuine practical benefit for patients, and very few regard ATLS primarily as a career advantage or mandate.

Sequences flanking the cAMP responsive core of the HTLV-I tax response elements influence CREB protease sensitivity.

The human T cell leukemia virus type I (HTLV-I) Tax protein activates transcription from the viral long terminal repeat and select cellular promoters by interacting with cellular DNA-binding proteins. The HTLV-I promoter contains three copies of a Tax-responsive element (TRE-1), each of which possesses a core cAMP response element (CRE). The cAMP response element-binding protein, CREB, binds TRE-1 and mediates Tax association with, and transactivation of, the viral promoter. These activities depend on DNA sequences that flank the core CRE. Although CREs are found in a variety of cellular promoters, cellular CREs vary in sequence from TRE-1, especially in the flanking regions, and are generally not Tax responsive. The molecular basis for differential Tax responsiveness of viral and cellular CREs has not been determined. Here we demonstrate that the conformation of CREB is influenced by the nucleotide sequence of its DNA-binding element. CREB showed altered sensitivity to V8, chymotrypsin, and trypsin proteases when bound to the HTLV-I TRE-1 element as compared to the rat somatostatin CRE element. The phosphorylation state of CREB did not influence its protease sensitivity on either element. Sequences flanking the core CRE-binding site in each element were found to specify protease sensitivity. Since the TRE-1-flanking sequences also modulate Tax association with CREB, and Tax transactivation of CREB-dependent LTR transcription, these results suggest that CREB conformation may determine the ability of Tax to bind CREB.

Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality.

BACKGROUND: Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT). OBJECTIVES: To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1982-1997), the Cochrane Library (1998, Issue 2), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. The Journal of Personality Disorders was hand searched, and contact was made with colleagues at ENMESH, ISSPD and in forensic psychiatry. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials of CMHT management versus non-team standard care. DATA COLLECTION AND ANALYSIS: The selection of trials, assessment of quality and data extraction was undertaken independently and in parallel by two reviewers. Where possible the data were entered into RevMan and an intention-to-treat analysis undertaken. Tests of heterogeneity were undertaken. MAIN RESULTS: CMHT management may be associated with fewer deaths by suicide and in suspicious circumstances (OR 0.32 CI 0.09-1.12). It causes less people to be dissatisfied with their care (OR 0.34 CI 0.2-0.59) and to leave the studies early (OR 0.61 CI 0.45-0.83). No clear difference was found in admission rates, overall clinical outcomes and duration of in-patient hospital treatment, although this was partly a consequence of poorly presented data. REVIEWER'S CONCLUSIONS: Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide.

Metaphase karyotypes and G-banding in sandflies of the Lutzomyia longipalpis complex.

Mitotic metaphase chromosomes (2n = 8) from brain cells of fourth instar sandfly larvae of four geographical strains of the Lutzomyia longipaplis complex were examined microscopically, with bright-field illumination, after staining by a new G-banding technique involving exposure of air-dried chromosome preparations to quinacrine and ultraviolet light. Differences of G-banding and/or position of the centromere on chromosome 4 (the smallest chromosome pair) distinguished four putative sibling species from Costa Rica, Colombia and Brazil (distinctive populations from Jacobina and Lapinha Caves). The karyotype of the population from Jacobina, Brazil, showed an apparently plesiomorphic pattern of G-banding. On the basis of their recognizably different mitotic karyotypes, cytogenetic identification of separate taxa in the L. longipalpis complex should be useful for specific female vector competence and ecology studies.