Biomedical subjects
B Taylor
Publications and source records attributed to B Taylor.
On the experience of spirituality.
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Children conceived by intracytoplasmic sperm injection.
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Mutations of the NF1 gene in children with juvenile myelomonocytic leukemia without clinical evidence of neurofibromatosis, type 1.
Juvenile myelomonocytic leukemia (JMML) is a pediatric myelodysplastic syndrome that is associated with neurofibromatosis, type 1 (NF1). The NF1 tumor suppressor gene encodes neurofibromin, which regulates the growth of immature myeloid cells by accelerating guanosine triphosphate hydrolysis on Ras proteins. The purpose of this study was to determine if the NF1 gene was involved in the pathogenesis of JMML in children without a clinical diagnosis of NF1. An in vitro transcription and translation system was used to screen JMML marrows from 20 children for NF1 mutations that resulted in a truncated protein. Single-stranded conformational polymorphism analysis was used to detect RAS point mutations in these samples. We confirmed mutations of NF1 in three leukemias, one of which also showed loss of the normal NF1 allele. An NF1 mutation was detected in normal tissue from the only patient tested and this suggests that JMML may be the presenting feature of NF1 in some children. Activating RAS mutations were found in four patients; as expected, none of these samples harbored NF1 mutations. Because 10% to 14% of children with JMML have a clinical diagnosis of NF1, these data are consistent with the existence of NF1 mutations in approximately 30% of JMML cases.
Confidential inquiry into quality of care before admission to intensive care.
OBJECTIVE: To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions. DESIGN: Prospective confidential inquiry on the basis of structured interviews and questionnaires. SETTING: A large district general hospital and a teaching hospital. SUBJECTS: A cohort of 100 consecutive adult emergency admissions, 50 in each centre. MAIN OUTCOME MEASURES: Opinions of two external assessors on quality of care especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing, and circulation, and oxygen therapy and monitoring. RESULTS: Assessors agreed that 20 patients were well managed (group 1) and 54 patients received suboptimal care (group 2). Assessors disagreed on quality of management of 26 patients (group 3). The casemix and severity of illness, defined by the acute physiology and chronic health evaluation (APACHE II) score, were similar between centres and the three groups. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48%), and 6 (23%) respectively (P=0.04) (group 1 versus group 2, P=0.07). Hospital mortalities were 7 (35%), 30 (56%), and 8 (31%) (P=0.07) and standardised hospital mortality ratios (95% confidence intervals) were 1.23 (0.49 to 2.54), 1.4 (0.94 to 2.0), and 1.26 (0.54 to 2.48) respectively. Admission to intensive care was considered late in 37 (69%) patients in group 2. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. CONCLUSIONS: The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement for intensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care.
Common bile duct injury during laparoscopic cholecystectomy in Ontario: does ICD-9 coding indicate true incidence?
BACKGROUND: Recent reports in the scientific and lay press have suggested that bile duct injuries during laparoscopic cholecystectomy are common in Ontario. The reports were based on administrative data collected by hospital medical records departments and the Canadian Institute for Health Information (CIHI). The current study involved a direct inspection of hospital records to determine if the CIHI data accurately captured the rate of clinically significant bile duct complications. METHODS: For the period 1991 to 1995, records of bile duct injuries after laparoscopic cholecystectomy were independently evaluated to clarify the clinical significance of the complications. Of 21 Ontario hospitals for which data on complications had been reported in the media, 18 provided detailed information on all patients reported to have suffered bile duct complications classified by the hospital as "major". In addition, each institution provided information on a random sample of one-sixth of the patients who had suffered complications classified as "minor". The reviewer then examined each relevant hospital chart to assess the grade and significance of the reported complications. RESULTS: All 24 bile duct injuries classified by the hospitals as "major" were confirmed as major (clinically relevant) injuries. Of the 80 bile duct complications classified by the hospitals as "minor", 76 (95%) were irrelevant to patient outcome. The discrepancy between data collected and reported frequency of injury lies in the use of nonspecific coding methods. INTERPRETATION: The rate of significant bile duct injuries cannot be inferred from nonspecific codes taken from the International Classification of Diseases, ninth revision, and presented in hospital discharge records. Therefore, such data must be interpreted with extreme caution.
Comparisons of acute toxicity of selected chemicals to rainbow trout and rats.
Median lethal concentration (LC50) and dose (LD50) for 217 chemicals were compared over several exposure routes in rainbow trout and rats. Data were compiled primarily from on-line databases and included octanol-water partition coefficient (Kow), trout LC50, and trout and rat LD50 for oral, dermal, and intraperitoneal (i.p.) routes. Kow and molar lethality data were log-transformed for correlation and regression analyses. Median ratios (rat oral LD50/trout LC50 = 156, rat/trout oral LD50 = 0.80, rat/trout dermal LD50 = 0.43, rat/trout i.p. LD50 = 0.55) demonstrated the effect of similar versus dissimilar exposure routes on lethality, reflecting toxicokinetic differences. Simple linear regressions revealed significant correlations (Bonferroni P < 0.05) for trout LC50 versus rat oral LD50 and for trout LD50 versus rat LD50 when matched on exposure route. When Kow was included with multiple regression to consider the effect of hydrophilic/lipophilic partitioning on uptake and toxicity, correlations improved only for trout LC50 versus rat oral LD50 and for trout i.p. LD50 versus rat i.p. LD50. Stratification of data into pesticides and nonpesticides failed to refine prediction of trout LC50 from rat oral LD50. Simple regressions reported here and in the literature relating fish LC50 and rat oral LD50 exhibited varying degrees of correlation (r = 0.26-0.99), reflecting differences in interspecies sensitivity, chemical group evaluated, and experimental methodologies.
Randomised controlled trial of combined diphtheria, tetanus, whole-cell pertussis vaccine administered in the same syringe and separately with Haemophilus influenzae type b vaccine at two, three and four months of age.
An open randomised controlled multicentre study compared the immunogenicity and reactogenicity of three vaccines given by injection at two, three and four months of age. Children (89) received Haemophilus influenzae type b (Hib) vaccine (SmithKline Beecham Biologicals [SB]) administered in the same syringe with combined diphtheria-tetanus-whole-cell pertussis (DTPw) vaccine (Evans); 75 received Hib vaccine (SB) administered as a separate injection with DTPw vaccine; 66 received Hib vaccine (Pasteur Merieux [PM]) administered as a separate injection with DTPw vaccine. All subjects in both groups receiving Hib (SB) vaccine had levels of antibodies to the Hib polysaccharide polyribosylribitol phosphate (PRP) greater than 0.15 microgram ml-1 as did 97% of those receiving Hib (PM) vaccine 1 month after administration of the final vaccine dose. Subjects in all three groups demonstrated an immunological response to pertussis, diphtheria and tetanus antigens. The geometric mean titres of the group given Hib (SB) and DTPw vaccine mixed in the same syringe were lower than the other groups. There were no apparent differences between the treatment groups in the incidence of local or systemic reactions, or serious adverse events. This study has confirmed that it is possible to halve the number of injections necessary to offer protection, with advantages to parents, children, doctors and nurses, using a combined DTPwHib vaccine and in accordance with the UK's accelerated primary immunisation schedule at two, three and four months of age.
Dementia care. How nurses rate.
The aim of this qualitative research was to invite home carers to share their perceptions of the quality of nursing care they witnessed their relative with dementia receive, when he or she was admitted to an acute care setting for an acute illness episode or other health related concern. Twenty participants were recruited through the local Alzheimer's Support Groups and newspapers. Biographical data were collected relating to the carer's and relative's age, gender, nature of relationship, date of Alzheimer's diagnosis, period of domiciliary care, and existing psychosocial and economic support systems. Each carer was interviewed for about one hour, to allow sufficient time for recollection of memories of hospitalisations within the previous 12 months. The semistructured interviews were audiotaped for verbatim transcription. Computer-assisted thematic analysis identified themes and sub-themes regarding aspects of nursing care that home carers witnessed with which they were pleased and not pleased. Based on the home carers' accounts recommendations were made for nurses relating to improving the care of people with dementia in acute care settings.
The role of dispositional and situational factors in cognitive interference.
Two studies investigated the cross-temporal stability and cross-situational consistency of cognitive interference. In Study 1, 70 college students reported on the intrusive thoughts they experienced during 2 course examinations and a self-reflective task. In Study 2, 55 college athletes reported on intrusive thoughts following 2 course examinations and 2 regular season football games. Major findings were (a) cognitive interference showed both cross-temporal stability and cross-situational consistency, (b) it was predicted by a measure of dispositional intrusive thinking, (c) the link between cognitive interference and dispositional intrusive thinking was not accounted for by indices of depressive symptomatology and trait anxiety, and (d) the degree of cross-situational consistency of cognitive interference and the content of these intrusive thoughts were influenced by situational factors.
Astrocytic mitochondrial respiratory chain damage: effect on cellular ATP levels.
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Carotid endarterectomy among Medicare beneficiaries: a statewide evaluation of appropriateness and outcome.
BACKGROUND AND PURPOSE: We sought to examine the appropriateness and the surgical outcomes of carotid endarterectomy (CE) in unselected community hospitals to identify opportunities for improvement. METHODS: We performed a retrospective review of all CEs performed on Medicare beneficiaries in Georgia in 1993 (n = 1945). Conclusions regarding appropriateness were based on current guidelines as interpreted by a physician reviewer and were supported by the aggregate results of structured, blinded overreading by clinicians with relevant expertise. Adverse outcomes were confirmed and rated as to severity by a physician. Outcomes were correlated with demography, vascular anatomic findings, comorbidity, surgical techniques, and hospital characteristics. RESULTS: The majority of the patients (51%) were asymptomatic at presentation. CEs were performed appropriately in 96.1% of the cases in accordance with current guidelines. There was no significant difference in the rate of appropriateness between the symptomatic (96%) and the asymptomatic patients (96.4%). Survival without stroke or myocardial infarction (MI) was 94.3%. The 30-day mortality was 1.9%; moderate to severe strokes occurred in 1.8%, stroke-related death in 0.7%, MI in 1.1%, and MI-related death in 0.5%. Those hospitals performing <10 CEs in the observed year had a statistically significant higher morbidity and mortality as well as an increase in less severe complications such as hematomas, wound dehiscence, wound infection, and pneumonia than did hospitals with higher volume of CEs.. Older patients and women had statistically significantly higher morbidity and mortality. Patients with a Charlson Severity Index score of > or =1 had a risk for adverse outcomes 3.4 times higher than patients with a score of 0 after adjustment for age and sex. CONCLUSIONS: The great majority of CEs performed in Georgia on Medicare patients were appropriate, according to current guidelines. Slightly more than half of the patients were asymptomatic as defined in the Asymptomatic Carotid Atherosclerosis Study. In hospitals performing <CEs in the index year, we noted higher morbidity and mortality, as well as an increase in less severe complications. This relationship between the volume of surgery and outcome was confirmed in the analysis of the 30-day mortality for all Medicare cases (n = 10,569) performed in Georgia from 1991 to 1995. This was the most important opportunity for improvement identified in this study. In view of the increased use of CE, it is important to continue to monitor the patterns of practice for this procedure to improve outcomes.
Sexual functioning in ambulatory men with HIV/AIDS.
Sexual functioning is often neglected in the care of HIV-infected patients. Little information exists about the relationship between hormonal factors, psychological factors, medication, HIV disease stage and sexual functioning among persons with HIV disease. In this study, 50 HIV+ men completed the Derogatis Sexual Functioning Inventory (DSFI), and had serum hormonal assays drawn (testosterone, thyroid function test, leuteinizing hormone, prolactin and oestradiol). Although all the subjects reported some degree of sexual dysfunction, persons with symptomatic HIV/AIDS reported more negative mood, lower sexual satisfaction scores and worse body image than persons with asymptomatic HIV. Persons with asymptomatic HIV also tended to have normal testosterone levels compared with persons with symptomatic HIV/AIDS. No relationship was found between medications and low testosterone, although numbers were small. These results suggest that sexual dysfunction is prevalent among persons with HIV disease, is more common as patients become symptomatic and progress to AIDS and that both physiological (low testosterone) and psychological issues play a role.
On humanity in nursing.
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Reflections on the possibilities of holistic nursing.
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Does AIDS impair the absorption of antituberculosis agents?
SETTING: Case reports of low serum concentrations of antituberculosis drugs, with resultant treatment failure and emergence of drug-resistant organisms in patients with the acquired immune-deficiency syndrome (AIDS), have prompted suggestions that therapeutic drug monitoring (TDM) may be indicated in patients co-infected with the human immunodeficiency virus (HIV) and Mycobacterium tuberculosis. OBJECTIVE: To test whether the bioavailability of antituberculosis drugs is altered in HIV-infected patients with tuberculosis. METHOD: Twenty-seven hospitalized tuberculosis patients (13 with AIDS, 14 HIV-negative) were entered into a pharmacokinetic trial. Following the supervised administration of standardized doses of isoniazid, rifampicin and pyrazinamide, the plasma concentrations of the drugs were measured repeatedly over 12 hours and the following parameters were derived for each agent: maximum measured drug concentration (Cmax), time-to-maximum measured drug concentration (Tmax) and area-under-the-concentration-time curve to 12 hours (AUC). RESULTS: No significant differences emerged between the two groups in Cmax, Tmax, and AUC for isoniazid and pyrazinamide. For rifampicin the AIDS patients showed a greater AUC (P < 0.01) than the controls, but there were no significant differences in Cmax and Tmax. CONCLUSION: There was no evidence that HIV infection reduced the plasma concentrations of antituberculosis drugs.
Homozygous inactivation of the NF1 gene in bone marrow cells from children with neurofibromatosis type 1 and malignant myeloid disorders.
BACKGROUND: The risk of malignant myeloid disorders in young children with neurofibromatosis type 1 is 200 to 500 times the normal risk. The gene for neurofibromatosis type 1 (NF1) encodes neurofibromin, a protein that negatively regulates signals transduced by Ras proteins. Genetic and biochemical data support the hypothesis that NF1 functions as a tumor-suppressor gene in immature myeloid cells, but inactivation of both NF1 alleles has not been demonstrated in leukemic cells from patients with neurofibromatosis type 1. METHODS: Using an in vitro transcription and translation system, we screened bone marrow samples from 18 children with neurofibromatosis type 1 and myeloid disorders for NF1 mutations that cause a truncated protein. Mutations were confirmed by direct sequencing of genomic DNA from the patients, and from their affected parents, in cases of familial neurofibromatosis type 1. RESULTS: Specimens from 9 of the 18 children contained abnormal peptide fragments, and truncating mutations of the NF1 gene were found in specimens from 8 of these children. The normal NF1 allele was absent in bone marrow samples from five of the eight children. We detected the same mutation in DNA from the affected parent of each child with familial neurofibromatosis type 1. CONCLUSIONS: Both alleles of the NF1 gene are inactivated in leukemic cells in some patients with neurofibromatosis type 1. NF1 appears to function as a tumor-suppressor gene in immature myeloid cells.
Guidelines for conducting economic outcomes studies for endoscopic procedures.
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