Biomedical subjects
Publications and source records attributed to D Walsh.
This report describes our experience in the use of bioelectrical impedance analysis (BIA) as a method of nutritional assessment in a cancer patient with ascites. The BIA was an unreliable measure of body composition in this setting.
OBJECTIVES: To validate a specific enzyme-linked immunosorbent assay for the rapid-acting human insulin analogue, insulin aspart, in human serum, human plasma, and porcine plasma. DESIGN AND METHODS: For the enzyme-linked immunosorbent assay, two murine monoclonal antibodies were developed that bind to two different epitopes on the insulin aspart molecule. Key parameters for validation were imprecision, accuracy, matrix effects, dilution-linearity, and cross-reactivity. RESULTS: No cross-reactivity was found with human and porcine insulin, human proinsulin, or human C-peptide. The assay is sensitive (limit of quantification = 11.5 pmol/L), accurate (95-107% recovery with human serum, human plasma, and porcine plasma in the range 16-800 pmol/L), and has a 14.7% total imprecision within the entire analytical range. Dilution of samples gave linear results with human serum as the diluent. CONCLUSIONS: The insulin aspart-specific enzyme-linked immunosorbent assay described in this study is well suited to study the bioavailability, bioequivalence, and pharmacokinetics of this insulin analogue.
There has been growing interest in the United States in postgraduate training in palliative medicine. In order for this to proceed in an organized fashion, educational standards need to be developed. We must define what our knowledge base is and what we require of a specialty-trained individual. This article reports the development of the first fellowship program in the United States, with the goal of encouraging further discussion and ultimately obtaining specialty recognition.
BACKGROUND: This paper focuses on the long-term course of social disability in schizophrenia assessed at first onset, and after 1, 2 and 15 years in incidence cohorts in six European centres in Bulgaria, Germany, Ireland, The Netherlands, the Czech Republic and the United Kingdom. The study population comprises 349 patients comprising 75% of the original cohorts. METHODS: Social disability was assessed in a standardized way with the WHO Disability Assessment Schedule. RESULTS: Social disability in schizophrenia appears to be a persistent phenomenon. Its severity decreased overall in the period of follow-up, but this was not so in a small group traced to hospital or sheltered accommodation. Only 17% of subjects had no disability and 24% still suffered from severe disability. The great majority lived with their family, a partner, or alone. A deteriorating course was more frequent than late improvement. Gender, age, onset, duration of untreated psychosis or type of remission during the first 2 years did not predict the long-term outcome of disability. Severity of disability at the first three assessments of the illness contributed significantly to the explanation of its variance at 15 years. CONCLUSION: Disability generally ameliorates, but less than expected or hoped. It needs continuing attention and care in this era of de-institutionalization.
In population exposure studies, personal exposure to PM is typically measured as a 12- to 24-hr integrated mass concentration. To better understand short-term variation in personal PM exposure, continuous (1-min averaging time) nephelometers were worn by 15 participants as part of two U.S. Environmental Protection Agency (EPA) longitudinal PM exposure studies conducted in Baltimore County, MD, and Fresno, CA. Participants also wore inertial impactor samplers (24-hr integrated filter samples) and recorded their daily activities in 15-min intervals. In Baltimore, the nephelometers correlated well (R2 = 0.66) with the PM2.5 impactors. Time-series plots of personal nephelometer data showed each participant's PM exposure to consist of a series of peaks of relatively short duration. Activities corresponding to a significant instrument response included cooking, outdoor activities, transportation, laundry, cleaning, shopping, gardening, moving between microenvironments, and removing/putting on the instrument. On average, 63-66% of the daily PM exposure occurred indoors at home (about 2/3 of which occurred during waking hours), primarily due to the large amount of time spent in that location (an average of 72-77%). Although not a reference method for measuring mass concentration, the nephelometer did help identify PM sources and the relative contribution of those sources to an individual's personal exposure.
Two collaborative studies have been conducted by the U.S. Environmental Protection Agency (EPA) National Exposure Research Laboratory (NERL) and National Health and Environmental Effects Research Laboratory to determine personal exposures and physiological responses to particulate matter (PM) of elderly persons living in a retirement facility in Fresno, CA. Measurements of PM and other criteria air pollutants were made inside selected individual residences within the retirement facility and at a central outdoor site on the premises. In addition, personal PM exposure monitoring was conducted for a subset of the participants, and ambient PM monitoring data were available for comparison from the NERL PM research monitoring platform in central Fresno. Both a winter (February 1-28, 1999) and a spring (April 19-May 16, 1999) study were completed so that seasonal effects could be evaluated. During the spring study, a more robust personal exposure component was added, as well as a more detailed evaluation of physical factors, such as air-exchange rate, that are known to influence the penetration of particles into the indoor environment. In this paper, comparisons are made among measured personal PM exposures and PM mass concentrations measured at the NERL Fresno Platform site, outside on the premises of the retirement facility, and inside selected residential apartments at the facility during the two 28-day study periods. The arithmetic daily mean personal PM2.5 exposure during the winter study period was 13.3 micrograms/m3, compared with 9.7, 20.5, and 21.7 micrograms/m3 for daily mean overall apartment, outdoor, and ambient (i.e., platform) concentrations, respectively. The daily mean personal PM2.5 exposure during the spring study period was 11.1 micrograms/m3, compared with 8.0, 10.1, and 8.6 micrograms/m3 for the daily mean apartment, outdoor, and ambient concentrations, respectively.
BACKGROUND: Record linkage of routine hospital data to population-based research findings presents an opportunity to explore the relationships between classical risk factors and hospital activity. METHODS: The objectives of this study were to examine, in Paisley and Renfrew, the effect of risk factor variables on the likelihood of experiencing an acute hospital admission with six major medical conditions. The subjects were 8,349 women and 7,057 men, aged 45-64 in the early to mid-1970s. The main outcome measures were acute hospital admission with principal diagnosis of: any malignant neoplasm; malignant neoplasm of trachea, bronchus and lung; ischaemic heart disease; respiratory disease; cerebrovascular disease; or diabetes mellitus. RESULTS: Smokers were almost eight times more likely to be admitted with lung cancer and, to a lesser extent, were more likely to be admitted for the other conditions investigated with the exception of diabetes mellitus. Forced expiratory volume was also an independent risk factor for admission with lung cancer and strokes. Higher levels of cholesterol were associated with increased risk of admission with ischaemic heart disease but less with cancer (including lung cancer). With the exception of admissions for cerebrovascular disease, deprivation category was found to have no independent effect on the likelihood of experiencing any of the morbidity outcomes examined. CONCLUSIONS: These data confirm that associations first established between risk factors and mortality outcomes (e.g. smoking and lung cancer) are also found between risk factors and hospital admissions for the same causes. This in itself is unremarkable, but the results are of interest for three reasons. First, they illustrate the potential of record linkage to map the effects of risk factors. Second, they demonstrate the size of the effect risk factors have on the risk of admission. Third, they provide a surprising finding that deprivation category does not act as an independent risk factor for the majority of the categories of admission investigated.
OBJECTIVE: Schizophrenia is clinically heterogeneous. Recent linkage studies suggest that multiple genes are important in the etiology of schizophrenia. The authors examined the hypothesis of whether the clinical variability in schizophrenia is due to genetic heterogeneity. METHOD: Using data from the Irish Study of High-Density Schizophrenia Families (N=265 pedigrees; N=1,408 individuals), the authors attempted to predict, from major symptoms and signs of psychosis, evidence for linkage within families for schizophrenia-related disorders to chromosomal regions 5q21-5q31, 6p24-6p22, 8p22-8p21, and 10p15-10p11. RESULTS: No substantial evidence was found for associations between clinical features of schizophrenia and linkage to chromosomes 5q, 6p, or 10p. However, affected individuals from families with evidence for linkage to 8p had significantly more affective deterioration, poorer outcome, more thought disorder, and fewer depressive symptoms than affected individuals from the other families in the study. CONCLUSIONS: These results raise the possibility that the putative susceptibility gene for schizophrenia localized in the 8p22-8p21 region may predispose individuals to the core dementia-praecox syndrome described by Kraepelin more than 100 years ago.
OBJECTIVE: The deficit syndrome is a subtype of schizophrenia characterized by primary and enduring negative features of psychopathology. It appears to reflect a distinct subtype within the syndrome of schizophrenia. Little is known about the familial or genetic aspects of the deficit syndrome. The purpose of this study was to determine whether deficit versus nondeficit subtypes are correlated in sibling pairs affected with schizophrenia. METHOD: The present study was based on the Irish Study of High-Density Schizophrenia Families. From the earlier study the authors selected a subset of patients who were members of sibling pairs in which both siblings had been diagnosed with "core" schizophrenia, which included schizophrenia, simple schizophrenia, and schizoaffective disorder with poor outcome. The Schedule for the Deficit Syndrome was used to make deficit versus nondeficit diagnoses, which were based on chart examinations by reviewers blind to sibling status. This method resulted in 65 patients being diagnosed with the deficit syndrome and 401 patients diagnosed as nondeficit (prevalence=13.9%). This group included 347 full sibling pairs, which were analyzed for resemblance with respect to deficit versus nondeficit subtype by means of logistic regression. RESULTS: Deficit versus nondeficit subtypes were significantly correlated in sibling pairs concordant for core schizophrenia. CONCLUSIONS: Familial factors contribute significantly to whether a person has the deficit subtype of schizophrenia. This familial contribution could be genetic or environmental.
BACKGROUND: Several reports postulate that manic depression and schizophrenia share environmental risk factors. Although obstetric adversity has been suggested as a risk factor for schizophrenia, few studies have examined its relationship to bipolar affective disorder. AIMS: To assess the rate of obstetric complications incurred by patients with mania compared with controls. METHOD: From the Dublin Psychiatric Case Register we identified individuals with a discharge diagnosis of mania and traced their birth records. Each case was matched with a control of the same gender, born in the same hospital, in the same year, matched for maternal age, parity and social class. Two obstetric complications scales were used to make blind evaluations of labour and delivery data. RESULTS: Patients with mania did not experience a greater frequency or severity of labour and delivery complications than their matched controls. Rates of obstetric adversity were unrelated to the presence or absence of family history of psychiatric disorder. Obstetric adversity was unrelated to the age at first diagnosis. CONCLUSIONS: These findings suggest that obstetric adversity is not a risk factor for later mania.
BACKGROUND: Controversy continues regarding an association between obstetric complications and risk of schizophrenia in early adult life. AIMS: To compare the rate of labour and delivery complications among persons who developed schizophrenia with controls; to establish whether any complication is associated with later schizophrenia. METHOD: We located the labour ward records of 431 individuals with schizophrenia and of same-gender controls from the same hospital birth series. Mothers were matched by age, socio-economic group and parity. Individual complications were evaluated blindly using two obstetric complication scales. RESULTS: Overall, the rate of labour and delivery complications for those who developed schizophrenia did not differ from that of controls. Males who had presented to psychiatric services before the age of 30 had a greater frequency of and more severe labour/delivery complications than their matched controls. CONCLUSIONS: Other than among young-onset males we found no increase in labour and delivery complications among cases.
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The health care industry is changing and nursing case management is an integral part of restructured care in many institutions. Health care organizations must evaluate services and outcomes. The terminally ill comprise a large portion of patients in any health care delivery system. Hospitals that provide formal cancer care services need to evaluate where palliative care and hospice fit. Shifts in patient care will be evident due to changes in demographics, payor initiatives, and technological advances. Providing care for patients with advanced disease and the role of nursing have evolved over the past 10 years. One important area that has not changed is the passion and caring evident in the nurse's everyday practice.
This chapter will outline a general approach to symptom assessment, using the interdisciplinary approach to pain as a model. Due to the implications of cognitive impairment for treatment compliance, consent, and caregiver burden, assessment of cognitive function will be reviewed in detail. Problem areas in assessment are identified, along with aids to improve assessment and emphasize the key contribution of the nurse. We will also focus on measurement issues from both clinical and research perspectives.
The relief of physical and psychological symptoms is an essential part of palliative care. Advanced cancer is an acute process; because the clinical picture changes rapidly, symptoms must be reassessed regularly, and a careful history is essential. Defining the relationship of the symptoms to the disease can defuse fear and encourage a sense of control in patients and their families. We review the pathophysiology, causes, prevalence, consequence, and management of common symptoms in advanced cancer.
Complications due to cancer and its treatment are common and increase in incidence and severity as the disease progresses. Central nervous system complications affect 15% to 20% of patients, and up to 75% have bone metastases at some point during the disease process. Endocrine abnormalities include hypercalcemia, adrenal insufficiency, and inappropriate antidiuretic syndrome. Hematologic disorders, malignant effusions, and gastrointestinal (GI) problems may cause significant morbidity.
Given modern techniques of pain assessment and management, it is now possible to be optimistic about cancer pain control. Assessment of cancer pain must include information about the site(s) of pain, pathophysiology, pain severity, and quantification of analgesic responses. Correct diagnosis of common pain patterns including breakthrough and incident pain are essential. The principles of analgesic use are well defined. The concept of rescue dosing in safe analgesic titration and management of breakthrough/incident pain is a key concept. Individualization of opioid dosing is important and this is facilitated by a number of dosing strategies. Choice of specific opioid is often less important than correct dosing, as side effects are similar among the commonly prescribed drugs. Anticipations and management of common side effects improve the therapeutic index. Alternate routes of administration are important, usually because of loss of the oral route of administration. Misunderstandings about opioids are common and patient and family education paramount. Adjuvant analgesics are necessary for good pain control, but have important differences in indications, usage, and side effects compared with opioids. First-rate pain management is a basic professional and humanitarian responsibility of the skilled clinical oncologist.