Biomedical subjects
Publications and source records attributed to J Adams.
A case vignette of out-of-hospital refusal of emergency care is reported with accompanying discussion. This case illustrates the challenges faced by out-of-hospital emergency care personnel in these scenarios and provides guidance to the emergency physician and emergency medical technician. Recommendations are provided for preparing the emergency medical services system to handle these cases.
Establishment of nursing centers is one of the most important and most exciting trends in the profession of nursing. Nurse practitioners have been taking the lead in the management and staffing of nursing centers. The purpose of this study was to provide a description and an analysis of an academic nursing center. Through a series of observations and interviews, an interdisciplinary team investigated the history and organizational development of the center; the everyday delivery of services; staffing; and participants' assessment of the efficiency and quality of its services and recommendations for improving the services provided in the examined nursing center.
A volunteer sample of 158 aerobics instructors, 46 competitors, and 102 general participants completed 2 assessments of exercise dependence, the Negative Addiction Scale and the Commitment to Running Scale. Pearson rs showed scores on the measures related significantly for the total sample (.33), the participants (.35), and the instructors (.36), but the correlation of .23 for scores of competitors was not significant. Although scores on the two scales were significantly correlated, each test accounted for less than 11% of the variance for the total sample. While there is some commonality, these instruments largely measure different qualities and care should be taken when comparing "exercise dependence" across samples if assessed by different tests.
Forty-nine patients with posterior tibial tendon dysfunction (4 patients had bilateral involvement) were treated with orthoses. Forty feet were treated with molded ankle-foot orthoses, and 13 feet were treated with University of California Biomechanics Laboratory shoe inserts with medial posting. A total of 37 women and 12 men were included in the study. The mean follow-up period was 20.3 months (range, 8-60 months). The average age of the patients was 66 years (range, 42-89 years). Sixty-seven percent of patients had good to excellent results, according to a functional scoring system based on pain, function, use of assistive device, distance of ambulation, and patient satisfaction. The average period of orthosis use was 14.9 months (range, 1.5-29 months), with an average length of daily orthosis wear of 12.3 hours. One patient elected to undergo surgical treatment rather than continuing with long-term orthosis use. Thirty-three percent of patients had discontinued using the orthosis at the time of follow-up evaluation. Three patients were unable to wear the orthosis because of concurrent medical conditions. Nine patients stopped wearing the orthosis after experiencing discomfort and inconvenience. Although these patients continued to exhibit signs and symptoms of posterior tibial tendon dysfunction, they were not disabled enough to consider further treatment. Four patients tolerated orthosis treatment poorly and were treated surgically. Patients with posterior tibial tendon dysfunction can be treated by aggressive nonoperative management using molded ankle-foot orthoses or University of California Biomechanics Laboratory shoe inserts with medial posting. Surgical treatment can be reserved for patients who fail to respond to an adequate trial of brace treatment. Nonoperative management using an orthosis is particularly useful for elderly patients with a sedentary lifestyle or for patients at high risk because of medical problems.
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Home care teams caring for people with AIDS often must depend on informal caregivers to help their patients. If the informal caregivers have better tools to help, patients are more likely to get the best care possible. This training program for care partners is a perfect way to provide those tools.
Molecular modeling analysis of the recently published X-ray crystal structure of nevirapine bound to wild type human immunodeficiency virus type 1 reverse transcriptase (WT-RT) indicated the presence of a lipophilic cavity proximal to the 4-position of the inhibitor. A series of 4-substituted derivatives of nevirapine were thus synthesized to assess structure-activity relationships (SARs) and to see if increased binding to this region might translate into greater activity against mutant RTs. The results show that compounds with an appropriately spaced aryl ring appended to the 4-position of the dipyridodiazepinone ring system show good activity against WT-RT. Furthermore certain derivatives appear to inhibit the Y181C mutant RT. Attempts to combine these results with the recent discovery that 2-substituents enhance activity against the Y181C mutant led to a few compounds with moderate activity against both enzymes. The SAR of these two positions, however, could not be combined in a simple fashion.
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Previous studies have found lower mortality rates for AIDS-related Pneumocystis carinii pneumonia (PCP) in hospitals with higher levels of experience with PCP. It is not known if patients are selectively referred to better hospitals or if there is a learning curve whereby outcomes improve as physicians gain experience in treating PCP. We assessed cases of PCP at 140 Veterans Administration (VA) Medical Centers in the United States. During 1987-1991, 3,981 patients were hospitalized with first-episode AIDS-related PCP. Mortality at 30 days after admission. For these 3,981 hospitalizations at the 140 study hospitals, the 30-day mortality was 19%. Logistic regression models indicate that older age, race, geographic area, earlier year of treatment, hospitalization in the previous 12 months, and lower levels of hospital experience with AIDS were significant predictors of mortality at 30 days after admission. Compared with hospitals that had treated three cases or fewer of first-episode PCP, the odds of mortality at 30 days at hospitals that treated > 50 cases of first-episode PCP were 0.73 (95% confidence interval 0.58-0.91), after controlling for differences in characteristics of the patients, year, and region. Mortality of patients with AIDS-related PCP decreases as VA hospitals gain experience. Longitudinal analyses over a 5-year period suggest that a learning curve best explains this finding.
Our objective was to estimate the saving of life by thrombolysis and resuscitation in acute myocardial infarction (AMI) before and after hospital admission. We studied all 1516 patients admitted to a Scottish teaching hospital in 1990 and 1992 who had a final diagnosis of AMI, and 311 patients enrolled in the Grampian region early anistreplase trial (GREAT). Cardiac arrest occurred in 250/1516 (16%) hospital patients. Of these, 77 (31%) were discharged alive--a saving of 51 lives per thousand cases. 797 (53%) patients received thrombolysis, of whom 114 (14%) died. Assuming the same relative reduction in mortality as in the second international study of infarct survival (ISIS-2; 23%), 34 lives were saved by thrombolytic therapy, representing 22 lives per thousand cases. Of 311 patients in GREAT, 15 (5%) had prehospital cardiac arrest, with 7 patients surviving to discharge (48%)--a saving of 23 lives per thousand cases. Those patients given domiciliary thrombolysis had a one month mortality of 6.7% (11/163) compared with 12.2% (18/148) for those receiving hospital thrombolysis--a saving of 55 lives per thousand cases for prehospital thrombolysis. This is additional to 28 lives per thousand estimated for thrombolytic therapy in hospital, totalling 83 lives saved per thousand cases of AMI receiving thrombolytic therapy prehospital. In hospital, more lives were saved by resuscitation than by thrombolytic therapy, but this ratio was reversed in the period before hospital admission. These results emphasise the paramount importance of resuscitation in hospital, and the enhanced efficacy of thrombolysis when given at the earliest opportunity.
Measurements of the proximal femur by dual X-ray absorptiometry (DXA) are assuming increasing importance in clinical and epidemiological studies. However, different DXA manufacturers have adopted varying approaches to measuring the femoral neck and trochanter regions with the result that there is as yet no agreement on normal ranges and how to cross-calibrate between different machines. In this Concerted Action (of the EU's 2nd Framework Programme), 12 clinical centers in eight countries recruited a total of 855 female and 517 male Caucasian subjects who were judged to be free of conditions known to cause secondary osteoporosis and who had not been treated with drugs known to affect bone mass. The DXA machines used were made by Hologic, Lunar, and Norland. Each machine was cross-calibrated with the European Spine Phantom prototype designed by Kalender. All femoral neck and trochanter results were expressed as standardized values and were first examined for possible bias due to between-brand differences in choice of areas for measurement. On average, trochanter areas were similar between brands but Norland chose a narrower neck region for analysis. Bone mineral density (BMA or BMD g/cm2) was log-normally distributed for all groups at the femoral neck but normally distributed at the trochanter in men and postmenopausal women. There were substantial between-center differences after cross-calibration in age-adjusted mean values at both sites and also in the rates of apparent bone loss with age and the amounts of scatter within populations about mean age-adjusted values. With the proviso that locally derived normal ranges would allow more accurate comparisons for clinical purposes, European normal ranges were derived for both neck and trochanter. Data obtained with the three individual brands of machine fitted these overall ranges well. Bone loss was apparent in premenopausal women at the femoral neck but not the trochanter. Postmenopausal women's data was somewhat better fitted by reference to years since menopause than to chronological age. This work provides a basis for conducting future epidemiological and clinical studies with more than one brand of machine as long as each individual subject, if measured consecutively, is measured on the same machine throughout.
The role of ascorbate in the production and secretion of procollagen by human intestinal smooth muscle cells and the conditions in culture for optimal ascorbate bioefficacy were studied. Procollagen synthesis and secretion were determined by the incubation of cells with L-[5-3H]proline, and the quantitation of radiolabelled procollagen bands in the cell layer and the culture medium by polyacrylamide slab gel electrophoresis and densitometry. When cells were cultured without ascorbate in the culture medium, procollagen secretion into the medium was 75% less than in cells receiving fresh ascorbate daily. In the cell layer, in contrast, procollagen accumulation was fourfold greater in the scorbutic cells than in the ascorbate-replete cells. These findings contrasted with those in a control line of scorbutic human dermal fibroblasts in which a 95% decrease in procollagen secretion was not associated with any procollagen accumulation in the cells. In the intestinal smooth muscle cells, the absence of ascorbate resulted in a 25 and 50% decrease in steady-state levels of procollagen I and III mRNA, respectively, compared to a 40 and 75% decrease in fibroblasts. Heat inactivation of the serum in the culture medium augmented the promotion of procollagen secretion by ascorbate two- to fourfold. L-ascorbate phosphate did not increase the activity of L-ascorbate when replaced in medium either daily or every 4 days, and its efficacy was not augmented by serum heat inactivation. The changing of culture medium induced collagen secretion in the absence of ascorbate, but this process was markedly enhanced by ascorbate and induced a transient decrease in the steady-state levels of both procollagen and nonprocollagen mRNAs. The predominant action of L-ascorbate on HISM cells in vitro is to promote procollagen secretion and not procollagen synthesis. L-ascorbate-phosphate is not an adequate substitute for L-ascorbate in this cell line.
Up to now it has not been possible to reliably cross-calibrate dual-energy X-ray absorptiometry (DXA) densitometry equipment made by different manufacturers so that a measurement made on an individual subject can be expressed in the units used with a different type of machine. Manufacturers have adopted various procedures for edge detection and calibration, producing various normal ranges which are specific to each individual manufacturer's brand of machine. In this study we have used the recently described European Spine Phantom (ESP, prototype version), which contains three semi-anthropomorphic "vertebrae" of different densities made of stimulated cortical and trabecular bone, to calibrate a range of DXA densitometers and quantitative computed tomography (QCT) equipment used in the measurement of trabecular bone density of the lumbar vertebrae. Three brands of QCT equipment and three brands of DXA equipment were assessed. Repeat measurements were made to assess machine stability. With the large majority of machines which proved stable, mean values were obtained for the measured low, medium and high density vertebrae respectively. In the case of the QCT equipment these means were for the trabecular bone density, and in the case of the DXA equipment for vertebral body bone density in the posteroanterior projection. All DXA machines overestimated the projected area of the vertebral bodies by incorporating variable amounts of transverse process. In general, the QCT equipment gave measured values which were close to the specified values for trabecular density, but there were substantial differences from the specified values in the results provided by the three DXA brands. For the QCT and Norland DXA machines (posteroanterior view), the relationships between specified densities and observed densities were found to be linear, whereas for the other DXA equipment (posteroanterior view), slightly curvilinear, exponential fits were found to be necessary to fit the plots of observed versus specified densities. From these plots, individual calibration equations were derived for each machine studied. For optimal cross-calibration, it was found to be necessary to use an individual calibration equation for each machine. This study has shown that it is possible to cross-calibrate DXA as well as QCT equipment for the measurement of axial bone density. This will be of considerable benefit for large-scale epidemiological studies as well as for multi-site clinical studies depending on bone densitometry.
BACKGROUND & AIMS: Collagen synthesis by smooth muscle cells plays an important role in intestinal fibrosis. Corticosteroids inhibit collagen synthesis in fibroblasts. The aim of this study was to examine the effect of corticosteroids on the expression of collagen by human intestinal smooth muscle (HISM) cells in vitro. METHODS: Collagen synthesis was determined by the sensitivity of radiolabeled protein to collagenase. Secretion was determined by polyacrylamide gel electrophoresis of radiolabeled procollagen in the medium. Procollagen messenger RNA was determined by Northern blot analysis. RESULTS: Collagen synthesis by confluent HISM cells was not affected by corticosteroids at 10(-10) to 10(-5) mol/L but, in subconfluent cultures, was nonspecifically increased 50% at 10(-5) mol/L. Procollagen secretion was nonspecifically increased 60% at 10(-6) mol/L dexamethasone without any effect on the type III/I ratio. Procollagen I and III messenger RNA levels responded in a biphasic manner: a 45%-65% increase at 10(-10) mol/L and a 15% and 30% decrease at 10(-8) and 10(-6) mol/L. In fibroblasts, collagen synthesis was inhibited 85% by dexamethasone, procollagen secretion was decreased 70%, the type III/I ratio decreased from 70:1 to 18:1, and procollagen messenger RNA was inhibited 25% and 60% (types I and III). CONCLUSIONS: Collagen expression by HISM cells is refractory to corticosteroids and, at certain concentrations, is augmented.
There have been few studies that have examined emotional, behavioral, and physical symptoms that discriminate between well-defined groups of sexually abused and nonabused children. This study examined the results of a structured parent interview (SASA) completed on three matched samples of prepubescent females: 68 who were selected for nonabuse (NA Group), 68 from a sexual abuse clinic in which a perpetrator confessed (SA Group) and 68 seen at the same clinic who did not have a perpetrator confession (AA Group). Parents of girls in both the SA and AA groups reported increased sleep problems, fearfulness, emotional and behavioral changes, concentration problems, and sexual curiosity and knowledge. When contrasting the known (SA) with the allegedly abused sample (AA), self-consciousness, nightmares, and fearfulness of being left alone emerged significantly more frequently in the SA sample.
This study examined the prevalence and clinical correlates of sexually inappropriate behaviors in all youth treated at a tertiary care public sector psychiatric hospital over a 5-year period. A retrospective chart review was completed on 499 subjects. Subjects were grouped in four mutually exclusive categories: no inappropriate sexual behaviors (n = 296), hypersexual (n = 82), exposing (n = 39) and victimizing (n = 82) behaviors. Those with histories of sexually inappropriate behaviors had much higher rates of being sexually abused (82 vs. 36%), and also had higher rates of physical abuse and neglect, behavior disorders, developmental problems, and family histories of antisocial behavior. They were less likely to have affective disorders. The hypersexual group had a higher proportion of females, and was associated in part with variables relating to sexual abuse and posttraumatic stress disorder. The more severe offending groups (exposing and victimizing) were associated with variables related to sexual abuse, developmental delays, lower IQ's, peer problems, and other acting-out behavior problems. These findings underscore the importance of evaluating for sexually inappropriate behaviors in seriously mentally ill youth, especially in those with histories of sexual abuse.
OBJECTIVE: In this study we examined demographic, social, and clinical variables related to sexual abuse histories in a sample of severely mentally ill youth. METHOD: Data were collected via a retrospective chart review of all patients treated over a 5-year period (1987-1992) at a tertiary care public sector psychiatric hospital. The sample was divided into four groups: no history of sexual abuse (n = 226); isolated events (n = 62); intermittent abuse (n = 61); and chronic (n = 150). RESULTS: Youth with sexual abuse histories were more often female, had higher rates of social chaos and associated physical abuse and neglect, and had higher rates of post-traumatic stress disorder (PTSD) and substance abuse disorders. Chronically abused subjects came from the most chaotic and abusive backgrounds; were younger when first abused; had the highest number of abusers; were more likely to have been molested; and were more often abused by their father/stepfather and/or their mother/stepmother. Using logistic regression analyses, sexual abuse histories were predicted by sexually inappropriate behaviors, symptoms of PTSD and borderline personality disorders, dissociative symptoms, substance abuse and animal cruelty. CONCLUSION: Sexual abuse histories were quite common in this sample. Sexually abused subjects had increased rates of inappropriate sexual behaviors, substance abuse, and post-traumatic reactions; and were frequently exposed to other confounding environmental risk factors, including physical abuse, family problems and social chaos.