Biomedical subjects
Publications and source records attributed to M Cooke.
Despite the misgivings of many members of the veterinary profession, tendering for meat hygiene and other veterinary service contracts is becoming increasingly commonplace. In the article below, Mr Martin Cooke, a member of the BVA Company Services Advisory Committee and a veterinarian with extensive experience of public sector work, gives some advice on preparing and submitting a competitive tender.
Routine human immunodeficiency virus (HIV) antibody screening of umbilical cord blood identifies neonates at risk for HIV infection but may hold risks as well as benefits for infants and mothers. We describe the effect of testing on infant placement and care and report the women's understanding of pretest counseling and consent. In a case-control analysis of 327 tested infants, seropositive infants (13) had a higher rate of discharge to home (62%) than did controls (31%). More case infants (100%) received follow-up care and vaccinations than control infants (46%). Of 32 women interviewed after HIV antibody test informed consent, only 31% understood that a positive cord blood test result was inconclusive for the infant, and most (78%) did not identify any associated socioeconomic risks. Most (88%) stated an interest in learning their serostatus, but only 22% returned for test results. Despite the benefits of HIV antibody testing of at-risk infants, current testing and counseling procedures inadequately inform women, limiting the testing benefits to them.
The care of HIV-infected patients is demanding, raising concerns among health care workers regarding safety, competence, and emotional endurance. Many health care workers are reluctant to undertake this challenging work. For many professions within health care, for example nursing, there is a clearly articulated responsibility to treat all ill individuals. Less unanimity on this point continues among physicians. Clearly, a first issue is to continue the discussion of the nature of physicians' professional responsibilities and to convey an understanding of the duties of physicians to medical students and to those considering careers as doctors. Meanwhile, efforts must continue to recruit individuals in all areas of health care to work with HIV-infected people. To some extent, this process will happen as a natural consequence of the evolution of the epidemic and its decreasing geographic and demographic restriction. "Mainstreaming" AIDS care will also require continuing attention to important issues, such as acquiring and maintaining the requisite professional competence in the management of HIV-related illnesses, ensuring the availability of support services that are required for the comprehensive care of HIV complications, and continuing education on and proactive monitoring of infection control practices. All of these activities assist in the creation of a positive environment for the care of AIDS patients. In addition, the emotional consequences of caring for HIV-infected people should be directly addressed, although there is less information on which strategies are useful. A supportive working environment, characterized by some meaningful element of control by all health care workers not just the medical staff, nonauthoritarian management, explicit and responsive processes for approaching the inevitable ethical dilemmas that arise in the care of HIV-infected patients, and a recognition of the emotional, psychological, and technical aspects of medical care are essential. In such an environment, health care providers will be able to develop and institute programs that address their particular needs. Strategies that have been helpful are diverse and include support groups, rotation of clinical assignments, part-time work, social activities away from the workplace, and collective spiritual activities.
Three selective surveillance methods were compared to a reference method in their ability to detect hospital-acquired infection (HAI) in patients occupying 122 beds of a district general hospital. The time for data collection was also assessed. The selective methods consisted of: (a) ward liaison surveillance (WLS), conferring with nursing staff twice weekly to determine patients with infections; (b) risk factor surveillance (RFS), the follow-up of patients with "clues" that indicated a risk of infection; and (c) laboratory-based ward liaison surveillance (LBWLS), the follow-up of positive microbiology reports by reviewing case records, in addition to conferring with nursing staff. The reference method consisted of total continuous clinical surveillance and the review of laboratory reports. During the 11-month period of the study, the reference method identified 306 HAI in 3,326 patients. LBWLS identified 71%, WLS 58%, and RFS 49% of HAI. The time for data collection (per week) was 7.75 hours for LBWLS, 4.3 hours for WLS, and 7.9 for RFS. In the United Kingdom, LBWLS was concluded to be an effective method of surveillance.
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We investigated decisions to withhold or withdraw life support from patients in the medical-surgical intensive care units at the Moffitt-Long Hospital of the University of California and San Francisco General Hospital, from July 1987 through June 1988. Among 1719 patients admitted to the two intensive care units, life support was withheld from 22 (1 percent) and withdrawn from 93 (5 percent). The reason for limiting care was poor prognosis. Of these 115 patients (18 of whom were considered brain-dead), 89 died in the intensive care unit (accounting for 45 percent of all deaths there), and all but 1 of the remaining patients died after transfer from the intensive care unit. Thirteen (11 percent) had earlier expressed the wish that their terminal care be limited, but this affected care in only four cases. Only 5 of the 115 patients made the actual decision to limit care; the others were incompetent at the time. Of the latter, 102 had families who participated in the decision; family members of the other 8 incompetent patients could not be found, and the decisions were made by physicians. Only 10 families initially disagreed with the recommendations to limit care, and they later agreed. The median duration of intensive care among the patients from whom life support was withheld or withdrawn was eight days at Moffitt-Long Hospital and four days at San Francisco General, as compared with medians of three and one days, respectively, for other patients who died in the intensive care units. We conclude that although life-sustaining care is withheld or withdrawn relatively infrequently from patients in the intensive care unit, such decisions precipitate about half of all deaths in the intensive care units of the hospitals we studied. In most of these cases the patients are incompetent, but physicians and families usually agree to limit care.
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These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from transcriptions, they are prepared by Homer A. Boushey, MD, Professor of Medicine, under the direction of Lloyd H. Smith, Jr, MD, Professor of Medicine and Associate Dean in the School of Medicine. Requests for reprints should be sent to the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, CA 94143.
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Voluntary screening for human immunodeficiency virus (HIV) infection may help prevent the spread of the HIV epidemic if persons who test positive alter behaviors that may transmit infection. Protecting persons from unknowingly being exposed to HIV infection must be balanced against respecting the autonomy of individuals being screened. Seropositive patients may feel a stigma and be subjected to discrimination if confidentiality of test results is breached. In patients without high-risk behaviors, the positive predictive value of HIV testing may be substantially increased if tests are done in reference laboratories and if further confirmatory tests are run on a second blood specimen. For persons with high-risk behaviors, HIV testing can be recommended to those who want to reduce uncertainty about their HIV status or whose medical care would change if they were seropositive. Health care workers can maximize benefits of screening and minimize harm by educating and counseling patients before HIV testing, discussing the confidentiality of HIV test results, urging patients to disclose positive test results to sex partners, and advising patients on how to reduce high-risk behaviors.
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We have isolated a 34-kilobase pair genomic thrombospondin clone and determined the sequence of 2033 base pairs of the 5'-flanking region, the first entirely untranslated exon and the first intron. A number of interesting regulatory motifs were identified. The transcription start site, determined by primer extension and S1 nuclease analysis, was shown to be 20-30 bases 3' of a TATA-like sequence, TTTAAAA. We have also shown that a thrombospondin promoter-bovine growth hormone fusion gene is transcribed in transiently transfected cells. We conclude that the genomic clone contains the transcriptional signals of the thrombospondin gene and will therefore be useful in the analysis of cis-acting elements that regulate the expression of this gene.
We recently surveyed the medical house staff at the University of California, San Francisco, and found that residents had a good understanding of the poor prognosis of patients with the acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia who require intensive care for respiratory failure, and tended to favor early discussions with patients regarding resuscitation and intensive care. We used the same questionnaire to survey the house staffs of four other programs varying in geography and exposure to patients with AIDS. We found a striking correlation between the number of patients with AIDS cared for by the residents, the assessment of the prognosis of patients with AIDS with P carinii pneumonia, and house-staff attitudes toward discussions about resuscitation and intensive care. The results of this study suggest that the intensity of exposure to patients with AIDS determines the assessment of prognosis, and that one or both of these factors strongly influences attitudes toward intensive care. Regardless of these attitudes, early discussion of resuscitation and intensive care between physicians and patients with AIDS and P carinii pneumonia seems warranted.
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