Autoamplification of NFATc1 expression determines its essential role in bone homeostasis

NFATc1 and NFATc2 are functionally redundant in the immune system, but it was suggested that NFATc1 is required exclusively for differentiation of osteoclasts in the skeletal system. Here we provide genetic evidence that NFATc1 is essential for osteoclast differentiation in vivo by adoptive transfer of NFATc1^−/− hematopoietic stem cells to osteoclast-deficient Fos^−/− mice, and by Fos^−/− blastocyst complementation, thus avoiding the embryonic lethality of NFATc1^−/− mice. However, in vitro osteoclastogenesis in NFATc1-deficient cells was rescued by ectopic expression of NFATc2. The discrepancy between the in vivo essential role of NFATc1 and the in vitro effect of NFATc2 was attributed to selective autoregulation of the NFATc1 gene by NFAT through its promoter region. This suggested that an epigenetic mechanism contributes to the essential function of NFATc1 in cell lineage commitment. Thus, this study establishes that NFATc1 represents a potential therapeutic target for bone disease and reveals a mechanism that underlies the essential role of NFATc1 in bone homeostasis.     

Section 136, The Mental Health Act 1983; levels of knowledge among accident and emergency doctors,senior nurses,and police constables

Objectives: Section 136 of the Mental Health Act 1983 empowers the police to detain those suspected of being mentally ill in public places, and convey them to a place of safety. In practice, accident and emergency (A&E) departments are often used. The authors assessed levels of knowledge of section 136 between A&E doctors, senior nurses, and police constables.

Methods: Doctors and senior nurses in all (A&E) departments in the Yorkshire region were asked to complete a multiple choice tick box type questionnaire, as were police constables from the Humberside Police Force.

Results: 179 completed questionnaires were returned, of which 16 were completed by consultants, 14 by SpRs, 24 by SHOs, 33 by senior nurses, and 92 by police officers. Some 24.1% of A&E staff and 10.9% of police failed to recognise that a person has to appear to be suffering from a mental disorder to be placed on a section 136; 40.2% of police did not know that section 136 is a police power; 55.2% of A&E staff and 14.1% of police incorrectly thought that a person could be placed on a section 136 in their own home; 43.75% of consultants and 50% of SpRs did not consider A&E departments to be a place of safety; 49.4% of A&E staff and 29.3% of police thought that patients could be transferred on a section 136. Only 10.3% of A&E staff and 22.8% of police had received any formal training.

Conclusions: The knowledge among A&E staff and the police of this difficult and complex piece of mental health legislation is poor and requires action through formal education and training. This study not only reflects the levels of knowledge within the groups, it may also reflect the different perceptions of each group as to their role and duties within section 136 of the Mental Health Act 1983.

     

Suppression of Helicobacter pylori infection during intensive care stay: Related to stress ulcer bleeding incidence?

Purpose: To assess the prevalence of active Helicobacter pylori infection in patients admitted to the intensive care unit, to determine the effect of selective gut decontamination on the persistence of this organism, and to explore the possible relationship between H. pylori infection and stress ulcer bleeding incidence. Materials and Methods: We determined in a prospective observational study of 300 consecutive, mechanically ventilated patients the activity of H. pylori infection and the incidence of stress ulcer–related upper gastrointestinal bleeding over time. H. pylori infection was detected by Laser-Assisted Ratio Analyzer (LARA)- ¹³C-urea breath test (Alimenterics, Inc., NJ) and serology. Stress ulcer prophylaxis was not prescribed. Endoscopy was performed in cases of upper gastrointestinal bleeding. Results: The prevalence of active H. pylori infection on admission was 38% as detected by urea breath test, and declined to 8% on the third day, and to 0% on the seventh day after admission as a result of antibiotic treatment. Stress ulcer–related upper gastrointestinal bleeding occurred in 1.0% (3 of 300) of the patients; none were infected with H. pylori on admission or at the time of bleeding. Conclusions: H. pylori infection monitored by LARA- ¹³C-urea breath test was rapidly suppressed during intensive care treatment, which can be explained by the routine use of antibiotics for gut decontamination.The low incidence of stress ulcer–related bleeding might be related to the prevention of H. pylori–associated stress lesions by effective suppression of this microorganism, but further studies are warranted to test this hypothesis. Copyright © 2002 by W.B. Saunders Company     

Ultrasound therapy effect in carpal tunnel syndrome

Objective: To investigate the overall effect of repeated ultrasound treatment in carpal tunnel syndrome (CTS).Design: Patient-blinded, placebo-controlled, before-after treatment trial.Setting: University hospital PM&R department outpatient clinic and neurology department electromyography laboratory.Patients: Eighteen women with diagnosis of CTS in 30 hands.Interventions: Three groups, each with 10 cases of CTS, were randomly established. Continuous ultrasound therapy, with intensities of 1.5W/cm² (group A), 0.8W/cm² (group B), and 0.0W/cm² (group C), was applied to palmar carpal tunnel area for 5 minutes, 5 days a week, for 2 weeks.Outcome Measures: Patients were evaluated clinically and electrophysiologically before and after the treatment.Results: At the end of treatment, statistically significant improvement was obtained in clinical parameters in all groups: pain (p < .05), pain/paresthesia at night/day (p < .05), and frequency of awakening at night (p < .05). Although there was no statistically significant before-after difference in electrophysiologic studies, slightly decreased motor nerve conduction velocity and increased motor distal latency were noted in groups A and B, but not in group C.Conclusion: Ultrasound therapy in CTS was comparable to placebo ultrasound in providing symptomatic relief, and the probability of a negative effect on motor nerve conduction needs to be considered.     

Prehospital use of paracetamol among children attending the accident and emergency department

Methods: A prospective cohort study of carers of children attending a paediatric accident and emergency (A&E) department. Carers of children completed a questionnaire to identify domestic patterns of paracetamol use. Data were collected on temperature of the child in the A&E department, administration of antipyretics in the A&E department, diagnosis, and disposal from the A&E department.

Results: Seventy five adults attending the A&E department consented to involvement. Sixty five of the children were feverish on arrival in the A&E department. Twenty one children (32.3%) had not received paracetamol before attending. There was a significant relation between knowledge of the antipyretic properties of paracetamol and administration (χ²=5.0, p<0.05). There was a significant correlation between fever and administration of paracetamol in the A&E department (χ²=23.7, p<0.01), however, 15 feverish patients (24.6%) were not treated.

Conclusions: Most carers administer paracetamol appropriately in the prehospital setting. Administration correlates significantly with knowledge of its benefits. There is scope for education of carers and A&E department staff in the in the appropriate use of antipyretics such as paracetamol.

     

Use of,and outputs from,an assault patient questionnaire within accident and emergency departments on Merseyside

Objectives: To describe the implementation, use of, and outputs from an assault patient questionnaire (APQ) introduced in accident and emergency (A&E) departments to determine Crime & Disorder and Community Safety priorities on Merseyside, a metropolitan county in north west England, UK.

Methods: Why and how the APQ was implemented, data collected, and information obtained. The subsequent incorporation of the APQ into the Torex Patient Administration System (PAS) at the Royal Liverpool University Hospital A&E department and its routine completion by trained reception staff.

Results: Analysis is based upon anonymised data—for example, patient ID and date of birth information is suppressed. A summary of "baseline" information obtained from the data collected is provided.

Conclusions: It is possible for the APQ to be implemented at no extra cost in a large A&E department in an acute general teaching hospital. Valuable intelligence can be obtained for Crime & Disorder Act and Community Safety processes. The APQ forms part of a medium to long term strategy to prevent and reduce violent assaults in the community that subsequently require treatment in an A&E department. Such incidents include assaults both inside and outside licensed premises, attacks by strangers on the street, and domestic violence. Emphasis is also placed upon the feedback of results to staff in A&E departments.

     

A general method of Bayesian estimation for parametric imaging of the brain

We report a general method of Bayesian estimation that uses prior measurements to improve the signal-to-noise ratio of parametric images computed from dynamic PET scanning. In our method, the ordinary weighted least squares cost function is augmented by a penalty term to yield , where C is a PET concentration history and Ω_C is its variance, f is the model of the concentration history, K = [k₁,k₂,…,k_m]^T is the parameter vector, is the vector of population means for the model parameters, Ω_K is its covariance, Φ_K(K,S = 0) is the conventional weighted sum of squares. S > 0 is chosen to control the balance between the prior and new data. Data from a prior population of subjects are analyzed with standard methods to provide maps of the mean parameter values and their variances. As an example of this approach we used the dynamic image data of 10 normal subjects who had previously been studied with ¹¹C-raclopride to estimate the prior distribution. The dynamic data were transformed to stereotactic coordinates and analyzed by standard methods. The resulting parametric maps were used to compute the voxel-wise sample statistics. Then the cohort of priors was analyzed as a function of S, using nonlinear least squares estimation and the cost function shown above. As S is increased the standard error in estimating BP in single subjects was substantially reduced allowing measurement in BP in thalamus, cortex, brain stem, etc. Additional studies demonstrate that a range of S values exist for which the bias is not excessive, even when parameter values differ markedly from the sample mean. This method can be used with any kinetic model so long as it is possible to compute a map of a priori mean parameters and their variances.     

Importance of emergency identification schemes

Objective: To establish awareness and credibility of emergency identification schemes among emergency personnel and to assess if information on specific medical conditions would influence ambulance personnel regarding destination hospitals.

Methods: Questionnaires were sent to senior staff (n=380) of accident and emergency (A&E) departments and operational directors of ambulance headquarters (n=39) throughout the United Kingdom. Hospitals were divided into regional divisions to assess differences in responses across regions.

Results: The majority of respondents (99%) had heard of emergency identification schemes and felt that it was important for patients with special conditions to carry some form of identification. Nearly all ambulance respondents (97%) indicated it was routine to search for body worn emblems in contrast with only 71% of A & E staff. However, more than half of ambulance respondents (53.9%) stated information on emblems/cards would not influence their choice of destination hospital.

Conclusions: The importance of how information on pre-existing medical conditions can influence care, is highlighted by the BSCC valve issue, where immediate diagnosis is essential for patient survival. It is vital that all staff routinely search patients for this information and if necessary act upon the information provided.

     

Are health professionals getting caught in the crossfire? The personal implications of caring for trauma victims

Objectives: To investigate the long term psychological sequelae of treating multiple victims of traumatic incidents, such as violent crime and motor vehicle accidents, and to assess staff exposure to violent patients in the emergency department.

Methods: A self administered questionnaire booklet was distributed to all full time and part time staff working within the Johannesburg Hospital Trauma Unit during September 2002. Participation was voluntary. The questionnaire was specifically designed for the study as no relevant, validated questionnaire was found to be suitable. Psychological assessment comprised two standardised measures, the impact of event scale-revised and the Maslach burnout inventory.

Results: Thirty eight staff members completed the questionnaire, a response rate of 90%. Over 40% of respondents had been physically assaulted while at work and over 90% had been verbally abused. Staff reported a significant level of post-traumatic symptoms, evaluated by the impact of event scale-revised (median = 17.5, range = 0–88), as a result of critical incidents they had been involved in during the previous six months. At least half of the respondents also reported a "high" degree of professional burnout in the three sub-scales of the Maslach burnout tnventory—that is emotional exhaustion, depersonalisation, and personal accomplishment.

Conclusions: Preventative measures, such as increased availability of formal psychological support, should be considered by all trauma units to protect the long term emotional wellbeing of their staff.

     

Use of out of hours services: a comparison between two organisations

Background: Increasing numbers of self referrals at the accident and emergency (A&E) department cause overcrowding, while a substantial number of these patients exhibit minor injuries that can be treated by a general practitioner (GP).

Methods: Two different organisations of out of hours care in two Dutch cities (Heerlen and Maastricht) were investigated. Important differences between the two organisations are the accessibility and the location of primary care facility (GP cooperative). The Heerlen GP cooperative is situated in the centre of the city and is respectively 5 km and 9 km away from the two A&E departments situated in the area of Heerlen. This GP cooperative can only be visited by appointment. The Maastricht GP cooperative has free access and is located within the local A&E department. During a three week period all registration forms of patient contacts with out of hours care (GP cooperative and A&E department) were collected and with respect to the primary care patients a random sample of one third was analysed.

Results: For the Heerlen and Maastricht GP cooperative the annual contact rate, as extrapolated from our data, per 1000 inhabitants per year is 238 and 279 respectively (χ²_(1df)=4.385, p=0.036). The contact rate at the A&E departments of Heerlen (n=66) and Maastricht (n=52) is not different (χ²_(1df)=1.765, p=0.184). Some 51.7% of the patients attending the A&E department in Heerlen during out of hours were self referred, compared with 15.9% in Maastricht (χ²_(1df)=203.13, p<0.001).

Conclusions: The organisation of out of hours care in Maastricht has optimised the GP's gatekeeper function and thereby led to fewer self referrals at the A&E department, compared with Heerlen.

     

Pathological crying and laughing: Treatment with sertraline

Objective: To evaluate the efficacy of sertraline for treating pathological laughing and crying after stroke.Design: Case series.Setting: Inpatient rehabilitation units of a community and a tertiary-care hospital.Patients: One patient was a 62-year-old right-handed man who had two strokes approximately 2 years apart and had computed tomography consistent with a cerebral infarct involving the left middle cerebral artery branches in the left parietal lobe. A second patient was a 72-year-old right-handed man who had a right middle cerebral artery infarct. He had a questionable history of depression prior to the stroke.Intervention: Both patients had poststroke labile affect that was interfering with their rehabilitation. Sertraline was prescribed.Main Outcome Measures: Pretreatment and posttreatment scores on the Pathological Crying and Laughing Scale and Functional Independent Measure.Results: Both patients showed significant improvement after taking sertraline—improvement that was reflected in their pretreatment and posttreatment scores on the Pathological Crying and Laughing Scale and Functional Independent Measure. The staff noted improvements in sleeping, eating, social interaction, and therapy participation. Both patients tolerated the sertraline well and had no significant side effects.     

Use of peak Doppler gradient across ventricular septal defects leads to underestimation of right-sided pressures in patients with “sloped” Doppler signals

In patients with “sloped” appearance of the Doppler signal across a ventricular septal defect (VSD), the peak Doppler velocity seems to overestimate the catheterization-derived peak-to-peak gradient, resulting in underestimation of right-sided heart pressures. In 11 patients with sloped Doppler signals across the VSD, ventricular pressure tracings were compared with simultaneous recordings of the Doppler signal. The average peak Doppler gradient (40.2 ± 19.2 mm Hg) overestimated the catheterization-derived peak-to-peak gradient (20.2 ± 13.6 mm Hg) significantly (P ≤ .001). Doppler mean gradient (20.2 ± 11.3 mm Hg; P = ns) and end-systolic gradient (17.0 ± 12.5 mm Hg; P ≤ .05) were closer estimates of the catheterization peak-to-peak gradient. All Doppler gradients showed good correlation to the catheterization peak-to-peak gradient with r² values of 0.77, 0.73, and 0.91. We conclude that Doppler mean or end-systolic gradients should be used for calculation of right-sided heart pressures in this patient population. (J Am Soc Echocardiogr 2001;14:1197-202.)     

Anti-Trichomonas vaginalis activity of synthetic lipophilic diamine and amino alcohol derivatives

Taking in account the increased prevalence of metronidazole-resistant infections, alternative drugs are necessary for the treatment of trichomonosis. We report in this work the preparation and the in vitro anti-trichomonads activity of two diamines 1 and 2, and three different lipophilic amino alcohol derivatives 3, 4 and 5. These compounds were tested for in vitro activity against two isolates of Trichomonas vaginalis and displayed inhibition of the parasite growth. Five concentrations of each compound were tested. The butanediamine derivative 1, at a final concentration of 5.85 μM, presented a cytotoxic effect against 47% of T. vaginalis trophozoites. Furthermore, the cytotoxicity of 1 did not present statistically significant difference when compared to metronidazole in the same range of concentration (0.1–1.5 μg/mL).     

Recognizing Excellence in Nursing Service: A First-hand Report From an ED Manager at a Magnet Hospital in Boston

Ms. Hughes is not alone in her praise of the Magnet Recognition Program:

“They (Magnet hospitals) foster respect and caring for the individual (patients and staff.) and actively bring out the best in people.”

¹

“These hospitals have been cited as cultures of excellence, the measure of goodness, and the ‘gold standard’ in nursing.”

²

“Magnet hospitals are infused with values of quality care, nurse autonomy, informal, nonrigid verbal communication, innovation, bringing out the best in each individual, and striving for excellence.”

³

“Magnet hospitals…consistently provide the highest quality of care.”

⁴

The staff realized that what they were showcasing was special as they saw it through the eyes of outsiders.

Colleen Goode, RN, PhD, is Vice President for patient services at the University of Colorado Hospital in Denver. After receiving their Magnet designation in January 2002, Dr Goode explained, “This is one of the highest achievements a hospital can attain in the nursing world. Magnet status recognizes the caliber of the nursing staff, and what that professionalism translates into in terms of patient care and health care services. I am extremely proud of our nurses and our growing reputation as a first-rate hospital.”¹In explaining why the Program was developed, the American Nurse Credentialing Center states: “Recognizing quality patient care and nursing excellence, the Magnet Recognition Program provides consumers with the ultimate benchmark to measure the quality of care that they can expect to receive. As a natural outcome of this, the program elevates the reputation and standards of the nursing profession.”¹All of this positive evidence as to the value of the Magnet Recognition Program leads one to exclaim, “It's about time! Finally, finally a program which recognizes and honors the importance of good nursing!”     

The CNO's Role in Professional Transformation at the Point of Care

The CNO has many roles and responsibilities in making possible a transformation to excellence at the intersection where the nurse and patient interact. Without a conscious, evidence-driven approach built from analysis and evidence-based leadership interventions, the flywheel to propel professional practice won't get started. And if the CNO sees herself as a hierarchical figure and views frontline professionals as children who need raising, the transformation to professional practice will not happen. Unless the CNO sees himself as one who serves the front line and values the people at the front lines as partners, the transformation to excellence won't happen. In the words of Florence Nightingale in 1859:¹⁴

“Let whoever is in charge keep this simple question in her headNot how can I always do this right thing myself, butHow can I provide for this right thing to always be done?”

ED staff members’ personal use of complementary therapies and their recommendations to ED patients: A southeastern US regional survey

Background Use of complementary and alternative therapies has increased in the United States during the past 5 years. Little is known about the use of these therapies in emergency departments. Methods The Center for the Study of Complementary and Alternative Therapies, University of Virginia, surveyed staff in 10 emergency departments in the southeast region of the United States with the purpose of exploring ED practitioners’ personal use of complementary therapies and recommendations of these therapies to patients. Results ED staff reported back rub or massage, music, and prayer or spiritual practices as the 3 most frequently used complementary therapies for personal well-being. Back rub or massage and spiritual practices including prayer and group support were most frequently recommended to patients. Clinicians expressed interest in acquiring additional knowledge of complementary therapies and support for integration of these therapies in emergency departments. Conclusions Use of complementary therapies for personal well-being and for patient care by ED staff in the southeast region of the United States is limited. Most ED staff are not familiar with these therapies, but a majority of staff (70%) want to learn more about them. Findings suggest that ED nurses would like additional training in, and better referral patterns to, complementary therapies. (J Emerg Nurs 1998;24:495-9)     

Gadd45β and Gadd45γ are critical for regulating autoimmunity

The number of effector T cells is controlled by proliferation and programmed cell death. Loss of these controls on self-destructive effector T cells may precipitate autoimmunity. Here, we show that two members of the growth arrest and DNA damage-inducible (Gadd45) family, β and γ, are critical in the development of pathogenic effector T cells. CD4⁺ T cells lacking Gadd45β can rapidly expand and invade the central nervous system in response to myelin immunization, provoking an exacerbated and prolonged autoimmune encephalomyelitis in mice. Importantly, mice with compound deficiency in Gadd45β and Gadd45γ spontaneously developed signs of autoimmune lymphoproliferative syndrome and systemic lupus erythematosus. Our findings therefore identify the Gadd45β/Gadd45γ-mediated control of effector autoimmune lymphocytes as an attractive novel target for autoimmune disease therapy.     

Florida’s bicycle helmet law and a bicycle safety educational program: Did they help?

Introduction: This research studied the effectiveness of Florida’s mandatory helmet law for children and a community bicycle safety campaign promoting helmet use. Children’s use of helmets before and after the law’s enactment and the type and extent of head injuries sustained in bicycle crashes were evaluated. Methods: The trauma and medical records from Broward General Medical Center’s Pediatric Referral Trauma Center provided demographic data, injury severity scores, and information on the type and extent of head injuries sustained. Data were compared using independent sample t tests and Pearson χ² statistics with .05 as the significance level. Results: Each group consisted of 72 children, predominantly 7- to 12-year-old boys. Known helmet use rose from 5.6% to 20.8%, with children aged 10 to 12 years having the greatest increase in helmet use (27%). Helmet use rose in urban and suburban areas. Changes in the type and extent of head injuries were mixed. Injury severity scores were higher for nonhelmeted children in the after-law group. Discussion: Although helmet use increased, especially among the 7- to 12-year-olds targeted during the bicycle safety campaigns, bicycle helmet use remains too low, and nonhelmeted children continue to have a higher risk for serious injuries. Community bicycle safety programs that promote helmet use remain an important adjunct to mandatory helmet use laws. (J Emerg Nurs 1999;25:496-500)