Liquid-chromatographic measurement of purine nucleotides in blood cells

In this anion-exchange "high-performance" liquid-chromatographic method of analysis for purine nucleotides, the nucleotides are separated with high efficiency and selectivity on a weak anion exchanger (Hypersil APS 2, 3-micron particle size) by elution with a gradient of eluent pH and concentration. Applying this method to analysis for these compounds in human blood cells, we determined them in a patient with adenosine deaminase deficiency who was treated with a bone-marrow transplantation, finding that the transplantation did not entirely correct the patient's abnormalities of purine metabolism.     

Prognostic evaluation of primary non-small cell lung carcinoma patients using biological fluid variables. A systematic review

We have systematically reviewed the biomedical literature to try to establish whether laboratory variables might give any additional prognostic information in non-small-cell lung cancer (NSCLC) patients independently of the usual radioclinical parameters. In each study, we acknowledged the independent prognostic value of a biological fluid variable if it had been demonstrated through a multivariate statistical analysis in which at least the following had been included: patient's weight loss, age, gender, performance status, histology, stage and extent of the disease. The clearest conclusion that can be derived from the 42 studies we reviewed is that it remains to be clearly demonstrated whether or not the "new" tests (tumour markers, p53 antibodies, etc.) are superior to the "old" tests (serum LDH, calcium, albumin or other proteins, blood cell counts, etc.), even though a number of studies did suggest that serum cyfra 21-1 has a pre-therapeutic prognostic significance in NSCLC. From the four studies in which the same powerful statistical methodologies were used (i.e. Cox models in association with RECPAM analysis), it could be derived that serum calcium and perhaps the blood neutrophil and lymphocyte counts might have independent pre-therapeutic prognostic significance in advanced NSCLC. Further studies are needed to demonstrate whether repeated measurements during therapeutic follow-up can bring any independent prognostic information. Provided that both laboratory and statistical expertise is clearly guaranteed in future primary studies published in this particular biomedical field, it might perhaps become possible to propose laboratory variables as additional prognostic parameters in NSCLC.     

Mehrdimensionale Erfassung der Schmerzwahrnehmung und ihre Bedeutung für das Verhalten chronischer Rückenschmerzpatienten

A consecutive series of 98 patients presenting at an orthopedic outpatient clinic with chronic low back pain of at least 6 months' duration and with no organic findings (ruled out by clinical and radiological examination) were evaluated by means of a questionnaire which included the constructs "patient history," "pain-related restrictions," and "depression." Pain perception was evaluated with an adjective list revealing four main factors: two affective factors, i.e., "suffering from pain" and "anxiety," and two sensory factors, i.e., "acuteness" and "rhythmics of pain." The two affective factors (as against the sensory factors) subsequently influence the degree of pain intensity (measured with a visual analog scale), the patient's history and the patient's perceived impairment of daily life. Depression (von Zerssen scale) correlated with pain factors only when the whole range of pain factors was considered. The implications for treatment in patients with a high score for affective factors in the adjective list (indicator for a low success rate with traditional therapy) are discussed.     

Functional autonomy and use of leisure time by the elderly

The authors evaluate the relationship among the degree of functional autonomy and use of leisure time or activities, including an analysis regarding the influence of a patient's sex. To carry out this evaluation, the study used the "EVA" scale, or the Functional Autonomy Scale of Values, on 43 elderly patients over 65 years of age who receive at least one home visit per month. Among the conclusions of this study, the authors deduce that the degree of functional incapacity bears an influence on the use of spare time without observing any significant relationship as to the patient's sex. The authors make some recommendations as to how to improve the EVA scale.     

Nursing tools and strategies to assess cognition and confusion

Terms used to describe a patient's mental state, such as "confused", are often considered to be ambiguous and the meaning personal to individuals describing what they observe. Cognitive deficits are often subtle in their presentation and can easily be overlooked in the arena of acute nursing, with its focus on physical status. Clinicians are reported as not adequately assessing cognitive status and yet such deficits may impact on a patient's activities of living at all levels. Identification of alternations in a patient's mental status is important in maintaining patient safety and dignity. This article aims to review bedside assessment of a patient's mental status and the implications for nursing practice.     

The patient experience of treatment for hepatitis C.

This study has used qualitative hermeneutics to explore the patient's experience of treatment for hepatitis C. Hepatitis C treatment may pose numerous physical and emotional challenges. There is a need to understand the experience from a holistic nursing perspective in order to facilitate the patient's well-being. Individuals undergoing combination treatment for hepatitis C participated in a hermeneutic dialogue, which provided the investigators with an emic perspective. Dialogue content, reflection, and preunderstanding were hermeneutically analyzed. Similar treatment experiences elicited four common emotions (sadness, anger, fear, and frustration). Analyzing the similar experiences led to two emerging themes: (1) "That is not who I am," connoted by rejecting the notion of being a "typical" patient, seeing treatment as not so bad, being "different" during treatment, and feeling abandoned because of treatment; and (2) "looking beyond the experience" was noted by looking for faith beyond traditional healthcare and looking for understanding. The hepatitis C treatment experience was seen as a process: having a start, a middle, and an end, without being all-consuming. Implications for holistic nursing care are presented.     

The first consultation

The first time patient consultation with a psychiatrics nurse is the first step in a patient's therapeutic procedure when he/she consults a mental health center. Obviously, its importance is based on three aspects: 1. the reception and initial aid provided to a patient, 2. determining the degree of the patient's needs and recording pertinent information in a clinical file which will allow for better planning of successive treatment, 3. in a diagnosis of a patient's problems and selecting the most opportune nursing care plan. We wish to place special stress on those problems and treatments which we refer to as "intra-consultation" and which enable better communication and patient confidence with respect to successive ongoing treatment and "extra-consultation" care; these features are those precise ones which make first time patient consultation a nurse's activity. This study refers to 500 consultations which occurred during 1996-97 under the auspices of a general study of basic nursing care plans.     

Patients (getting themselves) referred to psychosomatic rehabilitation--guidelines for sociomedical evaluation and management of extrinsically motivated patients

This paper reflects the thinking, experience as well as diagnostic and therapeutic strategies of the Gelderland specialized clinic for psychotherapy and psychosomatic medicine with regard to extrinsically motivated patients, i.e., patients "sent" for treatment. The objective is to develop a therapeutic concept and to establish guidelines concerning the sociomedical aspects to be taken into account in this patient group. The problem analysis should start out at the situation at hand initially: Not only do these patients as a rule refuse to take an active part in therapy; they all to often attempt to sabotage any rehabilitation offers perceived as running counter to their own desires and goals (e.g. pension, retraining, collection of benefits during illness-related unemployment, etc.). Attempts to elucidate the psychosomatic problem complex of these patients are in addition hampered by their predominantly body-centred concept of disease. The particular motivational and therapy-related features of these patients are illustrated by case studies. A standardized procedure for sociomedical performance appraisals is presented which takes the specific features of this patient group into account and has stood the test in the clinical setting. Special mention should be made of: pre-admission diagnostics, inpatient psychodiagnostics, multidisciplinary systematic behavioural observation of the patient in the framework of group therapy, and a sensitive approach to conveying diagnostic results to the patient. The double role of psychotherapist and appointed expert is one demanding the highest degree of professional expertise. Besides, the expectations of the social security and financially responsible agencies which "sent" the client have to be taken into account as well. The sociomedical evaluation serves as the starting point for all therapeutic efforts and identification of the extent of a patient's extrinsic motivation. Along with a thorough review of the patient's medical records, pre-admission diagnostic efforts are in place in this respect for assessing a patient's motivation for therapy.     

Caregiver thoughts and feelings in response to different perspective-taking prompts

Both conceptual and empirical evidence in the caregiving literature suggest that "how" informal caregivers are prompted to think about patient experiences can impact their ability to achieve perceptual agreement with patients on symptom events. Researchers have begun to test the effects of different clinical questions with caregivers or a proxy on their perceptual agreement with patient self-reports. However, there are gaps in understanding caregivers' underlying thoughts and feelings when they are prompted to take different vantage points on the patient's symptom experiences. To assess these thoughts and feelings, content analysis was performed on verbal responses to an open-ended interview schedule, in which caregivers were questioned about their thoughts and feelings in one of three randomly assigned instructional conditions-neutral, imagine-patient, and imagine-self perspective-taking. Responses were classified into one of five cue categories: patient-oriented, caregiver-oriented, generalized other, feeling distanced, and other. Caregivers tended to respond to patient symptom experiences in ways that suggest it is innate for caregivers in intimate relationships to make an effort to imagine the patient's viewpoint on symptom events. When caregivers were prompted to imagine the patient's perspective, "labeling" processes were also triggered that denote a categorization process in which caregivers interpreted the meaning of simple patient information arising in the care situation. A large portion of caregivers in the neutral and imagine-patient conditions reported feeling distanced from patients in light of perceived communication difficulties.     

Emergency screening for ethylene glycol in serum

We have exploited the "interference" of ethylene glycol in the Du Pont aca triglyceride method to develop a convenient and rapid screening method for detecting ethylene glycol in serum. Pretreatment of patient's serum with lipase, glycerol kinase, and other cofactors usually added for triglyceride analysis removes triglycerides and glycerol, but not ethylene glycol, from the sample. The aca triglyceride method may then be used to estimate the ethylene glycol concentration in serum.     

Endogenous insulin-like growth factor (IGF) binding proteins cause IGF-1 resistance in cultured fibroblasts from a patient with short stature.

The ED50 of insulin-like growth factor (IGF)-I-stimulated alpha-aminoisobutyric acid (AIB) uptake (mean +/- SD) in cultured fibroblasts from a child with short stature that we have reported (1.40 +/- 0.24 nM), is significantly higher than the ED50 of IGF-I-stimulated AIB uptake in fibroblasts from 11 normal subjects (0.42 +/- 0.12 nM) and from 127 short children (0.35 +/- 0.11 nM). Similarly, the ED50 of IGF-I-stimulated thymidine incorporation in fibroblasts from this child is 2.8 times higher than that in fibroblasts from four normal subjects. To minimize potential modulation of IGF-I action by endogenous IGF binding proteins in these assays, fibroblast responsiveness to [Q3,A4,Y15,L16]IGF-I, an IGF-I variant that has a 600-fold reduced affinity for serum IGF binding proteins, has been examined. The biological activity of this variant is comparable in the patient's and normal fibroblasts, suggesting that the resistance to IGF-I action cannot be attributed to a defective IGF-I receptor. To investigate directly the possibility that IGF-I sensitivity in the patient's fibroblasts is reduced by endogenous IGF binding proteins (IGFBP), binding proteins that are secreted into AIB assay buffer during a 3-h collection and that are cell-associated at the end of the collection have been analyzed. Ligand blot analysis of conditioned AIB assay buffer demonstrates that fibroblasts from the patient secrete 1.3-2.2 times more of Mr 46,400/42,900, 32,000, and 26,800 binding proteins than normal fibroblasts. The major difference between fibroblasts from the patient and from normal subjects is a striking 10-fold increase in the amount of a cell surface Mr 32,000 binding protein in the patient's fibroblasts. The Mr 32,000 binding protein is similar in size to IGFB-1 and different from IGFBP-2 and IGFBP-3, but it does not cross-react with an antibody against IGFBP-1. We conclude that the resistance to IGF-I action in the patient's fibroblasts is caused by an abnormal production and/or cell association of IGF binding proteins.     

Peculiarities and complexities of questioning the patient in myocardial infarct]

The author depicted several cases of myocardial infarction which onset or preinfarction angina symptoms were taken by the patients for a catarrhal disease. The signs enabling the doctor to exclude the "catarrhal" origin of patient's feelings were indicated. The author suggested that the term of "catarrhal" variant of myocardial infarction onset" should be used as a pattern of its atypical onset.     

Treatment of hypothermia in trauma victims: thermodynamic considerations

The relatively high specific heat of the human body makes hypothermia very difficult to treat. Although there are many treatment methods available, most evaluations of rewarming techniques are based on clinically observed rewarming rates, and they do not take into account initial core temperature, ambient temperature, the patient's own heat production, the effects of anesthesia, paralytic agents, and other variables. A heat transfer model is proposed that simulates the flow of heat through the body of a hypothermic patient. The model uses first principles involved in heat transfer and thermodynamics to describe the effects of currently available rewarming techniques. A commercially available routine is used to solve the equations, which also include any heat exchange between the patient's body and the environment, as well as metabolic heat generation as a function of time and core temperature. This thermodynamic analysis of rewarming, based on computer modeling of heat transfer, provides a scientific basis on which to establish guidelines for appropriate selection of treatment strategies for hypothermia, and it indicates that direct blood warming or infusion of warm intravenous fluids are the most effective rewarming techniques.     

Patient-practitioner perceptions: can chiropractors assume congruence?

BACKGROUND: Advances in mind-body medicine have resulted in the realization that beliefs can modulate pathophysiologic processes. Because symbolic interaction affects health status, perceptions and the congruence between the perceptions of chiropractors and their patients become a relevant clinical consideration. OBJECTIVE: A case study to explore the congruence of health-relevant perceptions of chiropractors and their patients was undertaken. METHOD: This Australian case study was undertaken to explore the concurrence of patient-practitioner perceptions with respect to the patient's stress levels, the importance of injury as a causative factor in the presenting symptom and the responsibility the patient should take "in getting themselves well." Purposive sampling of practitioners and convenience sampling of patients was undertaken. Data were collected by means of a patient questionnaire and a practitioner questionnaire and interview. Data were analyzed to determine the congruence of patient-practitioner perceptions within each of 173 consultations. RESULTS: A total of 9 practitioners and 173 patients participated. Within each patient-practitioner dyad, congruence of perceptions was <50% in each of 3 dimensions examined. Most patients believed they should take a high level of responsibility for "getting well." DISCUSSION: Although the results of a case study cannot be extrapolated to the chiropractic patient population, this study does suggest that it may be prudent for chiropractors to ascertain the extent to which their patients share their perceptions of the presenting clinical problem. "Thinking hats" are proposed as a helpful perception management tool. CONCLUSION: This exploratory study suggests that practitioners should not assume that their patients share their perceptions. Given that each patient-practitioner encounter is unique, it may be prudent for chiropractors to actively ascertain the patient's opinions. A patient's perception of his or her responsibility for "getting well" should be harnessed in developing management plans with high compliance.     

Phlebitis in children

The authors' objectives are to determine the occurrence of phlebitis in patients hospitalized in the General Pediatrics Unit and to define the possible factors associated to its development. The authors carried out a prospective study in the "Sant Joan de Deu" Hospital in Barcelona during the month of July and from the 15th of September until the 15th of October in 2002. A one variant and two variant analysis using the chi squared method as the basis for estimating which associations took place. There were 153 patients admitted having 201 peripheral veins canalized; occurrence of phlebitis was 8.4%; a venous cord (53%) was the most frequent clinical sign. In cases of phlebitis, the back of a patient's hands (64.7%) was the main spot to make an insertion using a 22G "Vasocán" catheter (70.6%). Phlebitis appeared 2 days after insertion; the high number of antibiotics administered increased the risk of phlebitis (p>0.05). Conclusion: Phlebitis is a frequent problem in pediatrics patients having endo-venous treatment, susceptible to prevention by means of the implementation of control measures and a program of continuous vigilance.     

Primary care physician and patient factors that result in patients seeking emergency care in a hospital setting: the patient's perspective.

Much has been written about "abuse" and "overutilization" of Emergency Departments (EDs). We undertook to study, from the patient's perspective, physician and patient factors that influence the patient's decision to seek ED care. The study was designed as a convenience cohort, multi-centre survey, conducted in 13 hospitals in the Greater Toronto Area. In our study group of 948, most ambulatory patients (93%) seeking care in an ED have a primary care physician. From the patient's perspective, most (76%) primary care physicians are not educating their patients about which situations warrant ED care and up to 54% are not informing their patients about which services are offered in the office. As many as 55% of patients presented to the ED because it was more convenient. Only a minority (23%) of patients felt their acuity of illness warranted an ED visit. Primary care physicians need to play a stronger role in educating their patients about the utilization of emergency care and the services offered in the office setting.     

Evidenced-based nursing: knowledge, performance and learning in nursing care

As part of the nursing process, nurses choose an academically secured intervention in response to a patient's problem, implement it and evaluate it. "Evidence based" describes a learning and working method which has the advantage of being applied in real, professional problem situations. Not only the learner but also the professional nurse can improve their competencies for professional acting. Following the problem- and motivation orientated approach of Roth (1983), the implicit learning steps of this method can be illustrated. The implementation of evidence-based nursing can raise high expectations. However, there are also critical aspects connected to it that need further exploration.     

An evaluation of the detection capacity of a computer-assisted real-time delta check system.

We developed of computer programs to evaluate the clinical reliability of test results by comparing each new result with previous results for the same patient, and to signal discrepancies in real time. These "delta check" discrepancies are noted, and they must be reviewed by the laboratory staff before results can appear on a patient's record. During a month, I reviewed 1403 such delta check messages and detected 55 (3.9%) that could not be explained on the basis of the patient's clinical condition. Of these, 23 represented true laboratory errors, which were corrected. The recognition of discrepancies before they appear on patients' reports has facilitated the operation of the clinical chemistry laboratory. Mislabeled and otherwise mishandled specimens are discovered before erroneous results appear on a patient's record.     

Insulin autoimmune syndrome associated with benign monoclonal gammopathy. Evidence for monoclonal insulin autoantibodies

A 64-yr-old man with benign monoclonal gammopathy developed recurrent episodes of severe hypoglycemia but lacked evidence of insulinoma or exogenous insulin administration. The patient's plasma was found to contain anti-insulin antibodies and large amounts of extractable insulin (1110 microU/ml), which was identified as human insulin by high-performance liquid chromatography (HPLC). The anti-insulin antibodies consisted solely of IgG and lambda-light chains. Scatchard analysis of these antibodies revealed an almost straight-line relationship, with markedly low affinity and high capacity. An immune complex made of 125I-labeled insulin and the patient's antibodies emerged in a molecular-sieve HPLC as almost a single peak, suggesting a homogeneous antibody population. In addition, the patient's M protein was separately shown to be the IgG and lambda-light-chain type. We suggest that the insulin autoantibodies responsible for the spontaneous hypoglycemia in this patient are monoclonal and of M protein origin.     

Mechanisms of action of cognitive therapy: The relative contributions of technical and interpersonal interventions

The contributions of changes in cognitions (degree of belief in automatic thoughts) and the patient's relationship with his therapist to mood changes occurring during sessions of cognitive therapy were examined in data collected from 17 depressed and anxious patients. Results showed that both changes in automatic thoughts and the patient's relationship with his therapist made independent, additive contributions to mood changes. In addition, two patient characteristics (initial degree of belief in automatic thoughts and diagnosis) made significant unique contributions to mood changes. The stronger the patient's initial belief in his automatic thoughts, the smaller the mood change occurring in the session. Smaller mood changes also occurred in patients with a personality disorder diagnosis. These results suggest that mood changes in cognitive therapy sessions are a function of three types of factors: technical cognitive therapy interventions, the patient's relationship with his/her therapist, and patient characteristics. A multiple regression model with independent variables measuring these factors accounted for 89% of the variance in mood change in the session.We thank our patients for their generous contributions. Anna Rose Childress and Juli Kinchla contributed to the inception of the study. We thank Jeffrey M. Perloff for advice concerning the statistical analysis. Jonathan Baron, Susan Krantz, Ricardo Muõz, S. Lloyd Williams, and the anonymous reviewers gave helpful comments on an earlier draft. This paper was presented at a meeting of the Society for Psychotherapy Research, Lake Louise, Canada, June 1984.