Dementia and the Over-75 Check: the role of the primary care nurse

Primary care nurses are very likely to provide a substantial part of the routine care for patients with dementia. In order to examine the knowledge and attitudes of the primary care nurses who undertake the Over-75 Check, towards assessing and managing patients with symptoms of dementia, and to assess their level of support for a clinical practice guideline, a postal questionnaire survey was undertaken of primary care nurses responsible for the Over-75 Check in 209 general practices in Gloucester, Avon and Somerset. The questionnaire ascertained some demographic information about the nurses, their training and the practice routine for the Over-75 Check. It also included a case vignette describing a typical presentation of dementia at an Over-75 Check. A 65% response rate was achieved. Only one-fifth of respondents ever used formal validated cognitive tests as part of the Over-75 Check. In response to the vignette, nearly 10% took no action at all and a further 25% simply referred the patient on. Amongst the remainder there was considerable variation regarding the tasks considered to be within their remit. The respondents strongly supported the introduction of guidelines. Given the variation in professional responsibilities between practices, it is proposed that a clinical practice guideline covering diagnosis, assessment and management of dementia should address the practice as a whole rather than be targeted to specific professionals. The guideline should prompt professionals carrying out an Over-75 Check to recognize symptoms of dementia and raise awareness of the range of tasks which need to be undertaken in confirming diagnosis, assessing needs and managing patients. Results from this study suggest that improved training and increased autonomy for primary care nurses would improve access to services for these patients and their carers.     

Successful treatment of severe aplastic anemia by bone marrow transplantation from HLA nonidentical family members: preliminary results utilizing cyclophosphamide and 600 cGY fractionated total body irradiation

We have performed bone marrow transplants on four children with severe aplastic anemia who lacked an human leukocyte antigen (HLA)-identical sibling donor. Patients were prepared with cyclophosphamide and 600 cGy fractionated total body irradiation, and then received marrow from a parent donor mismatched for one (two patients), two (one patient), or three (one patient) HLA antigens. All four patients engrafted. One died early of acute graft-versus-host disease. The three others showed sustained complete hematopoietic reconstitution. Two are alive and hematologically normal 43-87 months after transplant. Both have had acute and chronic graft-versus-host disease (CGVHD), and one of the two remains on immunosuppressive drugs. The fourth died at 48 months after transplant of CGVHD. The previous experience with HLA-incompatible marrow transplants is reviewed, and the rationale for this preparative regimen is discussed. Cyclophosphamide and 600 cGy fractionated total body irradiation is an effective preparative regimen for children with severe aplastic anemia receiving transplants from HLA-nonidentical parental donors, allowing engraftment and full hematologic reconstitution.     

Response of lower genital tract flora to external pelvic irradiation

Endocervical and vaginal cultures were obtained every week from patients undergoing external pelvic irradiation for gynecologic malignancy. Gram-positive aerobes accounted for 52 to 56% of isolates, gram-negative aerobes accounted for 15 to 16%, and anaerobes accounted for 29 to 32% of all isolates prior to therapy. No significant changes occurred during or after completion of radiation for the group. In individual patients, however, over 50% of organisms found on initial culture were no longer present on completion of external therapy.     

Asymptomatic bacteriuria in normal and high-risk pregnancy

A routine urine culture was performed in 1130 normal pregnant women and in 211 high-risk pregnancies (136 diabetics and 75 women with a previous urinary tract infection). Asymptomatic bacteriuria was found in 5.9% of the normal pregnancies, 12.5% among the diabetics and in 18.5% of the previous urinary tract infection patients. The higher incidence of a clinical urinary tract infection among patients with asymptomatic bacteriuria was found statistically significant (p less than 0.001) in all three groups. A high correlation was found between a negative urine culture in early pregnancy and the absence of development of cystitis and pyelonephritis in later pregnancy. The incidence of asymptomatic bacteriuria in normal pregnant women who developed cystitis later in pregnancy was 33.3% and in those developing pyelonephritis, 66%. In the two high-risk pregnancy groups, the incidence of asymptomatic bacteriuria among those developing clinical infection was even higher, 58.3 and 85.7%, respectively, among the diabetics, and 60 and 66.6% respectively, among the previous urinary tract infection patients.     

Twin pregnancy complicated by single intrauterine death. Problems and outcome with conservative management

During an 11-year period we encountered 16 pregnancies in which one twin died in utero and the pregnancy continued. Eight of these twin pregnancies were monochorionic. None of the women developed severe disseminated intravascular coagulation. The fetal outcome indicates that the prognosis for a surviving dichorionic twin is relatively good, with immaturity the main hazard. By contrast the surviving monochorionic twin has a poor prognosis with a high frequency of neurological damage. This damage is not related to intrapartum or neonatal problems and at present cannot be diagnosed before birth. There is no evidence that birth of the surviving twin by caesarean section will improve the prognosis. Early diagnosis of monochorionic twins and subsequent ultrasound follow up should identify fetal growth discrepancy and possible twin to twin transfusion requiring early delivery.     

Racial Variation in Serum Uric Acid Concentration in Pregnancy: a Comparison between European, New Zealand Maori and Polynesian Women

A prospective study was undertaken to measure serum uric acid levels in normal pregnant women of different races, to ascertain if there was any significant interracial variation. A total of 48 women were studied of which 13 were European, 11 New Zealand Maori, 22 Pacific Islanders and 2 Indian. In the second trimester, European, Maori and Cook Island women had similar uric acid levels and other Polynesian groups showed significantly higher levels. In the third trimester, both Maori and Cook Island women showed a marked rise so that their levels came to equal those of other Polynesian groups, all 3 having significantly higher levels than European women. The importance of these observations relates to the use of uric acid levels in the management of patients with gestational proteinuric hypertension. It is possible that in these cases unusually high results may alarm the clinician into hasty intervention.     

High initial values of beta-subunits of human chorionic gonadotropin in ovum donation pregnancies indicate better implantation.

Fifty-five patients were treated by ovum donation, and a control group of 165 patients underwent IVF. The number of pregnancies obtained were 28 and 25, respectively. The initial beta-hCG values, as well as the PRs and implantation rates, in the ovum donation series were significantly higher than those of the IVF series. The clinical significance and potential application of these observations are discussed.     

Enhancing in vitro fertilization of mouse oocytes by partial zona pellucida digestion

This work was undertaken in order to evaluate the effect of partial zona digestion on fertilization in vitro of mouse oocytes and assess zona surface changes induced by the procedure. Three hundred forty-six oocytes allocated for treatment were exposed to Ham's F-10 medium supplemented with 0.5% Pronase for either 3 min (188 oocytes) or 5 min (158 oocytes); 324 oocytes served as controls. Oocyte losses incurred as a result of the procedure were small (15 oocytes; 4.3%). Control and Pronase-treated oocytes were each divided into four subgroups and inseminated with 5 ×10 ⁵,5 ×10 ⁴,5 ×10 ³,or 5 ×10 ² sperm cells/ml. Fertilization was assessed 8 hr following insemination by the appearance of two pronuclei and development to the two- to four-cell stage the following day. The morphology of the zona pellucida following Pronase treatment was assessed by phase-contrast and scanning electron (SEM) microscopies performed immediately after treatment. Fertilization rate of control oocytes was 80% at a sperm concentration of 500,000/ml and gradually declined to ~30% at 500 cells/ml. In contrast, treated oocytes inseminated with 500 sperm cells/ml demonstrated a normal rate of fertilization. At this low sperm concentration the longer Pronase treatment was significantly (P < 0.05) more efficient in enhancing fertilization (69 and 88% for 3 and 5 min of Pronase treatment, respectively). Polyspermic fertilization was not observed in any of the subgroups. Phase-contrast microscopic examination of oocytes at the time of Pronase treatment showed an initial swelling of the zona pellucida for 30–60 sec with a time-dependent increase in its transparency. SEM demonstrated that the fine meshlike structure of the outer surface of zona pellucida digested away, leaving a smoother surface. These morphologic changes were not associated with a diminution in sperm binding or penetration. This work demonstrates that partial zona digestion, which causes uniform dissolution of the zona pellucida and reduction of its thickness, is simple and safe. The procedure significantly increased fertilization efficiency at very low sperm concentrations and could, by itself or in conjunction with other methodologies, improve the reproductive capacity of men producing sperm with a reduced penetrating ability.     

Retrospective maternal mortality case ascertainment in West Virginia, 1985 to 1989.

OBJECTIVE: The death of women from pregnancy-related causes remains a threat to national maternal and child health. Maternal deaths as persistent, albeit rare occurrences are overlooked if vital registration systems are relied on to report such deaths. STUDY DESIGN: Live birth records were matched with death records for women of reproductive age to detect if a woman died within 1 year of delivery. The data for potential cases were reviewed by committee and classified as maternal and nonmaternal deaths. RESULTS: Of all linked birth-death records, 32% were related to pregnancy: 81% were directly related to pregnancy and 19% were indirectly related to pregnancy. The most frequent causes of death were hemorrhage and embolism. Thirty-eight percent of the women were transferred to tertiary hospitals before death. The case ascertainment through this study improved maternal death detection by 100% over official vital statistics. CONCLUSION: Enhanced maternal mortality surveillance increased the detection of maternal death in West Virginia. Case review of these deaths yielded important information useful in shaping the state's perinatal system.     

Factors predicting postoperative sentence scores in postlinguistically deaf adult cochlear implant patients.

A sample of 64 postlinguistically profoundly to totally deaf adult cochlear implant patients were tested without lipreading by means of the Central Institute for the Deaf (CID) sentence test 3 months postoperatively. Preoperative promontory stimulation results (thresholds, gap detection, and frequency discrimination), age, duration of profound deafness, cause of deafness, lipreading ability, postoperative intracochlear thresholds and dynamic ranges for electrical stimulation, depth of insertion of the electrode array into the scala tympani, and number of electrodes in use were considered as possible factors that might be related to the postoperative sentence scores. A multiple regression analysis with stepwise inclusion of independent variables indicated that good gap detection and frequency discrimination during preoperative promontory testing, larger numbers of electrodes in use, and greater dynamic ranges for intracochlear electrical stimulation were associated with better CID scores. The CID scores tended to decrease with longer periods of profound deafness.