bluuebunny/crossref_metadata_2025 huggingface dataset:
Nicotine and Endogenous Opioids: Toward Specific Pharmacotherapy
Authors: Ismail Zahinoor , el-Guebaly Nady
Published: January 2017

Objective:

To address the theoretical framework behind opioid receptor antagonism for the treatment of nicotine abuse. The current literature is reviewed with a focus on opioid–nicotine interactions in animals and humans. Furthermore, previous studies addressing the effect of opioid antagonism on smoking behaviour are reviewed critically with a focus on suggestions and implications for future trials.

Method:

Computerized data bases and reference lists of existing articles were searched for prior publications in 3 areas: 1) the association between nicotine and endogenous opioids, 2) nicotine and reward, and 3) opioid antagonism in the treatment of nicotine use.

Results:

Nicotine affects the mesolimbic reward pathway postsynaptically via nicotinic cholinergic receptors and presynaptically via the central nervous system's (CNS) neurohumoral pathways. Thus nicotine results in the release of endogenous opioids that bind to μ receptors, which increases the release of dopamine along this pathway. Studies to date have shown mixed results on the effect of opioid antagonism on smoking behaviour.

Conclusions:

The role of opioid antagonism on smoking behaviour is unclear, despite the publication of 5 trials on the subject. Further trials of longer duration should be undertaken and use both longer-acting medications and those more specific to the μ receptor to further focus on the rewarding aspects of nicotine ingestion, thus addressing the craving for this drug. The development of adequate compounds has just begun, and psychiatrists can hope to have a more specific pharmacotherapy to address the cravings and short-term rewards of nicotine use.
Psychiatric Comorbidity in Pathological Gambling: A Critical Review
Authors: Crockford David Neil , el-Guebaly Nady
Published: January 2017

Objective:

To critically review the current literature on pathological gambling as regards the significant psychiatric comorbidities associated with it.

Method:

The authors synthesized information found via electronic searches (MEDLINE) and bibliographic-directed searches in over 60 publications.

Results:

Pathological gamblers frequently have comorbid substance use disorders. In addition, a subset appear to have comorbid antisocial personality disorder, but they represent a minority when compared with those people who have acquired their antisocial traits as a consequence of their gambling behaviour. A comorbidity with the mood disorders is probable, but methodological concerns and inconsistencies with the data prevent further delineation of this. Emerging research for other disorders possibly associated with pathological gambling is also reviewed.

Conclusion:

Pathological gambling is associated with significant psychiatric comorbidity. Recommendations for future research are described.
Valproic Acid Treatment of Agitation in Dementia
Authors: Herrmann Nathan
Published: January 2017

Objective:

Valproic acid, an anticonvulsant medication that enhances GABAergic neurotransmission, has been shown to be helpful in treating behavioural disturbances associated with dementia in several small case series. In an attempt to further document its effectiveness and safety, valproic acid was used to treat a group of elderly patients with dementia and severe agitation.

Method:

Sixteen patients, aged 68 to 95 years, who were previously unresponsive to other pharmacotherapeutic interventions, were treated prospectively with open-label divalproex sodium. Effectiveness was measured with the Behave AD (B-AD), the Cohen–Mansfield Agitation Inventory (CMAI), and the Clinical Global Impression Scale (CGIS). Doses ranged from 750 to 2500 mg, divided, per day, with levels of 184 to 742 µmol/L.

Results:

Scores on the CMAI declined from 68.8 to 61.0 (P < 0.005), and scores on the B-AD declined from 15.8 to 12.3 (P < 0.004). On the CGIS, 1 patient was rated as very much improved, 3 patients were much improved, 4 patients were minimally improved, and 8 patients were unchanged. The drug was prematurely discontinued in only 1 patient because of side effects.

Conclusion:

Valproic acid was shown to be well tolerated with modest effectiveness.
Creativity and Mental Illness: Is There a Link?
Authors: Waddell Charlotte
Published: January 2017

Objective:

To critically assess the scientific evidence for associating creativity with mental illness.

Method:

MEDLINE and secondary literature searches identified 29 studies and 34 review articles on creativity and mental illness. All studies were critically evaluated. Reviews were also assessed.

Results:

Of 29 studies that evaluated possible associations between creativity and mental illness, 15 found no evidence to link creativity and mental illness, 9 found positive evidence, and 5 had unclear findings. Most studies used flawed methodologies with weak (case series or case control) designs. There were no randomized or prospective cohort studies. Adequate criteria for determining causal association were not met. In 34 selective reviews, despite mixed evidence, many authors asserted that creativity and mental illness were positively or causally associated.

Conclusions:

There is limited scientific evidence to associate creativity with mental illness. Despite this, many authors promoted a connection. Explanations for this contradiction are explored, and social and research implications are discussed.
DSM-III-R Schizophreniform Disorder with Good Prognostic Features: A Six-Year Follow-up
Authors: Benazzi Franco
Published: January 2017

Objective:

To determine the outcome of DSM-III-R schizophreniform disorder with good prognostic features.

Method:

A 6-year follow-up of 20 cases was conducted with structured interviews (comprehensive assessment of symptoms and history) and assessments of functioning scales (global assessment of functioning, Strauss–Carpenter Scale).

Results:

Thirty-five percent of the cases had major affective disorders, 35% had schizophreniform episodes and major affective disorders, 5% had schizophreniform episodes only, 10% developed schizophrenia, and 15% had no disorders.

Conclusion:

The findings suggest an association between schizophreniform disorder with good prognostic features and affective illness.
Instruments d'évaluation de l'aptitude à subir son procès: Une recension de la documentation scientifique
Authors: Crocker Anne G , Ohayon Maurice , Caulet Malijaï
Published: January 2017

Objectifs:

Faire le point sur l'état des connaissances concernant les méthodes d'évaluation de l'aptitude à subir son procès (ASP). Établir le parallèle entre cet état des connaissances et les résultats d'études portant sur les facteurs associés aux décisions d'aptitude. Décrire les limites inhérentes au domaine de l'ASP.

Méthode:

Recension de la documentation pertinente à partir des bases de données Psychinfo et Medline, de 1967 à 1996 inclusivement.

Résultats:

Dix instruments permettant une collecte systématique d'information auprès des personnes faisant l'objet d'évaluation de l'ASP ont été recensés. Une description et une analyse des qualités psychométriques révèlent qu'ils sont cependant critiquables à certains égards.

Conclusion:

Bien que certaines recherches aient montré que le diagnostic soit le facteur le plus fortement associé à la décision d'aptitude, aucun instrument n'intègre une évaluation systématique de la psychopathologie. Or, si l'on tient compte des conséquences possibles des décisions, tant pour l'accusé que pour la société, ces évaluations et les recommandations qui en découlent sont d'une importance capitale.
Psychiatrists' Documentation of Informed Consent
Authors: Schachter Debbie , Kleinman Irwin
Published: January 2017

Objective:

The present study was undertaken to determine current attitudes and behaviour toward informed consent for antipsychotic medication and documentation of the informed consent process in patient charts.

Method:

Thirty psychiatrists treating a minimum of 10 patients on antipsychotic medication were selected from teaching and nonteaching hospitals. Clinicians completed questionnaires on their behaviour and attitudes regarding documentation of informed consent and antipsychotic medication. Physicians' charts were reviewed to ascertain documentation.

Results:

Psychiatrists reported sometimes documenting the informed consent process. The chart review revealed that, on average, each psychiatrist had documentation in 23% of charts. Physicians who either were affiliated with a teaching hospital or spent more time reading medical journals were more likely to document the informed consent process.

Conclusions:

Physicians who use antipsychotic medication as a treatment in their practice are not routinely documenting the informed consent process in patient records. Physicians should pay more attention to this aspect of record keeping because it is their only record of the consent process.
L'abus de substances psychoactives et l'adaptation sociale chez les psychotiques
Authors: Lépine Annie , Côté Gilles
Published: January 2017

Objectif:

Chez les sujets psychotiques, l'abus de substances psychoactives est-il associé à l'adaptation sociale?

Méthode:

Cinquante-cinq hommes psychotiques provenant d'un centre de détention ou d'un hôpital psychiatrique ont été évalués à l'aide de l'Échelle d'adaptation sociale (EAS-II) et d'une version française de la Phillips Rating Scale of Premorbid Adjustment in Schizophrenia (l'échelle d'évaluation de l'adaptation prémorbide de la schizophrénie de Phillips).

Résultats:

Chez les sujets psychotiques, l'abus de substances psychoactives est associé à certains indices d'adaptation sociale et d'adaptation sexuelle prémorbide.

Conclusion:

Des différences sont observées dans certains aspects du fonctionnement social, mais il est difficile de porter un jugement global sur l'adaptation sociale.
Noninvasive Ventilation to Facilitate Extubation in a Pediatric Intensive Care Unit
Authors: Pope John F. , Birnkrant David J.
Published: January 2017

Noninvasive ventilation has been used extensively to treat chronic respiratory failure associated with neuromuscular and other restrictive thoracic diseases, and is also effective in the treatment of acute respiratory failure, allowing some patients to avoid intubation. Noninvasive positive pressure ventilation is a potentially effective way to transition selected patients off endotracheal mechanical ventilation. The authors present a retrospective chart review of pediatric patients extubated with the use of noninvasive ventilation. Extubation with noninvasive positive pressure ventilation was attempted in 25 patients. The patients had a variety of diagnoses, including neuromuscular diseases, cerebral palsy with chronic respiratory insufficiency, asthma, and acute respiratory distress syndrome (ARDS), reflecting the diversity of patients with respiratory failure seen in our pediatric intensive care unit (ICU). Indications for noninvasive ventilation-assisted extubation were chronic respiratory insufficiency, clinical evidence the patient was falling extubation, or failure of a previous attempt to extubate. Extubation was successfully facilitated in 20 of 25 patients. Of the five patients failing an initial attempt at noninvasive ventilation-assisted extubation, two required tracheostomy, two were subsequently extubated with the aid of noninvasive ventilation, and one was subsequently extubated without the use of noninvasive ventilation. Risk factors for failure to successfully extubate with the assistance of noninvasive positive pressure ventilation included the patient's inability to manage respiratory tract secretions, severe upper airway obstruction, impaired mental status, and ineffective cough with mucus plugging of the large airways. AU patients had mild to moderate skin irritation due to the mask interface. No patient had any serious or long-term adverse effect of noninvasive positive pressure ventilation. All patients left the hospital alive. Noninvasive positive pressure ventilation can facilitate endotracheal extubation in pediatric patients with diverse diagnoses who have failed or who are at risk of failing extubation, including those with neuromuscular weakness.
Ethical Considerations in Organ Donation and Transplantation
Authors: Smith Craig R. , Lowell Jeffrey A.
Published: January 2017

Organ transplantation continues to be an excellent therapeutic option for patients with end-stage organ disease. Due to advances made in immunosuppression, surgical techniques, and critical care management, graft and patient survival rates continue to improve. Although advances in technology have dramatically changed in the field of organ transplantation over the last several decades and complicated ethical decision-making, the fundamental ethical principles of beneficence, nonmaleficence, autonomy, and justice have not. Organ transplantation still remains a problem of supply and demand and challenges transplant professionals to meet society's push to find new organ donor sources.
Nutrition and Nutritional Support in Critically Ill Patients
Authors: Dark Diana S. , Pingleton Susan K.
Published: January 2017

The use of intravenous nutritional support has increased dramatically in the last 20 years. Although it is not without controversy, administration of nutritional support is common practice in hospitalized patients including critically ill patients. Malnutrition continues to be reported in a significant number of hospitalized patients. The incidence of malnutrition in critically ill patients may be even higher than that reported in hospitalized patients overall. The consequences of malnutrition in a critically ill patient may be severe. Nutritional assessment and nutritional support can present special challenges to the intensivist. Techniques of nutritional assessment in critically ill patients are evaluated. Guidelines for the determination of the nutritional needs of these patients are outlined. Methods of delivery of nutritional support in critically ill patients are reviewed. Complications of nutritional support are discussed.
Justification and Implementation of an Operating Room Pharmacy Satellite
Authors: Donnelly Andrew J.
Published: January 2017

Many pharmacy departments today are expanding the services they provide to the operating room (OR) through establishment of operating room pharmacy satellites (ORPSs). This article discusses two key steps in this process: justification and implementation of the satellite. The ability to justify an ORPS is key to its establishment. If justification is not successful, the process ends. The justification process consists of four major steps: (1) familiarization with the ORPS concept, (2) performance of an initial assessment of the OR complex, (3) obtaining support for the ORPS from all key departments affected by its establishment, and (4) development of a formal proposal for the ORPS, including a financial analysis. Justification can be greatly facilitated by obtaining support for the satellite from the anesthesiology and nursing departments and by the ability to demonstrate a favorable financial analysis for the ORPS. Implementation should begin once administrative approval for the satellite has been received. For optimal results, all required steps should be outlined in a clear, concise manner. Development of a timeline listing these steps and the approximate time required for each one is an excellent way to ensure the implementation process remains on schedule. Finally, the process of establishing an ORPS does not end with successful justification and implementation of the facility. Pharmacy services must be routinely monitored and evaluated.
Investigational Radioimmunopharmaceuticals: Pharmaceutical Care Responsibilities and Opportunities
Authors: Levine Geoffrey
Published: January 2017

A recent survey of biotechnology-derived medicines and vaccines under development showed that the largest fraction of these were monoclonal antibodies for the detection and/or treatment of cancer. This article describes the role and function of the nuclear pharmacist in the initiation, development, and conduct of a prototype clinical trial in which a radiolabeledmonoclonal antibody (MAb) is used as a diagnostic imaging agent to detect the site of a tumor in a patient who is being managed in a hospital outpatient setting. Examples are used to illustrate selected pharmaceutical care issues in this investigational environment.
Critical Paths or Structured Care Plans: Not Just for Nursing
Authors: Andrusko-Furphy Kathryn T.
Published: January 2017

Pharmacists historically have not visibly documented their cognitive interventions. Traditionally, any of these interventions were notated in the margins of a prescription or the back of a prescription. As pharmacists began to expand their practice beyond dispensing, they embraced a pharmaceutical care model for patient care. In the 1990s, this process may remove the pharmacist from dispensing areas. Consequently, they may begin to find themselves removed from their only link historically to pharmacy documentation. Even those pharmacists who have been accustomed to documenting clinical monitoring interventions, often times do this without these interventions becoming an official part of the patient's medical record. If pharmacists are to be considered a part of the patient care team as the health care team moves more to a model of patient-focused care, they will need to begin to document their role in the patient's care coordination. The purpose of a care plan is to establish a predefined approach to a patient's care. If we are to be a part of that patient's care planning, then pharmacists must first get past this stigma that care plans are not just for nursing. Instead, we need to begin to understand their purpose, before we can begin to understand how to develop a structured care plan or critical path. The literature also refers to this interdisciplined concept as critical pathways, patient-focused care, care tracks, criteria mapping, care mapping, or clinical pathways. Unfortunately, each health care discipline is creating their own term.
Cancer Pain Management in Ambulatory Patients
Authors: Bressler Linda R.
Published: January 2017

Pain, by definition, is a subjective phenomenon. The subjective component in chronic pain due to cancer is very important. Opioid analgesics are the mainstay of treatment for cancer pain. Their use should be optimized to provide adequate pain relief. Optimal use includes understanding the concepts of tolerance, physical dependence, and psychological dependence. None of these should limit or inhibit pain management. Optimal use also includes familiarity with the clinical use of opioids. Regular use is generally preferred over “prn” use. Increased parenteral versus oral effectiveness of opioids, secondary to a high first-pass effect, is an important consideration when routes of administration must be altered. Familiarity with approximate equianalgesic doses allows for conversion from one opioid to another. Such conversion might help increase the convenience, increase the efficacy, or decrease the adverse effects of an opioid regimen. Knowledge of durations of action of opioids helps in the selection of dosing intervals to facilitate continuous pain relief. Morphine is the most common opioid chosen for cancer pain management, but others may be equally effective. Follow-up assessments with subsequent alterations are as important as the initial selection of drug, dose, and dosing interval. Adjuvant analgesics, such as nonsteroidal antiinflammatory drugs, anticonvulsants, or antidepressants, may enhance pain relief, especially in certain pain syndromes (eg, metastatic bone pain, neuropathic pain). These agents are usually used in addition to opioids.
Dissecting a Waiting List
Authors: Pope C. J. , Roberts J. A. , Black N. A.
Published: January 2017

This study examines a list of 1,283 patients waiting for general and orthopaedic surgery in an outer London borough. In general surgery varicose vein and hernia surgery accounted for 60% of those waiting more than one year. Of those who had waited more than a year on the orthopaedic list 25% were waiting for knee replacement surgery. The average length of time spent waiting was 10 months, with some people waiting over 5 years. The impact of the numbers waiting a long time on aggregate waiting time was highlighted by weighting the numbers waiting by the months spent waiting.

Analysis of urgency codes indicates that although there was a statistically significant relationship between urgency and the length of waiting time there were some anomalies. There was considerable inter-consultant variation in list size, waiting times and the case mix. Analysis of the flows onto the list and work done in one month showed that it would take a considerable time to clear some lists at present rates of activity.

Disaggregated information such as this which explores the flows of patients on to and off of the lists is essential for the management of waiting lists and will become increasingly important as waiting lists become a feature of — ‘contracts’ — service agreements, in the reformed NHS.
Factors and Perspectives Affecting Nursing Resource Consumption in Community Hospitals
Authors: Shukla Ramesh K.
Published: January 2017

The consumption of professional and non-professional nursing resources on medical/surgical nursing units varies sharply among community hospitals. In an effort to explain the variation, this study examines several factors: socio-economic characteristics of the population; supply of registered nurses; hospital characteristics such as size, complexity and diversity of services; patient characteristics such as case mix index and nursing care acuity index; and production system characteristics such as efficiency of technical support systems and the structure of nursing care delivery.

Nursing skill mix varies more than the staffing levels among hospitals. The research suggests that factors associated with a clinical-rational model such as nursing acuity index and the efficiency of clinical/support systems explains little, whereas factors associated with economic-rational model of hospital revenues – like case mix, number of hospital services, poverty (through Medicaid program) and age distribution (through Medicare program) – do significantly affect nursing resource consumption. The results point to the presence of resource allocation to nursing based on hospital revenues rather than patient care needs.
The Politics of Medical Quality: Auditing Doctors in the UK and the USA
Authors: Pollitt Christopher
Published: January 2017

Following the 1989 white paper Working for patients medical audit has emerged as the principal officially-approved means of assuring the quality of NHS medical care. Beneath the surface consensus, however, significant arguments continue concerning both the purposes and the character of such audit. A ‘medical model’ of medical audit is in competition with a more managerial approach, while consumer interests, however unsuccessfully, are also trying to claim a role. Comparison with the system of peer review in the USA indicates that medical audit in the NHS is likely to be particularly weak with respect to public accountability. Nevertheless, when taken together with other features of the white paper's proposals, the universalization of medical audit offers managers an opportunity to begin to constrain the behaviour of hospital doctors at the local level.
The Impact of Advertising on Price and Practice Volume-A Case Study of Dental Markets
Authors: Kwon Ik-Whan , Safranski Scott R. , Kim Joe H.
Published: January 2017

Advertising is often considered a catalyst which stimulates competition by communicating the important attributes (information) of goods and services to consumers. Theoretically, advertising makes demand responsive to strategic price differences. This advertisement-induced price elasticity puts competitive pressure on the providers' pricing strategy. It has been assumed that this effect also exists in the health care market. This study investigates the impact that the advertising of services has on the price and demand behaviour in the dental care market. The sampling frame includes 1,326 dentists, 558 (44.3%) of whom have advertised their services. The statistical results seem to dispute the claim that advertising lowers the consumer's price and increases the advertising dentist's market share.
Introduction of Hip Ultrasonography to the Neonatal Services of a Fife District General Hospital
Authors: Dean B. , Coid Donald R.
Published: January 2017

Ultrasonography of the hip is a new technique which is said to assist in the diagnosis of neonatal hip disorders. The authors were unaware of any reports of formal evaluation of the introduction of this new technology into a District General Hospital. This study outlines several aspects of patient care before and after the introduction of neonatal hip ultrasonography to a Fife hospital as an adjunct to a neonatal orthopaedic clinic. After introduction of ultrasound the proportion of patients where the consultant was ‘very confident’ in the diagnosis increased by 29% (95% confidence intervals 9% to 49%); the proportion of children requiring three or more x-rays in the year following referral fell by 46% (95% confidence intervals 27% to 65%) and the proportion of children requiring five or more follow up attendances in the year following referral fell by 56% (95% confidence intervals 38% to 74%).

Introduction of this technology has benefited patients by reducing their need to attend clinics and reducing their overall exposure to ionising radiation. There is a continuing need for ultrasonography to be provided in Fife neonatal orthopaedic outpatient clinics.
Should Emergency Readmissions be used as Health Service Indicators and in Medical Audit?
Authors: Henderson Jane , Graveney Mike J. , Goldacre Michael J.
Published: January 2017

This study examined the temporal relationships between index discharges from hospital and emergency readmissions in the area covered by the Oxford record linkage study in the years 1975–84. We report data on 204, 856 readmissions. Index admissions were grouped into elective and immediate categories and into medical and surgical specialty groups. The time intervals between elective prostatectomy or emergency appendicectomy and emergency readmissions were also examined as examples of specific operations. Readmissions clustered strikingly in the first few weeks following discharge. Over a third of emergency readmissions in the year following discharge occurred in the first four weeks. This close temporal proximity indicates that emergency readmissions are generally associated with the first index admission and therefore that emergency readmissions are appropriate topics for further investigation through health services research and medical audit.
A Causal Modeling Approach to Institutionalization
Authors: Mohr Ruth A.
Published: January 2017

A causal model of the institutionalization process is presented. Path analysis and logistic regression are performed on NHIS Longitudinal Study of Aging data. Based on initial analysis, the model is revised and re-evaluated. Convergent results support significance for four of five proposed predictors. Results are similar for men and women. Findings suggest unidentified factors are important to nursing home admission and that attention should be given to the process of decision-making that leads to admission.
Objectives, Information and Incentives in the NHS Internal Market
Authors: Anand Paul
Published: January 2017

In order to achieve and monitor success in the NHS internal market, it is important that information related to health care objectives is developed and used. The paper argues that these objectives are not always easy to specify but that four groups can be identified: efficiency, equity, quality and accountability/responsiveness. Although information management specialists have emphasised the construction and use of appropriate frameworks for planning information flows, whether appropriate information is used depends on the existence of incentives for its supply. Using concepts from game theory, the paper offers a non-technical examination of the incentives that the contracting environment imposes on the development of new information. The article concludes by suggesting that, for a variety of resons, the incentives to produce information which would help monitor medical outcomes and related objectives, as distinct from inputs or activities, are often weak and sometimes perverse.
A Cost-Constrained Model of Strategic Service Quality Emphasis in Nursing Homes
Authors: Davis M. A. , Provan K. G.
Published: January 2017

This study employed structural equation modeling to test the relationship between three aspects of the environmental context of nursing homes; Medicaid dependence, ownership status, and market demand, and two basic strategic orientations: low cost and differentiation based on service quality emphasis. Hypotheses were proposed and tested against data collected from a sample of nursing homes operating in a single state. Because of the overwhelming importance of cost control in the nursing home industry, a cost-constrained strategy perspective was supported. Specifically, while the three contextual variables had no direct effect on service quality emphasis, the entire model was supported when cost control orientation was introduced as a mediating variable.
Occurrence of Validating Clinical Findings in the Hospital Record for Appendectomy, Cholecystectomy and Intervertebral Disc Excision Patients: Comparisons among Hospitals and among Surgeons
Authors: Bradbury R. C. , Golec J. H. , Steen P. M.
Published: January 2017

This study examines the variation among 36 Pennsylvania hospitals, and the individual surgeons practicing in them, in the proportion of appendectomy, cholecystectomy and intervertebral disc excision patients with clinical findings in the hospital record that validate the need for surgery. Using admissions from January 1990 through June 1991, we performed logistic regressions on the probability of validating clinical findings controlling for patient age, sex, admission severity of illness, and Medicaid and Health Maintenance Organization membership. Our results show that hospitals, and surgeons, vary significantly in their validation rates for cholecystectomy and disc surgery and, to a lesser extent, appendectomy. We also found that increased procedure-specific volume at both the hospital and surgeon levels is not related to the odds of validating clinical findings. We define a future research agenda to investigate the reasons for the observed differences among hospitals and among surgeons.
Further Flexing? Issues of Employment Contract Flexibility in the UK Nursing Workforce
Authors: Buchan J.
Published: January 2017

This paper, based on research commissioned by the Royal College of Nursing (Buchan, 1995), reports on the changing working patterns and flexibility in the employment of nursing staff in the National Health Service (NHS) in the UK. It reviews relevant literature, examines official data and draws information from 12 case study NHS trusts.

Flexibility is invariably portrayed as a good thing, and as a means to a positive end, yet is rarely defined in detail, if at all. The aim of this paper is to consider flexibility not as a slogan or panacea, but in terms of the rationales for, and likely effects of, changing patterns of nursing work. It examines the reasons why NHS employers have been attempting to increase the flexibility of their nursing workforce.
Validity of Three Measures of Severity of AIDS for Use in Health Services Research Studies
Authors: Alemi F. , Walker L. , Carey J. , Leggett J.
Published: January 2017

Policy makers and hospital managers often use severity adjustments as a control for patient mix differences when evaluating outcomes of care. Unfortunately, few indices are carefully examined and therefore the evaluations based on these methods of severity adjustment are suspect. This paper examines the accuracy of three indices for measuring the severity of illness of AIDS patients. We examine the Diagnosis-Based Severity Index (DBSI), a modified version of DBSI referred to as MDBSI and the Composite Laboratory Index (CLI) in predicting survival of AIDS patients at one medical centre. We analysed the correlation between indices and months of survival. We also examined the percentage of variance in survival months explained by each index separately and together. Finally, we used survival analysis to examine whether DBSI classifies patients in groups with distinct patterns of survival. Only patients who had died were included in the analysis so that information on the patients' full course of illness was available. Of the 91 patients abstracted, 81 cases had date of AIDS, date of death, and the CLI. These 81 cases were the focus of the analysis. Both CLI and DBSI were predictive of months of survival but were not correlated to each other. Predictions of months of survival were improved if both indices were used together rather than separately. Survival analysis confirmed that patients classified by DBSI had distinctly different survival patterns. Each index measures different aspects of the severity of the patient's condition and when possible both indices should be used together. When laboratory data are not available, e.g. in Medicaid administrative files, the use of DBSI may be reasonable.
The Emerging AIDS Crisis in Russia: Review of Enabling Factors and Prevention Needs
Authors: Kalichman Seth C , Kelly Jeffrey A , Sikkema Kathleen J , Koslov Andrei P , Shaboltas Alla , Granskaya Juliana
Published: January 2017

Eastern Europe is experiencing increased rates of HIV/AIDS, and the Russian Federation is among the countries with the most alarming case rate increases. Behavioural and biological studies demonstrate that the transmission of HIV in Russia is occurring as a result of injection drug use, homosexual, and heterosexual risk behaviours. Factors that promote risk and therefore enable HIV transmission in Russia parallel those found in other countries, including epidemics of other sexually transmitted infections, economic instability, poverty, and social factors such as gender roles. Research is urgently needed to better understand and forecast the HIV epidemic in Russia, as well as to develop effective interventions to prevent a Russian AIDS crisis.
Detection of Human Cytomegalovirus Retinitis and Monitoring of Ganciclovir Treatment Using Conjunctival Swab with Polymerase Chain Reaction in AIDS Patients
Authors: Chiou S H , Liu J H , Wong W W , Chan Y J , Chang Y C , Wang J J , Liu C Y , Liu W T , Chen S C , Hsu W M
Published: January 2017

This report studies the accuracy of conjunctival swab polymerase chain reaction (CS-PCR) for the diagnosis of human cytomegalovirus retinitis (HCMV) in AIDS patients. PCR and virus culture were used for the detection of HCMV in conjunctival swab, serum, and urine specimens from 38 AIDS patients between April 1996 and April 1998. The clinical utility of the identification of HCMV retinitis by these 6 different methods was demonstrated by their prediction power to estimate AIDS patients at risk of contracting HCMV retinitis. The sensitivity, specificity, positive predictive value, and negative predictive value of CS-PCR for the detection of HCMV retinitis were 91.5%, 80.9%, 60.8%, and 92.7%, respectively; for serum PCR were 74.3%, 81.7%, 57.2%, and 90.3%; for urine PCR were 100%, 17.3%, 20.4%, and 100%; for conjunctival swab culture were 22.7%, 100%, 100%, and 86%; for serum culture were 27.3%, 98.1%, 75%, and 86.4%; and for urine culture were 90.9%, 44.2%, 25.6%, and 95.8%.
Patient Assessment of Anogenital Warts and the Success of Treatment with Home Applied Therapy
Authors: Carey F M , Quah S P , Dinsmore W , Maw R D
Published: January 2017

Home treatment with podophyllotoxin or imiquimod are commonly prescribed therapies for anogenital warts. It is important to ascertain if patients are locating all lesions for treatment and if they know when they are clear of them. We set out to assess patients' ability to determine the number and location of their genital warts and compare their observation with that of their examining doctor or nurse. Following instruction on the use of home treatment and being given an instruction leaflet patients were reviewed in four weeks' time. One hundred and fifty-five patients enrolled in the study—31% (48) male, 69% (107) female. At initial assessment 62.5% (30) of male patients and 59.8% (64) of female patients underestimated the extent of their disease: 10.5% (5) of male patients and 10.3% (11) of female patients overestimated their disease burden with some mistaking skin tags for genital warts. At review 29.4% (5) of male patients and 44.4% (20) of female patients still underestimated the extent of their infection. Patients undertaking home treatment for warts not only need detailed instruction on its use but should be reviewed to assess the success of treatment.
Transfusion-Associated HIV Infection in Mexico Related to Paid Blood Donors; HIV Epidemic
Authors: Volkow Patricia , Velasco Silvia Ruiz , Mueller Nancy , de Leon Samuel Ponce , Sierra-Madero Juan Gerardo , Sada Eduardo , Soto José Luis , Perez-Ancona Franz , Ruiz-Palacios Guillermo , Castillo José Ramón , Mohar Alejandro
Published: January 2017

The objective of the study was to describe the clinical, epidemiological profile and conditional incubation period in a group of transfusion-associated HIV-infected (TAHI) patients seen in five national tertiary care centres in Mexico from 1983 to April 1998. Date of transfusions, AIDS diagnoses, opportunistic infections and malignancies were collected. The incubation period was estimated through a non-parametric conditional analysis.

One hundred and fifty-seven TAHI cases were analysed. The frequency of TAHI by year of transfusion was: 0.6% in 1980 and 1981, 4.5% in 1984, 22.4% in 1985, 54.5% in 1986, 10.3% in 1987, 0.6% in 1988, 1.9% in 1989 and 1990, 1.3% in 1993 and 0.6% in 1994 and 1996. The median incubation period was 4.3 years.

A well-defined epidemic period of HIV-infection among blood-recipients was identified that coincided with the HIV-epidemic among paid donors. TAHI patients in Mexico developed AIDS in a shorter time than that described for other populations.
Asymptomatic Herpes Simplex Virus Shedding from the Genital Tract Whilst on Suppressive Doses of Oral Acyclovir
Authors: Bowman C A , Woolley P D , Herman S , Clarke J , Kinghorn G R
Published: January 2017

Forty-eight patients were recruited into a study of continuous oral acyclovir therapy for the suppression of recurrent genital herpes simplex virus (HSV) infection. Seven of these patients were shown to shed HSV in the absence of clinical signs or symptoms whilst on medication. The asymptomatic shedders did not differ significantly from the rest of the group in terms of age, interval from first attack to enrolment or number of recurrences prior to enrolment. Only one patient admitted to poor compliance as a trigger to asymptomatic HSV shedding.

Failure to suppress asymptomatic shedding during prophylactic acyclovir therapy may have implications for sexual transmission to partners and vertical transmission to neonates and requires further study.
Comparison of an Enzyme Immunoassay (ortho) with Cell Culture and Immunofluorescence for the Detection of Genital Chlamydial Infection
Authors: Mumtaz Gilanfar , Ridgway G L , Nayagam A T , Robinson A J
Published: January 2017

An enzyme immunoassay (EIA) test (Ortho Diagnostic Systems Ltd) was evaluated against cell culture for the detection of chlamydial genital infection. Specimens were obtained from 409 patients (204 men and 205 women). Sensitivity, specificity, predictive value of a positive result (PVP) and predictive value of a negative result (PVN) for the new test compared to cell culture were respectively 73.1%, 93.8%, 63.3% and 96% for men and 80%, 95.6%, 71.4% and 97.2% for women. Discrepancies were further evaluated by repeating the EIA, and by direct immunofluorescence (IF) on the EIA transport buffer. The sensitivity, specificity, PVP and PVN of the EIA against the combination of cell culture and direct IF were respectively 76.7%, 96%, 76.7% and 96% for men, and unchanged for women. Overall agreement between the EIA and the combination of cell culture and direct IF was 93.4%. The EIA is rapid and simple to perform and does not require elaborate equipment.
Eight Year Prospective Study of HIV Infection in a Cohort of Homosexual Men—Clinical Progression, Immunological and Virological Markers
Authors: Lau R K W , Hill A , Jenkins P , Caun K , Forster S M , Weber J N , McManus T J , Harris J R W , Jeffries D J , Pinching A J
Published: January 2017

Three hundred and fourteen homosexual/bisexual men at risk for human immunodeficiency virus (HIV) infection (170 seroprevalent HIV-positive, 144 seronegative) were prospectively studied over 8 years to assess rates of HIV infection and disease progression, in conjunction with cellular and HIV serological markers. In HIV-positive subjects, CD4+ lymphocyte counts rose strikingly during the period surrounding seroconversion, then fell progressively over the intervening period to a mean level of 300 cells/mm3 when AIDS developed. Changes in CD8+ lymphocyte counts were less consistent. The trend for HIV serological markers over the study period was of progressive decline in the proportion of subjects with anti-p24 antibody, associated with an increase in the proportion of subjects with detectable HIV antigenaemia. However, only 45% of subjects tested had lost anti-p24 antibody by the time of AIDS diagnosis, and HIV antigen was detectable up to 4 years before this. Different HIV serological patterns were also observed in subjects presenting either with Kaposi's sarcoma or opportunist infections. Our data support the continued use of cellular and virological markers in the evaluation of HIV disease; however, the variability observed in this study highlights their limited ability in predicting specific clinical events. Care should therefore be taken to encompass both clinical and laboratory information in the medical assessment of the HIV-infected individual.
A Preliminary Evaluation of a Prototype Western Blot Confirmatory Test Kit for Syphilis
Authors: Young H , Walker P J , Merry D , Mifsud A
Published: January 2017

A prototype Western blot kit was evaluated as a confirmatory test for syphilis using 131 sera characterized by other serological tests for syphilis. There were 114 treponemal sera (including 94 cases of early syphilis, 83 of which were untreated) and 17 non-treponemal problem sera (11 gave false positive reactions on screening with the TmpA recombinant antigen enzyme immunoassay (EIA), 3 gave false positive fluorescent treponemal antibody absorbed (FTA-abs) tests, and 3 false positive Captia Syphilis G EIA results). Based on the manufacturer's criteria of reactivity in multiple bands for designating a positive result the Western blot test gave a sensitivity of 99.1% (113/114) and a specificity of 88.2% (15/17) when indeterminate reactions were scored positive and 98.2% (112/114) and 100% (17/17) when indeterminate reactions were scored negative. Sensitivity was high in both treated and untreated infection. Corresponding sensitivities for the TPHA and FTA-abs when equivocal reactions were scored negative were 97.5% (111/114) and 99.1% (113/114). The high sensitivity of the FTA-abs in this study is probably due to the large number of untreated primary infections. Our results with the Western blot, confirm earlier studies using ‘in-house’ test systems and, support a role for a commercial Western blot test in the confirmatory diagnosis of syphilis. Further studies are required to confirm the high specificity and sensitivity of the kit in a larger series including a wider variety of non-treponemal cases as well as patients with untreated and treated infection.
Screening for Cervical Abnormalities in Women with Anogenital Warts in an STD Clinic: An Inappropriate Use of Colposcopy
Authors: Coker Richard , Desmond Noreen , Tomlinson David , Bretherton Kathy , Byrne Micheline
Published: January 2017

An audit of the use of colposcopy in women with anogenital warts was performed. Fifty women attending a clinic for sexually transmitted diseases in a District General Hospital with anogenital warts were examined by cervical cytology and colposcopy for cervical infection by human papillomavirus (HPV) or epithelial abnormality indicating cervical intraepithelial neoplasia (CIN) or both. Collated results showed a high prevalence of both conditions in these 50 women; 20 (40%) had evidence of cervical infection by HPV and 11 (22%) epithelial abnormalities consistent with CIN 1 or 2. However, neither CIN 3 nor invasive disease was detected. Colposcopy in this setting was shown to be a specific but insensitive tool and its role in the routine management of women with anogenital warts at our institution is not warranted.
Pathogenesis of the Antiphospholipid Antibody Syndrome
Authors: Lockshin MD
Published: January 2017

Endothelial and/or platelet activation likely initiates thrombus formation. Whether antiphospholipid antibody (aPL) is an activator, a toxic response, or a protective response is not clear, nor is it certain whether aPL is germ-line encoded or antigen-driven. The pregnancy model is particularly informative. Alternative hypotheses about thrombogenicity which relegate aPL to the role of bystander have not yet been excluded.
Lupus Anticoagulants/Antiphospholipid-Protein Antibodies: The Great Imposters
Authors: Triplett DA
Published: January 2017

Antiphospholipid-protein antibodies (APA) represent a family of immunoglobulins which recognize protein-phospholipid complexes. A variety of proteins have been implicated including: prothrombin, annexin V, β2-Glycoprotein I, and protein S. APA are detected utilizing either coagulation-based tests to identify lupus anticoagulants (LA) or solid phase ELISA assays to identify anticardiolipin antibodies (ACA). APA may be seen in a variety of different clinical settings including convalescence from infections, resulting from exposure to certain drugs, or in association with autoimmune diseases. Autoimmune APA have been linked to a variety of thromboembolic complications involving both arterial and venous sites. In addition, recurrent fetal loss has been linked to a APA. The underlying pathophysiology of the thromboembolic events remains controversial. Given the diversity of anatomic sites, more than one thromboembolic mechanism(s) is likely. Abnormalities of the protein C system most likely account for the venous thromboembolic events. Because of the spectrum of clinical complications, virtually any clinician may encounter patients with the APA syndrome (thrombosis, thrombocytopenia, recurrent fetal loss coupled with positive LA or ACA testing).
Antiphospholipid Antibodies Activate Vascular Endothelial Cells
Authors: Simantov R , Lo SK , Gharavi A , Sammaritano LR , Salmon JE , Silverstein RL
Published: January 2017

Antiphospholipid antibodies (aPL) are associated with a syndrome of arterial and venous thrombosis and recurrent fetal loss. We have shown that IgG purified from patients with aPL activate vascular endothelial cells (EC), converting the steady-state, non-thrombotic endothelial surface to a pro-thrombotic state. The aPL-activated EC are characterized by the expression of leukocyte adhesion molecules, including ICAM-1, VCAM, and E-selectin. EC activation is dependent upon the presence of β2-GP-I, a cofactor necessary for anticardiolipin reactivity. In addition, EC activation is not attributable to endotoxin contamination, Fc receptor interactions, or immune complexes, but rather is the result of the specific anticardiolipin reactivity of the IgG. Endothelial activation by aPL may be an important mechanism by which these antibodies cause a hypercoagulable state.