Are there associations among physical activity, fatigue, sleep quality and pain in people with mental illness? A pilot study.

Good mental health is imperative to well-being. Symptoms of fatigue, chronic pain and poor sleep are common in people with mental illness and contribute to substantial loss of functioning. Physical exercise interventions have shown to decrease these symptoms in a range of populations; however, their possible association with physical activity related to day-to-day functioning have not been explored in people hospitalized with severe mental illness. Inpatients (n = 4) of a metropolitan mental health facility were fitted with an Actiwatch, which collected physical activity and sleep measures for an anticipated 14-day data collection period. During this time, morning and evening pain and fatigue scores were collected on an 11-point numerical rating scale. Significant associations were found between morning pain and morning fatigue scores (ß = -0.44, P = 0.023), morning pain and physical activity (ß = 12.34, P = 0.042), and physical activity and evening pain scores (ß = 0.20, P = 0.017). Fatigue tended towards interfering more with quality of life than did pain, but this was not significant (P = 0.07). This study provided preliminary data suggesting associations between pain and fatigue, and intensity of pain and physical activity levels. This information can be used to generate hypotheses for future clinical trials.

Bare Below the Elbows: A comparative study of a tertiary and district general hospital.

A 'Bare Below the Elbows' (BBTE) dress code policy has been introduced by the majority of NHS trusts in the UK. The aim of this Irish study was to evaluate the impact of an educational intervention on perception of medical attire. The study was carried out in two centres: a tertiary referral centre (Beaumont Hospital) and a district hospital (MRH, Portlaoise). Two questionnaires, incorporating photographic evaluation of appropriate attire for consultants and junior doctors, were completed pre and post BBTE education. One hundred and five patients participated. Analysis pre BBTE education indicated patients considered formal attire and white coats most appropriate for consultants and junior doctors respectively. Post-intervention analysis revealed a significant reduction in the popularity of both (p <0.001), with scrubs and smart casual attire gaining significant support in both cohorts (p <0.001). Our findings demonstrated that patient opinion on medical attire is malleable. The support of such a policy may be achieved if patients are informed that the aim is to reduce the spread of healthcare-associated infections.

Venous thromboembolism risk and prophylaxis in the acute hospital care setting: the Irish results of the ENDORSE study.

ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting), is a multinational, cross-sectional survey of venous thromboembolism (VTE) risk prevalence and effective prophylaxis in the acute hospital care setting. Three Irish hospitals enrolled in the study. The American College of Chest Physicians (ACCP) guidelines were employed to evaluate VTE risk and prophylaxis. Of 552 patients, 297 (53.8%) and 255 (46.2%) were categorised as surgical or medical, respectively, with 175 (59%) surgical and 109 (43%) medical patients deemed to be at risk for VTE. Of these, only 112 (64%) and 51 (47%) received recommended VTE prophylaxis, respectively. The results are consistent with those observed in other countries and demonstrate a high prevalence of risk for VTE and a low rate of prophylaxis use, particularly in medical patients. Awareness of VTE guidelines should be an integral component of health policy.

Improving outcomes for psychoses through the use of psycho-education; preliminary findings.

A psycho-education programme is provided for patients suffering from psychosis in Scotland's only high secure hospital. An 18-month pilot study was carried out with consecutive case sample (treatment group) and 'treatment as usual' comparison group (control group). Pre, post and 6-month follow-up assessments were carried out. A range of outcome measures were used, including two measures of knowledge: a self-report assessment tool - Forensic Assessment of Knowledge Tool and the Understanding Medication Questionnaire. Other measures were used to establish level of insight, Schedule for the Assessment of Insight and assess mental state [Positive and Negative Syndrome Scale (PANSS)]. Results from (n = 48) participants indicate no statistical difference between the treatment and control group scores on any assessment prior to commencement of the intervention, indicating a well-matched sample group. However, all four assessments showed statistically significant changes post group. Treatment group showed an ability to improve knowledge and retain information about psychosis, which may account for their improved mental state and level of insight. Despite methodological limitations and a small sample group, this project has given an early indication of the positive value of this psycho-education programme in a forensic setting.

Characterization of a large genomic deletion in four Irish families with C7 deficiency.

Inherited deficiency of the seventh complement component (C7) is associated with increased susceptibility to Neisseria meningitidis infections. The disease is rare in most Western countries. Here we report new investigations of a large, but incompletely characterized genomic deletion of exons 8 and 9 [c.739-?_1093+?del], previously identified in three unrelated Irish families with C7 deficiency. We have analysed DNA from one individual, who is homozygous for the deletion, by PCR using primers progressively proximal to the deleted exons. Thus we were able to map the deletion boundaries. Amplification across the breakpoint and sequencing revealed an indel mutation that included a 6.4kb deletion together with an insertion of a novel 8bp sequence [c.739+1262_1270-2387delinsGCAGGCCA]. We demonstrated the same defect in the C7 deficient patients from each family and developed a duplex PCR method to enable the detection of alleles containing the deletion in heterozygotes. A member of a fourth family was found to be homozygous for the deletion defect. Thus, the deletion defect may be a more commonly distributed cause of C7 deficiency in Ireland.

Rare cerebellar metastases from oesophageal carcinoma.

BACKGROUND: Metastatic oesophageal carcinoma to the brain is an uncommon diagnosis that may cause abnormal neurological findings. AIMS: The case of a 56-year-old man who presented with brain secondaries as an initial manifestation of carcinoma of oesophagus is presented and the unique characteristics highlighted. RESULTS: Patient survival was for 12 months after initial presentation and treatment. CONCLUSION: Oesophageal carcinoma is a recognised cause of intracerebral metastatic tumours, though this is an uncommon occurrence.

Abdominoperineal resection: how is it done and what are the results?

Abdominoperineal resection (APR) for many years was the treatment of choice for most patients with rectal cancer. Recent advances in surgical technique and other treatment modalities have led to a marked increase in the rate of sphincter-sparing operations, with a concomitant decrease in APR. However, it is still necessary in selected patients, especially those with very distal tumors or poor sphincter function. This review will cover the history of APR, current operative strategy and complications, oncologic and quality of life results, as well as potential future advances.

Life skills programmes for chronic mental illnesses.

BACKGROUND: Most people with schizophrenia have a pattern of illness characterised by remission and relapses. The illness can become chronic and disabling. The social disability can require a variety of psychological, nursing and occupational therapies. Life skills programmes, addressing the needs associated with independent functioning, are often a part of the rehabilitation process. OBJECTIVES: To compare the effectiveness of life skills programmes with standard care for people with chronic mental health problems. SEARCH STRATEGY: CINAHL (1982-1997), The Cochrane Library (Issue 2, 1997), The Cochrane Schizophrenia Group's Register of Trials (April 1998), EMBASE (1980-1997), MEDLINE (1966-1997) and PsycLIT (1974-1997) were methodically searched. Hand searches and scrutiny of references supplemented this process. SELECTION CRITERIA: All relevant randomised or quasi-randomised controlled trials for life skills programmes versus standard care involving those with serious mental illnesses. DATA COLLECTION AND ANALYSIS: Searches were inspected by two reviewers (LR, MN) with a third (JC) acting as arbitrator. Data were extracted in the same way. Where possible an intention-to-treat analysis was undertaken on dichotomous data and normally distributed continuous data. MAIN RESULTS: Two randomised controlled trials were included with a total of 38 participants. Data were sparse and no clear effects were demonstrated. REVIEWER'S CONCLUSIONS: If life skills training is to continue as part of rehabilitation programmes a large, well designed, conducted and reported pragmatic randomised trial is an urgent necessity. There may even be an argument for stating that maintenance of current practice, outside of a randomised trial, is unethical.

C7 deficiency in an Irish family: a deletion defect which is predominant in the Irish.

Human deficiencies of terminal complement components are known to be associated with increased susceptibility to Neisseria meningitidis infection. Polymorphic DNA marker studies in complement deficient investigations allow identification of haplotypes associated with the deficiency and enable the possible identification of heterozygote carriers of the defect. We report studies of an Irish family in which the index case had suffered recurrent meningococcal disease and was found to be deficient in the seventh component of complement (C7). The availability of all family members enabled us to determine the segregating haplotypes. The defects in the family segregated with two very closely related C6 and C7 DNA haplotypes, one of which is known to be associated with the large Irish C7 DNA deletion defect. The index case and two C7 deficient siblings were found to be homozygous for this defect, a deletion that spans approx. 6.8 kbp and encompasses exons 7 and 8. The deletion defect of exons 7 and 8 of C7 has been found in homozygous form in another C7 deficient Irish individual, and is present in heterozygous form in C7 deficient members of a third Irish family. Therefore, this deletion defect occurs in five of the six deficient chromosomes of these three unrelated Irish families, raising the interesting question of how prevalent this defect may be within the Irish community.

Identification of a DinB/UmuC homolog in the archeon Sulfolobus solfataricus.

To date, eight closely related homologs of the Escherichia coli UmuC protein have been identified. All of these homologs appear to play critical roles in damage-inducible mutagenesis in enterobacteriaceae. Recently, a distantly related UmuC-homolog, DinB, has also been identified in E. coli. Using the polymerase chain reaction together with degenerate primers designed against conserved regions found in UmuC-like proteins, we have identified a new member of the UmuC-superfamily in the archeon Sulfolobus solfataricus. This new homolog shows high sequence similarity to DinB and a lower level of similarity to UmuC. As a consequence, we have called this new gene dbh (dinB homolog). Analysis of approximately 2.7 kb DNA encompassing the dbh region revealed several open reading frames (orfs). One, encoding a putative ribokinase, was located immediately upstream of dbh. This orf overlaps the dbh gene by 4 bp suggesting that both proteins might be coordinately expressed. Further upstream of the ribokinase-dbh locus was another orf encoding a potential ATPase homologous to two uncharacterized S. cerevisiae proteins (YD9346.02c and SC38KCXVI_20) and another E. coli DNA repair protein, RuvB. While this is the first report of a UmuC-like homolog in an archeon, we detected additional homologs using protein sequence comparisons in Gram-positive bacteria, cyanobacteria, and among potential human EST products, indicating that UmuC-related proteins comprise a ubiquitous superfamily of proteins probably involved in DNA repair and mutagenesis.

A novel Tn10 tetracycline regulon system controlling expression of the bacteriophage T3 gene encoding S-adenosyl-L-methionine hydrolase.

To study the effects of in vivo DNA methylation, we have developed an inducible system to control the intracellular concentration of S-adenosyl-L-methionine (AdoMet). The product of the bacteriophage T3 AdoMet hydrolase-encoding gene (amh), which degrades AdoMet to L-homoserine and 5'-methylthioadenosine, was employed to lower AdoMet concentrations in vivo. The amh gene was placed downstream from the inducible tetA promoter of the Tn10 tetracycline regulon substituting for most of the tetA gene. Unlike in the original isolates [Hughes et al., J. Bacteriol. 169 (1987) 3625-2632], this promoter allows controlled expression. These constructs are stable and can be induced in a dose-dependent manner. The system is maximally induced 2-3 h after addition of the inducer, autoclaved chlortetracycline (cTc). DNA methylation in vivo was assessed in this model system by BamHI cleavage of plasmid DNA isolated from cells cotransformed by two compatible plasmids, one carrying the inducible amh gene, the other M.BamHII methyltransferase encoding gene. The induction of amh decreased the intracellular pool of AdoMet which M.BamHII requires as a cofactor. Under these conditions, there is a decrease in DNA methylation. The unmethylated DNA is assayed by BamHI cleavage. This system will be useful for studying transcription, DNA replication, gene repair and other cellular phenomena affected by methylation.

Expression of dopamine beta-hydroxylase in Drosophila Schneider 2 cells. Evidence for a mechanism of membrane binding other than uncleaved signal peptide.

To characterize the mechanism of membrane attachment of dopamine beta-hydroxylase, an expression system producing the processed form of this enzyme has been developed. We have replaced the endogenous signal peptide of bovine dopamine beta-hydroxylase with a heterologous signal peptide which is efficiently recognized and cleaved in Drosophila Schneider 2 cells. A cDNA encoding this chimeric recombinant bovine enzyme has been stably transfected into Schneider 2 cells. The inducible expression of active dopamine beta-hydroxylase in these cells has been verified by Western blotting and enzyme activity assays. N-terminal sequence analysis of purified recombinant enzyme demonstrates complete removal of the signal peptide. Subcellular analysis shows that the recombinant enzyme exists as both a soluble and a membrane-bound form in these cells. These data demonstrate that the endogenous signal peptide is not required for the formation of the membranous dopamine beta-hydroxylase and further that the enzyme can be bound to membranes via a mechanism other than uncleaved signal sequence.

Cloning of the BamHI methyl transferase gene from Bacillus amyloliquefaciens.

We wish to report the initial characterization of a recombinant clone containing the BamHI methylase gene. Genomic chromosomal DNA purified from Bacillus amyloliquefaciens was partially cleaved with HindIII, fractionated by size, and cloned into pSP64. Plasmid DNA from this library was challenged with BamHI endonuclease and transformed into Escherichia coli HB101. A recombinant plasmid pBamM6.5 and a subclone pBamM2.5 were shown to contain the BamHI methylase gene based on three independent observations. Both plasmids were found to be resistant to BamHI endonuclease cleavage, and chromosomal DNA isolated from E.coli HB101 cells harboring either of the plasmids pBamM6.5 or pBamM2.5 was resistant to cleavage by BamHI endonuclease. In addition, DNA isolated from lambda phage passaged through E.coli HB101 containing either plasmid was also resistant to BamHI cleavage. Expression of the BamHI methylase gene is dependent on orientation in pSP64. In these clones preliminary evidence indicates that methylase gene expression may be under the direction of the plasmid encoded LacZ promoter.

Do sleep studies contribute to the management of patients with severe chronic obstructive pulmonary disease?

To determine whether studies of breathing and oxygenation during sleep are clinically useful, we have assessed whether the detection of excess nocturnal hypoxemia in patients with chronic obstructive pulmonary disease (COPD) is of prognostic importance. Ninety-seven patients with COPD were followed for 32 to 108 (median, 70) months after studies of overnight oxygenation. Significant relationships (p less than 0.001) were obtained between mean oxygen saturation (SaO2) asleep and awake. There was similarly a significant relationship between lowest SaO2 asleep and awake, but this relationship was improved by the inclusion of awake arterial carbon dioxide tension (PaCO2). The patients who were more hypoxic at night than predicted from these regression relationships had similar survivals to the patients who were less hypoxic at night than predicted, whether excess nocturnal hypoxia was defined in terms of mean or lowest SaO2 during sleep. In the 66 patients who did not subsequently receive long-term oxygen therapy, none of the indices of nocturnal oxygenation was related to survival, the only significant predictor of survival being daytime arterial oxygen tension (PaO2). For all 97 patients, both mean nocturnal SaO2 and lowest SaO2 during sleep were related to survival (p less than 0.05), and percent predicted vital capacity was also related to survival (p less than 0.05). Neither of the oxygen saturations during sleep significantly added to the more readily and cheaply measured percent predicted vital capacity in determining survival in these patients. Thus, in patients with COPD, excess nocturnal hypoxemia is not associated with an impaired prognosis, and so studies of oxygenation during sleep cannot be recommended in the routine clinical management of these patients.

Regional distribution of ventilation in chronic obstructive lung disease and the effect of salbutamol.

Regional distribution of ventilation was assessed in 5 normal volunteers, and 19 patients with symptomatic chronic obstructive lung disease (COAD) using the technique of gated lung ventilation imaging with 127Xe. The results of this technique were compared with the more conventional assessment of regional ventilation by analysis of 127Xe wash-out curves. Both techniques demonstrate loss of the normal gravitational distribution of ventilation in patients with severe COAD which is significantly reduced from normals in upper, middle and lower zones of each lung, being most marked in the lower zones (p less than 0.01). Gated lung imaging also shows a significant reduction of regional ventilation in patients with mild to moderate COAD compared to normals but only in the lower zones (p less than 0.05). Gated lung imaging provides a better quantitative method of assessing regional lung function than wash-out analysis and confirms loss of the normal gravitational distribution of ventilation in patients with obstructive lung disease and relates this to severity of disease. The distribution of ventilation was also assessed in 6 patients with severe COAD before and after placebo or salbutamol. There was a significant improvement of the distribution of ventilation to the lung bases after salbutamol (p less than 0.05).