Recognizing the Role of the Adult-Gerontology NP.

Whether certified in acute or primary care, AGNPs are prepared for many practice settings.

Transitions of Care Considerations for Nephrology Patients.

The need for a workforce able to address the health care needs of older adults has been well established. Individuals with kidney disease experience an extensive number of transitions of care across health care settings related to the kidney disease process and the number of health care providers involved in their care. Kidney disease is multifactorial, and the prevention of progression of disease and poor outcomes are key to improving the health of individuals with kidney disease. Nurses and nurse practitioners can improve the outcomes for individuals with complex comorbid conditions and kidney disease especially during the transitions of care.

Bloodspot acylcarnitine and amino acid analysis in cord blood samples: efficacy and reference data from a large cohort study.

BACKGROUND: In order to test the feasibility of cord blood screening for inherited metabolic disease, a two-year cohort study of births in six obstetric units from five towns in the north of England was undertaken. These towns have a high prevalence of consanguineous marriages, largely among the immigrant Asian community. The purpose of the study was to determine whether early detection of metabolic disease was possible and whether early intervention would improve prognosis. METHODS: Following parental consent, cord blood samples were collected at birth and analysed for acylcarnitine and amino acid profiles by tandem mass spectrometry in one of two laboratories. One laboratory used butylated derivatives, the other used underivatized samples. The same laboratories performed routine blood spot neonatal screening at 5-7 days of age on these babies. Patients with positive results were investigated and treated by a metabolic paediatrician as soon as possible. RESULTS: 24,983 births were examined. 12,952 samples were analysed as butyl derivatives, 12,031 samples were analysed underivatized. The following disorders were detected: medium-chain acyl-CoA dehydrogenase (MCAD) deficiency (1 case), 3-methylcrotonyl-CoA carboxylase (MCC) deficiency (2 cases), maternal carnitine transporter defect (2 cases), maternal MCC (1 case). The following disorders were diagnosed subsequently but were not detected by the cord blood screening: phenylketonuria (PKU) (1 case), maple syrup urine disease (MSUD) (2 cases), argininosuccinic aciduria (1 case), methylmalonic acidaemia (MMA) (1 case), glutaric aciduria type 2 (1 case), MCAD deficiency (2 cases), 3-hydroxy-3-methylglutaryl-CoA lyase deficiency (1 case). Comprehensive reference data for all analytes by both methods were obtained. CONCLUSIONS: Cord blood testing is of limited value in detecting inherited metabolic disease. The metabolites associated with most disorders examined were not elevated in cord blood. Some maternal disorders, carnitine transporter defect and 3-methlycrotonyl-CoA carboxylase deficiency, are detected. These remain of uncertain clinical significance. Comprehensive reference data have been obtained that will facilitate future interpretation of studies in cord blood.

Reference data for cerebrospinal fluid and the utility of amino acid measurement for the diagnosis of inborn errors of metabolism.

BACKGROUND: Cerebrospinal fluid (CSF) amino acid analysis is fundamental to the investigation of several inherited metabolic diseases, particularly those presenting with unexplained seizures. CSF glycine measurement is often crucial to the diagnosis of glycine encephalopathy (GE), low CSF serine concentrations are characteristic of 3-phosphoglycerate dehydrogenase deficiency (3-PGDD) and the presence of sulphocysteine is pathognomonic of sulphite oxidase deficiency (SOD), and a vital clue to molybdenum cofactor deficiency (MCD). Limited information is available in the literature on reference values of amino acids in CSF during infancy and CSF samples from healthy individuals are not easily obtained. METHODS: In order to establish paediatric CSF amino acid reference ranges, we performed a retrospective analysis of all quantitative CSF amino acid data collected in our laboratory over a five-year period. Amino acid analysis was performed using ion-exchange chromatography on a Biochrom-20 amino acid analyser with ninhydrin detection. CSF samples were collected from infants undergoing investigation for unexplained seizures. RESULTS: About 18 of the 95 samples received were excluded from the reference data-set; one was from a patient in whom a diagnosis of GE was confirmed by enzyme analysis, one was from a patient with CSF sulphocysteine of 19 micromol/L in whom a diagnosis of SOD was confirmed by enzyme analysis; the remaining 16 were clearly bloodstained (n = 4) or xanthochromic (n = 12). Frequency of distribution analysis revealed that concentration values for each amino acid demonstrated a right-skewed distribution which was not normalized by log transformation. Data were therefore analysed using non-parametric descriptive statistics and reference ranges were defined by the 2.5th and 97.5th centile limits. CONCLUSIONS: Our reference data were derived from 77 CSF samples taken from 77 infants. Median CSF glycine concentration was 9 micromol/L with a reference range of 3-19 micromol/L. For serine, the median CSF concentration was 52 micromol/L with a reference range of 25-105 micromol/L. Sulphocysteine was not normally present in detectable quantities (<1 micromol/L).

Sternocostoclavicular hyperostosis.

Sternocostoclavicular hyperostosis is a chronic arthro-osteitis affecting mostly juxtasternal structures. It is characterized clinically by painful swelling of the upper anterior chest wall and occasionally is associated with pustulosis palmaris and plantaris. Pathologically there is osteitis, periostitis, and new bone formation of periarticular structures. Two patients are described, and the clinical, laboratory, and radiological findings of 251 reported cases in the English literature are reviewed.

Trends in the inpatient care of persons with schizophrenia.

This report analyzes nationally representative data to examine inpatient services provided to persons with schizophrenia. The data are for patients admitted to general hospitals, private psychiatric hospitals, and State and county mental hospitals between 1970 and 1986 (weighted n = 860,637). The proportion of admissions diagnosed as having schizophrenia decreased from 21 percent in 1970 to 16 percent in 1986; this proportion decreased in public general hospitals and increased in private general hospitals. The rate of admissions for schizophrenia decreased in public general hospitals and State and county mental hospitals and increased in private general hospitals. The overall admissions rate decreased for whites with schizophrenia and increased for African-Americans, owing entirely to increased admissions of African-American males. Private general hospitals and State and county mental hospitals relied less over time on private insurance; the use of Medicare increased in both public and private general hospitals; and Medicaid use increased in private general hospitals. Further research on services for this population is necessary as a baseline for health care reform.

Alcohol expectancies and motives in a substance abusing male treatment sample.

Although prior research has demonstrated the utility of both alcohol expectancies and drinking motives in the prediction of alcohol use and problems, the specific relationship between these domains has not been examined in a clinical sample. One-hundred, forty-seven veterans on an inpatient substance abuse unit completed questionnaires measuring alcohol expectancies and alcohol motives and provided information on their alcohol consumption and related problems. Covariance structure modeling was used to test four theoretically competing models. Findings indicated that: (1) motives mediate the effects of expectancies on use and problems and expectancies do not exert an independent influence on consumption and alcohol problems and (2) contrary to past findings, alcohol use only partially mediates the relationship between enhancement motives and alcohol problems.

Novelty seeking as a predictor of treatment retention for heroin dependent cocaine users.

This study examined the relationship between novelty seeking between treatment retention and among heroin dependent cocaine users. Participants were treated with buprenorphine maintenance and contingency management. The Tridimensional Personality Questionnaire's (TPQ) Novelty Seeking scale was administered to 68 participants prior to buprenorphine induction. Demographics, mood and anxiety disorders, antisocial personality disorder, and substance use were also assessed. Variables with significant relationships with overall retention were entered into a logistic regression analysis. In addition, using a survival analysis, all variables with significant relationships with time to drop-out were entered into a multivariate proportional hazards regression with time dependent covariates. Results demonstrated that although high novelty seekers, in comparison to low novelty seekers, were more likely to drop-out by the end of treatment, they had higher retention rates during the early phases of treatment. It is suggested that buprenorphine and contingency management were viewed by participants as novel treatment components and thus facilitated high novelty seekers' success early in treatment. If replicated, results suggest that inclusion of novel treatment components might facilitate retention among this at-risk group.

Measurement of dopamine, HVA and HMMA in untimed urine samples: establishment of age-related reference data in children.

We describe assays for homovanillic acid, hydroxymethylmandelic acid and dopamine that have proven practical and reliable during 3 years of routine use. Homovanillic and hydroxymethylmandelic acids were measured as trimethyl silyl derivatives by capillary gas chromatography. Dilution of samples prior to extraction was found to be necessary to achieve consistent recoveries of these acidic metabolites. Dopamine was assayed by high pressure liquid chromatography with electrochemical detection using an optimized method of catecholamine isolation that involved both ion exchange and alumina extraction. Untimed urine samples were collected from 140 hospitalized children. Age related reference data for the excretion of all three metabolites are reported. We suggest certain precautions that should be observed when using untimed samples and relating the results to creatinine excretion.

Measurement of phenylalanine and tyrosine in plasma by high-performance liquid chromatography using the inherent fluorescence of aromatic amino acids.

An isocratic high-performance liquid chromatography (HPLC) method is described using the natural fluorescence of phenylalanine and tyrosine compared with that of an internal standard N-methyl phenylalanine. Plasma precipitated with 6% perchloric acid was separated isocratically using a base-deactivated C18 column with 5% acetonitrile in water as the mobile phase. Fluorescent measurements at an excitation wavelength of 215 nm and emission 283 nm showed only three peaks for tyrosine, phenylalanine and the internal standard eluting within 9 min. Inter-batch coefficients of variation for phenylalanine were 2.9% and 1.8% at levels of 70 and 567 mumol/L, respectively, and 2.9% at a level of 63 mumol/L for tyrosine. The results for phenylalanine for this method showed a small mean positive bias (11 mumol/L) when compared with the target all-method means for UK National External Quality Assessment Scheme samples (n = 31). The results for tyrosine showed a small positive mean bias (10 mumol/L) when compared with an ion-exchange chromatographic method (n = 40). This method provides a quick and simple alternative to those using HPLC with pre- or post-column derivatization for monitoring patients with phenylketonuria. It is also less subject to interferences than HPLC methods using ultraviolet detection, particularly for the early eluting tyrosine peak.

Covariance structure models of expectancy.

Antecedent variables under the broad categories of genetic, environmental and cultural influences have been linked to the risk for alcohol abuse. Such risk factors have not been shown to result in high correlations with alcohol consumption and leave unclear an understanding of the mechanism by which these variables lead to increased risk. This study employed covariance structure modeling to examine the mediational influence of stored information in memory about alcohol, alcohol expectancies in relation to two biologically and environmentally driven antecedent variables, family history of alcohol abuse and a sensation-seeking temperament in a college population. We also examined the effect of criterion contamination on the relationship between sensation-seeking and alcohol consumption. Results indicated that alcohol expectancy acts as a significant, partial mediator of the relationship between sensation-seeking and consumption, that family history of alcohol abuse is not related to drinking outcome and that overlap in items on sensation-seeking and alcohol consumption measures may falsely inflate their relationship.

Validation of cocaine and marijuana effect expectancies in a treatment setting.

This study sought to establish the validity of the Cocaine Effect Expectancy Questionnaire (CEEQ), and the Marijuana Effect Expectancy Questionnaire (MEEQ) in discriminating between patterns of drug use in a clinical population. Prior research with these questionnaires has involved primarily nonclinical samples. Expectancy literature has yielded ambiguous results in demonstrating the role of both positive and negative expectancies in regards to drug use patterns. The sample consisted of 149 males on an inpatient V.A. substance abuse unit. On the CEEQ, cocaine users, particularly frequent users, endorsed fewer global positive cocaine expectancies than infrequent or nonusers. Present-infrequent users endorsed greater arousal effects than either present-frequent or nonusers. Nonusers of cocaine endorsed greater relaxation than present users. On the MEEQ, nonusers expected more negative effects from marijuana than users. Present users expected greater relaxation and craving effects than past users or nonusers. These results indicate different roles for positive and negative expectancies in cocaine and marijuana use.

The utility of novelty seeking, harm avoidance, and expectancy in the prediction of drinking.

To test the hypothesis that two temperament scales (Novelty Seeking and Harm Avoidance) are differentially related to alcohol expectancies and drinking patterns, 140 adolescents from an inpatient psychiatric facility completed several self-report questionnaires measuring temperament, alcohol expectancies, and alcohol consumption. Moderated multiple regression analyses indicated that Novelty Seeking was significantly related to frequency of drinking and problem drinking, but that Harm Avoidance was not related to these variables. Results of the MANOVA indicated that high novelty seeking and low harm avoidant (Type 2) individuals had a significantly higher frequency of drinking than did individuals who were high on Harm Avoidance and low on Novelty Seeking (Type 1). Results also showed that expectancy and Novelty Seeking contributed significant independent and overlapping variance in the prediction of amount of drinking. Although Novelty Seeking was related to expectations of social functioning, other hypothesized relationships between temperament and expectancy were not supported.

Healing of incisions in the tongue: a comparison of results with milliwatt carbon dioxide laser tissue welding versus suture repair.

The healing of carbon dioxide laser weld closures produced by two commercial instruments of differing design were compared. Healing after laser welding was also compared to healing following conventional suture closure. Healing was evaluated histologically and by measurement of tensile strength over time. No histologic differences were found between closures produced by different lasers; however, in all cases suture closure resulted in slower healing times consistent with a foreign body reaction prolonging the healing process. Tensile strength measurements were performed at intervals over the first 21 days after the operation. Laser repair was found to be equivalent to or stronger than suture repair at every interval measured. The clinical use of the carbon dioxide laser for tissue welding of oral injuries should be investigated further, since it appears to be a good alternative to suture repair.

Cholesterol granuloma of the frontal sinus.

It is common to see cholesterol granuloma in the mastoid air cells, less common in the orbit, and uncommon in the paranasal sinuses. Cholesterol granuloma is thought to be due to an interruption to normal aeration with impaired lymphatic drainage, resulting in a closed cavity where it may form. These expanding cysts cause bone destruction and compression of the surrounding structures that lead to clinical symptoms. Diagnosis and management of cholesterol granuloma cysts can be challenging. Magnetic resonance imaging (MRI) and computed tomographic (CT) scans are usually diagnostic. We present a rare case of cholesterol granuloma in the frontal sinus, few cases have been reported in the literature.

The new informatics of national healthcare reform.

The President's Health Security Act has succeeded in attracting America's attention. Several of its initiatives have been well-publicized and hotly debated in Congress. The act also includes a number of implications for healthcare informatics, and devotes an entire chapter to this subject, although this area has not received as much publicity. Every behavioral healthcare provider's information system would be significantly affected by enactment of the Health Security Act. Selected forms and data elements for the management and delivery of behavioral healthcare services would need to be standardized. Organizations of behavioral healthcare providers, managed care companies and purchasers would increasingly share selected patient and subscriber information in aggregated form, for a variety of purposes. As a result, tougher laws to protect patient data privacy will likely be forthcoming. The following article gives an overview of the informatics needs of the soon-to-be reformed American healthcare system, into which behavioral healthcare will be integrated. As part of the larger system, behavioral healthcare services and information systems will need to comply with the same guidelines and requirements, outlined below, as other healthcare providers. Preparation to meet the information demands of the evolving healthcare system will require adaptation of existing computerized information systems, utilization of new technology, consultation with the system's major shareholders and attention to continuous quality improvement processes.