The Clinical Nurse Leader--new nursing role with global implications.

AIM: This paper describes the development of the Clinical Nurse Leader (CNL ©) role and education, the CNL's impact and potential to improve quality globally. BACKGROUND: The need for clinical nurse leadership to improve the quality of health care systems while controlling costs is recognized in reports internationally. In the USA, a new nursing role, the CNL, was developed in response to such reports. CONCLUSION: CNLs are master's level nurse graduates (although not necessarily recruited from a nursing background) with the skills and knowledge to create change within complex systems and improve outcomes while they remain direct care providers. This innovative role can be adapted worldwide to improve the quality of health care systems.

Unexpected death due to chloramine toxicity in a woman with a brain tumor.

It has been known for years that mixing household cleaning products can be hazardous. Nonetheless, from time to time, episodes of pneumonitis from such mixing occur. Although symptoms range from minor upper respiratory irritation to adult respiratory distress syndrome, deaths are very rare. We present the case of a woman with an undiagnosed oligodendroglioma who mixed bleach and ammonia (resulting in the formation of chloramine gas), and died while cleaning her bathroom. To our knowledge, this is the first such death reported from chloramine gas intoxication.

Fatal hyperthermia secondary to sunbathing in a patient with multiple sclerosis.

A 27-year-old white woman with a history of multiple sclerosis was found dead lying on a lounger, clad in a bathing suit. She had been sunbathing for 4 hours. Significant autopsy findings consisted of numerous variably sized demyelinated plaques involving the periventricular cerebral white matter and cerebellum. Elevation of core temperature in patients with multiple sclerosis leading to transient or permanent adverse neurologic signs and symptoms has been documented for more than 60 years. This case illustrates that a modestly increased core body temperature, even from a usually innocuous activity such as sunbathing, may be fatal in patients with multiple sclerosis.

The REFLECT approach to literacy and social change: a gender perspective.

PIP: The introduction to this article on the participatory learning approach to literacy and social change known as REFLECT locates the origins of the approach in the philosophy of Paulo Freire and notes that REFLECT was developed by ACTIONAID in pilot projects in Uganda, Bangladesh, and El Salvador and is now used in 25 countries by 90 groups. REFLECT considers gender equity integral to social change, analyzes the causes of inequalities, creates a process for examining social stratification, addresses conflict as a reality, is an evolving process that embraces innovation, recognizes the importance of individual transformation, and seeks an equitable practice of power at all levels in the process. The article describes how REFLECT sessions are conducted and how they result in women's increased mobility, increased participation in family and community, and changes in the gender division of labor. Examples show how REFLECT sensitizes men as well as women to gender issues, especially if the implementing agency is gender-aware. The article then contrasts the "primer method" of literacy training promoted by the "Women in Development" model to REFLECT's "Gender and Development" (GAD) approach that links literacy to empowerment, raises community consciousness of women's subordination, and creates local-global links. The article concludes by discussing ways to strengthen the GAD/feminist approach in REFLECT, given the fact that it is possible to avoid gender issues in most discussions.^ieng

Lipomas of the internal auditory canal.

Lipoma of the internal auditory canal is a rare tumor that may be confused clinically with the much more common vestibular schwannoma. We present two cases of lipoma of the internal auditory canal. The clinical presentation is indistinguishable from that of vestibular schwannomas. The high signal intensity on T1-weighted magnetic resonance imaging, both with and without contrast, is consistent with other reports of lipoma. Review of the literature shows that lipomas of the internal auditory canal are histopathologically similar to lipomas of the cerebellopontine angle. The symptoms, erosive effect on the auditory canal, and gross appearance of this uncommon tumor are sometimes difficult to differentiate from those of a vestibular schwannoma. The diagnosis can be established by intraoperative examination of frozen sections.

Tyrosine hydroxylase and cholecystokinin mRNA levels in the substantia nigra, ventral tegmental area, and locus ceruleus are unaffected by acute and chronic haloperidol administration.

1. The studies described herein were designed to test the hypothesis that a neuroleptic, haloperidol, may alter the level of expression of the tyrosine hydroxylase and cholecystokinin genes in discrete brain regions. 2. In situ hybridization was employed to quantitate changes in concentration of mRNA for tyrosine hydroxylase and cholecystokinin in the ventral tegmental area, substantia nigra, and locus ceruleus after acute or chronic treatment with haloperidol or vehicle. 3. Haloperidol had no effect on the level of tyrosine hydroxylase or cholecystokinin mRNAs, in the ventral tegmentum, substantia nigra, or locus ceruleus, at either 3 or 19 days of drug administration. 4. These data suggest that haloperidol administration does not alter the level of tyrosine hydroxylase or cholecystokinin mRNAs in midbrain dopamine neurons of the rat.

Hypothalamic effects on medullary reticular activation of deep back muscle EMG.

Medullary reticular stimulation can activate deep back muscle EMG in urethane-anesthetized female rats. Midbrain central gray stimulation can facilitate brainstem reticular control over deep back muscles. Since these deep back muscles lateral longissimus (LL) and medial longissimus (ML) execute the vertebral dorsiflexion of lordosis behavior, and since the motor control hierarchy sketched above parallels lordosis behavior circuitry, we tested the hypothesis that medial hypothalamic lesions (which, in behavioral experiments, decrease lordosis) can also reduce medullary reticular activation of deep back muscle EMG. Urethane-anesthetized rats were tested systematically for amplitude of lateral longissimus (LL) and medial longissimus (ML) EMG responses to electrical stimulus trains applied to the nucleus gigantocellularis (NGC) of the medullary reticular formation, before and after electrolytic lesions of the ventromedial hypothalamus (n = 18) or control sites (n = 30). Bilateral ventromedial hypothalamic lesions were able to greatly reduce EMG responses in LL and ML, often with a time course similar to previous lordosis behavioral results. Surprisingly, lesions at the anterior ventromedial nucleus pole were particularly effective, and may reflect importance of intraventromedial local neurons. Although, on the average, various control lesions were less effective, the ventromedial hypothalamic effect was not unique. For example, it was possible to see an EMG decrease following lesions of the dorsomedial thalamus. Nevertheless, EMG loss was not well correlated with changes in the cortical EEG, and thus does not appear to be a simple consequence of changes in "arousal." In conclusion, it appears that ventromedial hypothalamic neurons can affect medullary reticular control of back muscle EMG, but must share this role with other forebrain elements.

Tyrosine hydroxylase and galanin mRNA levels in locus coeruleus neurons are increased following reserpine administration.

The neuropeptide galanin coexists in 80-90% of the norepinephrine-containing neurons in the locus coeruleus. In situ hybridization histochemistry was used to examine the effects of reserpine treatment or swim stress on tyrosine hydroxylase and galanin mRNA concentrations in locus coeruleus neurons. Reserpine administration significantly increased tyrosine hydroxylase and galanin mRNA levels in the locus coeruleus. The reserpine-induced increase in tyrosine hydroxylase mRNA was significantly correlated with the reserpine-induced increase in galanin mRNA. Three consecutive days of swim stress did not significantly alter either tyrosine hydroxylase or galanin mRNA concentrations in the locus coeruleus. These data suggest that both tyrosine hydroxylase and galanin gene expression in locus coeruleus neurons may be regulated by a reserpine-sensitive mechanism.

Regional distribution of the GABAA/benzodiazepine receptor (alpha subunit) mRNA in rat brain.

A human cDNA clone containing the 5' coding region of the GABAA/benzodiazepine receptor alpha subunit was used to quantify and visualize receptor mRNA in various regions of the rat brain. Using a [32P]CTP-labelled antisense RNA probe (860 bases) prepared from the alpha subunit cDNA, multiple mRNA species were detected in Northern blots using total and poly A rat brain RNA. In all brain regions, mRNAs of 4.4 and 4.8 kb were observed, and an additional mRNA of 3.0 kb was detected in the cerebellum and hippocampus. The level of GABAA/benzodiazepine receptor mRNA was highest in the cerebellum followed by the thalamus = frontal cortex = hippocampus = parietal cortex = hypothalamus much greater than pons = striatum = medulla. In situ hybridization revealed high levels of alpha subunit mRNA in cerebellar gray matter, olfactory bulb, thalamus, hippocampus/dentate gyrus, and the arcuate nucleus of the hypothalamus. These data suggest the presence of multiple GABAA/benzodiazepine receptor alpha subunit mRNAs in rat brain and demonstrate the feasibility of studying the expression of genes encoding the GABAA/benzodiazepine receptor after pharmacological and/or environmental manipulation.

Vestibulospinal and reticulospinal interactions in the activation of back muscle EMG in the rat.

The effects of electrical stimulation of the lateral vestibular nucleus (LVN) and medullary reticular formation (RF) on electromyographic activity in axial muscles medial longissimus (ML) and lateral longissimus (LL) in the rat were studied. Long trains (150-500 ms) at 200-330 Hz and 20-100 microA were sufficient to activate ML and LL at latencies of 20-100 ms from the beginning of the train. Results of stimulation at 200-330 Hz to RF or LVN showed that muscle units were activated at a fixed latency from any effective pulse in the stimulus train. Using high frequency (1 kHz) trains of 3-6 pulses to LVN, EMG activity was detected at minimum latencies of 3.5-6 ms. When conduction times from the medulla to the spinal cord, and the spinal cord to the muscle are subtracted, this latency range is consistent with monosynaptic activation. In many cases, muscle units were recruited in order of size, with both RF and LVN stimulation. Combined stimulation of LVN and RF sites in n. gigantocellularis led to EMG activity in ML and LL at currents which were insufficient to evoke activity when presented singly. When stimulation of one site (300-400 ms train) was just sufficient to evoke a response, a shorter, overlapping train (100-150 ms) to the other site led to a higher rate of muscle activity that continued through the end of the long train, even after the short train had ended. In all cases, the effect of RF facilitating LVN was similar to the effect of LVN facilitating RF. The evidence for convergence between these two systems in the medulla and the spinal cord is discussed.

Electrical stimulation of the midbrain central gray facilitates reticulospinal activation of axial muscle EMG.

EMG responses were recorded from axial muscles transversospinalis, medial longissimus, and lateral longissimus in urethane-anesthetized rats during combined electrical stimulation of the reticular formation and midbrain central gray. Central gray stimulation facilitated reticular formation-evoked EMG activity in the back muscles of the rat. Electrical stimulation of the central gray lowered the threshold for reticulospinal activation of axial muscles and could maintain firing in these muscles after the end of a reticular formation train. Units were recruited in order of size from small to large. In only one case, central gray stimulation activated axial muscles directly without reticular formation stimulation. The central gray may be important in relaying hypothalamic influences to the reticular formation, which has direct access to the axial muscles responsible for lordosis behavior.

Electrical stimulation of the midbrain central gray facilitates lateral vestibulospinal activation of back muscle EMG in the rat.

Electrical stimulation in the midbrain central gray in urethane-anesthetized female rats increased responses of the deep back muscles lateral longissimus and medial longissimus to stimulation of the lateral vestibular nucleus (LVN). During central gray stimulation, LVN stimuli led to larger muscle responses, recruitment of new motor units, and decreased latency of muscle response. Effective central gray sites are hypothesized to act through axons descending to medullary reticular formation. Results are consistent with participation of these neuronal groups in the activation of lordosis behavior, a vertebral dorsiflexion that requires deep back muscle contraction, but these electromyographic results could also be relevant for other behaviors that require vertebral postural adjustments.