Preparedness to Respond to Family Violence: A Cross-Sectional Study Across Clinical Areas.

Introduction: Family violence (FV) is one of the most urgent health issues of our generation. While nurses play a vital role in identifying and supporting victim/survivors of violence, little is known about nursing readiness to respond across clinical areas. Objective: This study aimed to compare and contrast the knowledge, confidence, clinical skills, and perceived barriers of nurses across three clinical areas of a tertiary trauma hospital in Melbourne, Australia, in responding to FV. Method: A prospective, mixed methods design was used. The nursing staff at a large trauma hospital were approached to participate. Participants completed a brief online survey to quantify clinician-reported knowledge, clinical skills, and barriers to managing FV. Results: Two hundred and forty-two nursing staff electronically completed a brief survey to capture self-reported confidence, knowledge, clinical skills, and barriers to working effectively in the area. The descriptive analysis reflected service-wide deficits in knowledge, confidence, and self-reported clinical skills, irrespective of the work area. Deficits were identified on a background of limited structured training for FV among this cohort. Significantly higher rates of FV confidence and knowledge were identified among emergency department nurses relative to acute and subacute clinical counterparts. Conclusion: Nurse respondents overall reported low rates of confidence, knowledge, and clinical skills in responding to disclosures of FV. Findings reinforce the need for imbedded training programs to support frontline responses.

Nanoscale conductive pattern of the homoepitaxial AlGaN/GaN transistor.

The gallium nitride (GaN)-based buffer/barrier mode of growth and morphology, the transistor electrical response (25-310 °C) and the nanoscale pattern of a homoepitaxial AlGaN/GaN high electron mobility transistor (HEMT) have been investigated at the micro and nanoscale. The low channel sheet resistance and the enhanced heat dissipation allow a highly conductive HEMT transistor (Ids > 1 A mm(-1)) to be defined (0.5 A mm(-1) at 300 °C). The vertical breakdown voltage has been determined to be ∼850 V with the vertical drain-bulk (or gate-bulk) current following the hopping mechanism, with an activation energy of 350 meV. The conductive atomic force microscopy nanoscale current pattern does not unequivocally follow the molecular beam epitaxy AlGaN/GaN morphology but it suggests that the FS-GaN substrate presents a series of preferential conductive spots (conductive patches). Both the estimated patches density and the apparent random distribution appear to correlate with the edge-pit dislocations observed via cathodoluminescence. The sub-surface edge-pit dislocations originating in the FS-GaN substrate result in barrier height inhomogeneity within the HEMT Schottky gate producing a subthreshold current.

Nanoscale investigation of AlGaN/GaN-on-Si high electron mobility transistors.

AlGaN/GaN HEMTs are devices which are strongly influenced by surface properties such as donor states, roughness or any kind of inhomogeneity. The electron gas is only a few nanometers away from the surface and the transistor forward and reverse currents are considerably affected by any variation of surface property within the atomic scale. Consequently, we have used the technique known as conductive AFM (CAFM) to perform electrical characterization at the nanoscale. The AlGaN/GaN HEMT ohmic (drain and source) and Schottky (gate) contacts were investigated by the CAFM technique. The estimated area of these highly conductive pillars (each of them of approximately 20-50 nm radius) represents around 5% of the total contact area. Analogously, the reverse leakage of the gate Schottky contact at the nanoscale seems to correlate somehow with the topography of the narrow AlGaN barrier regions producing larger currents.

Interaction of malaria with a common form of severe thalassemia in an Asian population.

In many Asian populations, the commonest form of severe thalassemia results from the coinheritance of HbE and beta thalassemia. The management of this disease is particularly difficult because of its extreme clinical diversity; although some genetic and adaptive factors have been identified as phenotypic modifiers, the reasons remain unclear. Because the role of the environment in the course of severe thalassemia has been neglected completely and because malaria due to both Plasmodium falciparum and Plasmodium vivax has been prevalent in Sri Lanka, we carried out a pilot study of patients with HbE beta thalassemia that showed high frequencies of antibodies to both parasite species and that 28.6% of the children had DNA-based evidence of current infection with P. vivax. Malarial antibodies then were assessed in patients with HbE beta thalassemia compared with those in age-matched controls. There was a significant increase in the frequency of antibodies in the thalassemic patients, particularly against P. vivax and in young children. There was also a higher frequency in those who had been splenectomized compared with those with intact spleens, although in the latter it was still higher than that in the controls. The thalassemic patients showed significant correlations between malaria antibody status and phenotype. Patients with HbE beta thalassemia may be more prone to malaria, particularly P. vivax, which is reflected in their clinical severity. Because P. vivax malaria is widespread in Asia, further studies of its interaction with HbE beta thalassemia and related diseases are required urgently as a part of ongoing thalassemia control programs.

Jean Langlais (1907-91): an historical case of a blind organist with stroke-induced aphasia and Braille alexia but without amusia.

The subject of a prior report of a blind organist with aphasia and Braille alexia without amusia, published in French, has been identified as Jean Langlais. His artistic and medical history is presented, the latter via translation of the original 1987 paper.

Frequency and diagnostic utility of cognitive test instrument use by GPs prior to memory clinic referral.

BACKGROUND: Previous studies have indicated not only that cases of dementia are missed in primary care but also that many non-demented patients are referred for evaluation to secondary care. OBJECTIVES: To measure frequency of cognitive test instrument use in primary care prior to patient referral to secondary care and to assess the relationship between instrument use and ultimate diagnosis. METHODS: This was a prospective study conducted in a Cognitive Function Clinic, Regional Neuroscience Centre setting. The referral letters for all patients seen in the clinic over a 2-year period (n = 231) were examined for mention of cognitive test instrument use. Patients were evaluated by standard clinical, neuropsychological and neuroimaging methods and diagnoses were made according to widely accepted diagnostic criteria for dementia and dementia subtype. Primary care cognitive test use and final diagnosis were then compared. RESULTS: Evidence of cognitive test use in primary care was found in 20% of referrals. Patients evaluated with cognitive test instruments in primary care were more likely to receive a diagnosis of dementia, whereas those not tested were more likely to receive a diagnosis of 'not demented'. CONCLUSIONS: Use of simple cognitive test instruments in primary care may improve dementia diagnosis and reduce the rate of referral of non-demented patients.

Age-related changes in adaptation to severe anemia in childhood in developing countries.

Severe forms of anemia in children in the developing countries may be characterized by different clinical manifestations at particular stages of development. Whether this reflects developmental changes in adaptation to anemia or other mechanisms is not clear. The pattern of adaptation to anemia has been assessed in 110 individuals with hemoglobin (Hb) E beta-thalassemia, one of the commonest forms of inherited anemia in Asia. It has been found that age and Hb levels are independent variables with respect to erythropoietin response and that there is a decline in the latter at a similar degree of anemia during development. To determine whether this finding is applicable to anemia due to other causes, a similar study has been carried out on 279 children with severe anemia due to Plasmodium falciparum malaria; the results were similar to those in the patients with thalassemia. These observations may have important implications both for the better understanding of the pathophysiology of profound anemia in early life and for its more logical and cost-effective management.

Haemoglobin E beta thalassaemia in Sri Lanka.

Haemoglobin E beta thalassaemia is the commonest form of severe thalassaemia in many Asian countries, but little is known about its natural history, the reasons for clinical diversity, or its management. We studied 109 Sri Lankan patients with the disorder over 5 years. 25 patients were not receiving transfusion; transfusion was stopped with no deleterious effect in a further 37. We identified several genetic and environmental factors that might contribute to the phenotypic diversity of the disorder, including modifiers of haemoglobin F production, malaria, and age-related changes in adaptive function. Our findings suggest that haemoglobin E beta thalassaemia can be managed without transfusion in many patients, even with low haemoglobin levels. Age-related changes in the pattern of adaptation to anaemia suggest that different and more cost-effective approaches to management should be explored.

The global distribution of length polymorphisms of the promoters of the glucuronosyltransferase 1 gene (UGT1A1): hematologic and evolutionary implications.

The promoter region of the UDP glucuronosyltransferase 1 gene (UGT1A1) contains a run of thymine-adenine (TA) repeats, usually six (TA)(6). As well as its relationship to Gilbert's syndrome, homozygosity for the extended sequence, (TA)(7) (TA)(7), has been found to be an important risk factor for hyperbilirubinemia and gallstones in patients with hemoglobin E-beta-thalassemia and other intermediate forms of beta thalassemia. To assess the importance of this polymorphism in these common disorders a wide-scale population study of the relative frequency of the size alleles of the UGT1A1 promoter has been carried out. Homozygosity for the (TA)(7) allele occurs in 10-25% of the populations of Africa and the Indian subcontinent, with a variable frequency in Europe. It occurs at a much lower frequency in Southeast Asia, Melanesia, and the Pacific Islands, ranging from 0 to 5%. African populations show a much greater diversity of length alleles than other populations. These findings define those populations with a high frequency of hemoglobin E-beta-thalassemia and related disorders that are at increased risk for hyperbilirubinemia and gall bladder disease and provide evolutionary insights into how these polymorphisms have arisen and are so unequally distributed among human populations.

Age-specific and age-adjusted penetrance as poison center outcome measures.

BACKGROUND: The American Association of Poison Control Centers defines penetrance as the number of exposures per 1000 residents of a population during one year. This metric fails to account for confounding by age group variability. We demonstrate the error caused by using raw penetrance and present two alternate methods of calculation, age-specific penetrance and age-adjusted penetrance. METHODS: Data from the toxic exposure surveillance system were collected from calls to our 41 county regional poison centers in 1998. Age-specific penetrance (ASP) was calculated by dividing the number of exposures (E) in age interval "i" in county "A" by 1000 population in age interval "Pi" in county "A" or ASP = Ei/Pi. AAP is the summation of the weighted age-specific penetrance. Weights (w(si)) represent the relative age distribution of a standard population, in this case the 1998 US population. AAP = sigma(i) w(si) * Ei/Pi. RESULTS: [table: see text] County C has low raw penetrance and is known to have relatively fewer toddlers and presumably a lower incidence of poisoning. This demonstrates that raw penetrance misrepresents populations with small proportions of children and should not be used to compare promotion or prevention activities between populations. CONCLUSION: We recommend poison centers and the American Association of Poison Control Centers replace raw penetrance with age-adjusted penetrance as one measure of the effectiveness of a poison center's awareness efforts.

Genetic determinants of jaundice and gallstones in haemoglobin E beta thalassaemia.

Chronic hyperbilirubinaemia, gallstone formation, and gall bladder disease are unusually common in people with haemoglobin E beta thalassaemia in Sri Lanka. To determine whether this has a genetic basis we compared the bilirubin levels and frequency of gallstones in patients with different alleles of the UGT*1 gene. There was a significantly higher bilirubin level in those with the 7/7 genotypes compared with 6/6 and 6/7 genotype (p=0.032 and 0.0015 respectively), who also appeared more prone to gallstone formation. These results suggest that the UGT*1 genotpe is of importance in the genesis of gallstones in this population of patients.

The lipid-associated conformation of the low density lipoprotein receptor binding domain of human apolipoprotein E.

Apolipoprotein E (apoE) is a 34-kDa exchangeable apolipoprotein that regulates metabolism of plasma lipoproteins by functioning as a ligand for members of the LDL receptor family. The receptor-binding region localizes to the vicinity of residues 130-150 within its independently folded 22-kDa N-terminal domain. In the absence of lipid, this domain exists as a receptor-inactive, globular four-helix bundle. Receptor recognition properties of this domain are manifest upon lipid association, which is accompanied by a conformational change in the protein. Fluorescence resonance energy transfer has been used to monitor helix repositioning, which accompanies lipid association of the apoE N-terminal domain. Site-directed mutagenesis was used to replace naturally occurring Trp residues with phenylalanine, creating a Trp-null apoE3 N-terminal domain (residues 1-183). Subsequently, tyrosine residues in helix 2, helix 3, or helix 4 were converted to Trp, generating single Trp mutant proteins. The lone cysteine at position 112 was covalently modified with N-iodoacetyl-N'-(5-sulfo-1-naphthyl)ethylenediamine, which serves as an energy acceptor from excited tryptophan residues. Fluorescence resonance energy transfer analysis of apoE N-terminal domain variants in phospholipid disc complexes suggests that the helix bundle opens to adopt a partially extended conformation. A model is presented that depicts a tandem arrangement of the receptor-binding region of the protein in the disc complex, corresponding to its low density lipoprotein receptor-active conformation.

The relationship between heavy alcohol use and work productivity loss in active duty military personnel: a secondary analysis of the 1995 Department of Defense Worldwide Survey.

This cross-sectional study examines the association between heavy alcohol use among active duty military personnel and five work productivity loss events that may have an adverse effect on military performance and readiness. Data for light (N = 3,147) and heavy (N = 2,242) drinkers, categorized by gender and pay grade, were obtained from the 1995 Department of Defense Worldwide Survey. Drinking classification was predefined using a standard algorithm that factored quantity and frequency of wine, beer, and liquor consumed. The relative risks of experiencing a productivity loss event at a particular level and 95% confidence intervals were calculated by applying the Mantel-Haenszel method after adjusting for age. The relative risks for increased self-reported lateness, leaving early, low performance, and on-the-job injury were all higher for heavy drinkers than for light drinkers. This association between the heavy-drinking population and four of five work productivity loss events indicates that prevention programs should target all personnel.

Reducing time in bed after percutaneous transluminal coronary angioplasty (TIBS III).

BACKGROUND: This study is the third in a series of investigations on the requisite length of time that patients should be restricted to bed after coronary arteriography or percutaneous transluminal coronary angioplasty using a femoral artery approach. METHODS: A prospective, experimental-control group design with randomization was used initially to compare the incidence of bleeding between patients who remained in bed for 4 hours and patients who remained in bed for 6 hours after sheath removal following percutaneous transluminal coronary angioplasty. RESULTS: Rapid changes in the healthcare environment led to nurses collecting complete data sets for the experimental group only. The experimental group (n = 51) was 73% male and 27% female; mean age was 57 years (SD = 11.4 years). Mean time in bed was 4.1 hours (SD = 0.27 hours). Most patients (98%) did not bleed from the femoral artery access site after remaining in bed for 4 hours following sheath removal. Ninety-two percent of patients required analgesics while in bed. Mean length of stay after the angioplasty was 1.4 days (SD = 0.79 days). Bleeding occurred in one subject and was related to multiple invasive procedures and an activated clotting time of greater than 200 seconds. CONCLUSIONS: Requisite time in bed after percutaneous transluminal coronary angioplasty has been reduced to 4 hours at the University of Virginia Medical Center, the same time required for patients undergoing cardiac catheterization. Discomfort after the procedure remains to be addressed.

Thalassaemia in Sri Lanka: implications for the future health burden of Asian populations. Sri Lanka Thalassaemia Study Group.

BACKGROUND: Thalassaemias pose an increasing problem for the Indian subcontinent and many Asian countries. We analysed the different types of thalassaemia in the Sri Lankan population, surveyed gene frequencies in schoolchildren, and estimated the burden of disease and requirements for its control. METHODS: We analysed blood samples from patients attending clinics in nine hospitals and defined the different types of beta thalassaemia by high-performance liquid chromatography (HPLC) and DNA analysis. The range of mutations was obtained by analysis of beta-globin genes. Capillary blood was obtained from schoolchildren from different parts of the island and analysed by HPLC to provide an approximate assessment of the carrier frequency of beta thalassaemia and haemoglobin E (HbE). To estimate the frequency of alpha thalassaemia the alpha-globin genotypes were also analysed when it was possible. FINDINGS: Blood samples were obtained from 703 patients with beta thalassaemia and from 1600 schoolchildren. The thalassaemia mutations were unevenly spread. Although 23 different beta-thalassaemia mutations were found, three accounted for the thalassaemia phenotype in about 70% of the patients, most whom are homozygotes or compound heterozygotes for IVS1-5 (G-->C) or IVS1-1 (G-->A). The third common mutation, codon 26 (G-->A), which produces HbE, interacts with one or other of these mutations to produce HbE/beta thalassaemia; this comprises 13.0-30.9% of cases in the main centres. Samples from 472 patients were analysed to determine the alpha-globin genotype. Overall, 15.5% patients were carriers for deletion forms of alpha+ thalassaemia. Average gene frequencies showed that there will be more than 2000 patients requiring treatment at any one time, in the future, of whom those with HbE/beta thalassaemia will account for about 40%. INTERPRETATION: In Sri Lanka, interactions of the two common beta-thalassaemia alleles will nearly always result in a transfusion-dependent disorder. However, about 40% of patients will have HbE/beta thalassaemia, which has a variable course. The management of these disorders could require about 5% of the total health budget. We need to learn more about the natural history and appropriate management of HbE/beta thalassaemia if resources are to be used effectively.

Rapid detection of alpha-thalassaemia deletions and alpha-globin gene triplication by multiplex polymerase chain reactions.

We describe a sensitive, reliable and reproducible method, based on three multiplex PCR assays, for the rapid detection of seven common alpha-thalassaemia deletions and one alpha-globin gene triplication. The new assay detects the alpha0 deletions - -SEA, - (alpha)20.5, - -MED, - -FIL and - -THAI in the first multiplex PCR, the second multiplex detects the -alpha3.7 deletion and alphaalphaalphaanti3.7 variant, the third multiplex detects the -alpha4.2 deletion. This simple multiplex method should greatly facilitate the genetic screening and molecular diagnosis of these determinants in populations where alpha-thalassaemias are prevalent.

Early fungal endocarditis in homograft recipients.

Retrospective analysis of 200 homograft valve recipients at our institution revealed two cases of fungal endocarditis. Pathogenesis appears to be related to either recipient seeding in one elderly immunocompromised patient or a previously contaminated donor valve implanted in an otherwise healthy recipient. Therefore, our experience underscores the need for both meticulous prevention of fungal infection preoperatively in the recipient and elimination of previously contaminated homograft valves from the donor pool.

Human apolipoprotein E N-terminal domain displacement of apolipophorin III from insect low density lipophorin creates a receptor-competent hybrid lipoprotein.

The surface of Manduca sexta low density lipophorin (LDLp) particles was employed as a template to examine the relative lipid binding affinity of the 22 kDa receptor binding domain (residues 1-183) of human apolipoprotein E3 (apo E3). Isolated LDLp was incubated with exogenous apolipoprotein and, following re-isolation by density gradient ultracentrifugation, particle apolipoprotein content was determined. Incubation of recombinant human apo E3(1-183) with LDLp resulted in a saturable displacement of apolipophorin III (apo Lp-III) from the particle surface, creating a hybrid apo E3(1-183)-LDLp. Although subsequent incubation with excess exogenous apo Lp-III failed to reverse the process, human apolipoprotein A-I (apo A-I) effectively displaced apo E3(1-183) from the particle surface. We conclude that human apo E N-terminal domain possesses a higher intrinsic lipid binding affinity than apo Lp-III but has a lower affinity than human apo A-I. The apo E3(1-183)-LDLp hybrid was competent to bind to the low density lipoprotein receptor on cultured fibroblasts. The system described is useful for characterizing the relative lipid binding affinities of wild type and mutant exchangeable apolipoproteins and evaluation of their biological properties when associated with the surface of a spherical lipoprotein.