Implementing the Galasko Report on the management of head injuries: the Eastern Region approach.

OBJECTIVES: The Royal College of Surgeons (RCS) Report on the management of patients with head injuries under the chairmanship of Professor Galasko, published in June 1999, made important recommendations that will have a profound effect on the organisation of management of head injuries and major implications for resources. The Eastern Region carried out an audit study to determine the provision of current services available, to assess the shortfall and likely resource implications for the implementation of the report and hence lay the foundations for a strategic plan for change across the region. METHODOLOGY: A series of interviews with all 20 accident and emergency (A&E) departments across the Eastern Region and the two regional neuroscience units (RNU) was undertaken. The results of the survey and the implications of the implementation were fed back to and discussed at a multidisciplinary regional seminar. RESULTS: There is considerable variation and major deficiencies in the service provision currently available for the management of head injuries in the Eastern Region. There are major deficiencies in A&E resources, care of moderate head injuries and rehabilitation and follow up of patients. There is a significant shortfall in resources for the implementation of the recommendations. CONCLUSION: There are major deficiencies in the overall management of head injuries. Although the RCS Galasko Report recommendations were agreed to be very desirable, they cannot be implemented without a large increase in resources in terms of funding, staffing and training.

Soluble-fibre concentrate lowers plasminogen activator inhibitor-1 in baboons (Papio ursinus).

The effects of a soluble NSP (fibre) concentrate (SFC) on plasma fibrinogen and plasminogen activator inhibitor-1 (PAI-1), serum and liver lipids and lipoproteins and glucose tolerance were compared with those of bezafibrate (BF), a lipid-lowering drug, in obese baboons (Papio ursinus). The basal diet was a high-fat (37% of total energy), low-NSP (12.4 g/d) Westernized diet, supplemented for 8 weeks with either 20 SFCg/baboon per d or 6.7 mg BF/kg body weight per baboon per d. SFC supplementation significantly lowered PAI-1, total serum cholesterol, HDL-cholesterol and circulating free fatty acid levels. BF significantly lowered total serum cholesterol, but unexpectedly raised serum triacylglycerol levels. Although not statistically significant, the mean liver triacylglycerol concentration of baboons fed on BP was lower than that of baboons fed on SFC supplements. These results suggest that: (1) the mechanism of action of the two cholesterol-lowering treatments differ, with BF having a liver triacylglycerol-lowering effect and (2) the SFC ahd additional beneficial effect on fibrinolysis by lowering PAI-1 levels.

A SNARE complex containing syntaxin 3 is present in ribbon synapses of the retina.

In contrast to conventional synapses, which release neurotransmitter transiently, ribbon synapses formed by photoreceptors and bipolar cells of the retina release neurotransmitter continuously and modulate the rate in response to light. Both modes of release are mediated by synaptic vesicles but probably differ in the regulation of docking and fusion of synaptic vesicles with the plasma membrane. We have found that syntaxin 1, an essential component of the core fusion complex in conventional synapses, is absent from ribbon synapses of the retina, raising the possibility that these synapses contain a different type of syntaxin or syntaxin-like protein. By immunoprecipitating syntaxin 1-depleted retina and brain extracts with a SNAP-25 antibody and microsequencing the precipitated proteins, syntaxin 3 was detected in retina complexed with SNAP-25, synaptobrevin, and complexin. Using an anti-syntaxin 3 antiserum, syntaxin 3 was demonstrated to be present at high levels in retina compared to brain. Immunofluorescent staining of rat retina sections confirmed that syntaxin 3 is expressed by photoreceptor and bipolar cells in the retina. Thus, in the retina, expression of syntaxin 3 is correlated with ribbon synapses and may play a role in the tonic release of neurotransmitter.

Microsequencing and cDNA cloning of the Calvin cycle/OPPP enzyme ribose-5-phosphate isomerase (EC 5.3.1.6) from spinach chloroplasts.

Ribose-5-phosphate isomerase (RPI) catalyses the interconversion of ribose-5-phosphate and ribulose-5-phosphate in the reductive and oxidative pentose phosphate pathways in plants. RPI from spinach chloroplasts was purified and microsequenced. Via PCR with degenerate primers designed against microsequenced peptides, a hybridisation probe was obtained and used to isolate several cDNA clones which encode RPI. The nuclear-encoded 239 amino acid mature RPI subunit has a predicted size of 25.3 kDa and is translated as a cytosolic precursor possessing a 50 amino acid transit peptide. The processing site of the transit peptide was identified from protein sequence data. Spinach leaves possess only one type of homodimeric RPI enzyme which is localized in chloroplasts and is encoded by a single nuclear gene. Molecular characterization of RPI supports the view that a single amphibolic RPI enzyme functions in the oxidative and reductive pentose phosphate pathways of spinach plastids.

Characterization of neutrophil iodination for the assessment of phagocytic and opsonic function in septic patients.

To increase our understanding of the nature of surgical infection, further studies on the host defense abilities of infected patients are required. Therefore, a more thorough investigation of the iodination method for the measurement of polymorphonuclear leukocyte function and serum opsonic activity was undertaken to characterize its application in surgical infection. A significant relationship was found between the phagocytic indices derived from different standard neutrophils or sera measured on the same day. When expressed as a value of normal phagocytic indices minus abnormal phagocytic indices, this relationship was constant from day to day despite wide variations in the absolute phagocytic index values. This finding enables direct comparisons to be made between the values obtained both from the same patient and from different patients during the course of their illness by reference to daily control values. We also found that the system was sufficiently sensitive to detect, in a dose-responsive manner, the changes induced in normal neutrophil phagocytosis and serum opsonic activity by a specific bacterial challenge with either K. pneumoniae or E. coli. In addition, zymosan, which is utilized in the iodination reaction but also has immunoadjuvant properties, was found to enhance neutrophil function but depress serum opsonic activity in the face of such bacterial challenges. We conclude that the iodination technique is a credible method for the indirect measurement of polymorphonuclear phagocytosis and serum opsonic function in the face of a bacterial challenge and can be reliably employed in studies of septic patients provided these findings are taken into account.

Muramyl dipeptide and polymorphonuclear leukocyte chemotaxis in vitro.

Muramyl dipeptide (MDP) is an immunostimulatory agent that has been shown repeatedly to provide protection against the effects of some forms of experimental surgical infection. The mechanisms of this protection are incompletely understood, and in order to further define them, the impact of MDP upon in vitro polymorphonuclear (PMN) leukocyte chemotaxis was examined in the presence of both normal and opsonic depleted serum. We have also evaluated the effect of MDP as a chemoattractant itself and the response of neutrophils along with MDP to a standard chemoattractant, n-formyl-L-methionyl-L-leucyl-L-phenyl-alanine (FMLP), using the agarose assay for chemotaxis. MDP has weak but significant chemotactic activity itself, with a peak effect at a concentration of 5 X 10(-8) micrograms/ml for neutrophils. These effects are enhanced by the addition of 10% serum. MDP more strongly enhances neutrophil chemotaxis to FMLP. The enhancement of chemotaxis may be a factor in the protection that MDP exerts against some experimental bacterial challenges.

Hypnosis for reduction of vomiting associated with chemotherapy and disease in adolescents with cancer.

Vomiting is often a major source of distress for adolescent oncology patients. This study evaluates the effectiveness of hypnosis in reducing the vomiting associated with chemotherapy and disease in 12 adolescents with cancer. Eight patients receiving chemotherapy demonstrated significant reductions in the frequency (p less than 0.01) and intensity (p less than 0.05) of emesis. Six of the eight patients also demonstrated a shortened duration of emesis. The ninth patient, whose vomiting was secondary to her brain tumor, showed a gradual but steady reduction in vomiting with eventual total elimination following hypnosis intervention. Three patients rejected hypnosis. Trait anxiety scores for the group were significantly lower at retest 6 months following hypnosis intervention (p less than 0.05). Significant changes in scores of health locus of control, impact of illness, or self-esteem were not found. These data support the efficacy of hypnosis for reducing vomiting when used in the context of a comprehensive clinical approach to the cancer patient.

Adolescents with cancer. Hypnosis for the reduction of the acute pain and anxiety associated with medical procedures.

Eighteen adolescents with cancer were trained in hypnosis to ameliorate the discomfort and anxiety associated with bone marrow aspirations, lumbar punctures, and chemotherapeutic injections. Two patients rejected hypnosis. The remaining 16 adolescents achieved significant reductions in multiple measures of distress after hypnosis training. Preintervention data showed no pattern of spontaneous remission or habituation, and, in fact, an increasing anticipatory anxiety was observed before hypnotic treatment. Group reductions in pain and anxiety were significant at levels ranging from p less than 0.02 to p less than 0.002 (two-tailed t-tests). Significant reductions were also found in Trait Anxiety. A non-significant trend toward greater self-esteem was present. The predicted changes in the Locus of Control and General Illness Impact were not found. Comparisons between hypnosis rejectors and successful users unusually showed higher levels of pretreatment anxiety in the former. The pragmatic nature of hypnosis as part of comprehensive medical care in oncology is noted.

beta-Endorphin immunoreactivity and acute behavioral distress in children with leukemia.

Endogenous opiates have been implicated in pain and stress experiences. In order to directly assess the relationship between endorphin activity and acute behavioral distress, beta-endorphin immunoreactivity (beta-EPI) was measured by radioimmunoassay in cerebrospinal fluid of 75 children with acute leukemia undergoing routine lumbar puncture. These data were related to four measures of behavioral distress collected during the procedure. For children 4 years of age and above, beta-EPI correlated inversely with age (r = -.31,p less than or equal to .05). All behavioral measures also inversely correlated with age (r = -.26 to -.67,p less than or equal to .05 to .001). Females had a significantly lower mean beta-EPI than males (p less than or equal to .01), and exhibited greater behavioral distress. beta-EPI and behavioral measures interacted with the use of specific antileukemia agents. L-Asparaginase was associated with lower beta-EPI (p less than or equal to .05), while prednisone was associated with lower behavioral distress on three of the four measures (p less than or equal to .05 to .01). After controlling for age, sex, and chemotherapy, beta-EPI and nurse ratings of anxiety were positively correlated (partial correlation coefficient = .31, p less than or equal to .05). Correlations between beta-EPI and other behavioral measures demonstrated positive trends. Results of this study are interpreted as support for the reactive nature of beta-EPI in cerebrospinal fluid to acute distress, and may help explain documented sex differences in distress behavior. Potential clinical implications and directions for further research are discussed.

Use of hypnosis for multiple symptoms in an adolescent girl with leukemia.

An adolescent girl with chronic myelogenous leukemia was treated with hypnosis for several disease- and treatment-related problems during the last 4 months of her life. Data were collected before and after hypnosis on the nature and intensity of the patient's acute pain and anxiety during bone marrow aspirations, chronic headache and backache, nausea and vomiting during chemotherapy, anorexia, and the discomfort associated with spiking temperatures. Comparisons of baseline and posthypnosis reports suggest that hypnosis was successfully used for acute and chronic pain, anxiety, unpleasant body sensations and, possibly, nausea and vomiting. The hypnotic techniques used, the limitations of hypnosis and clinical issues in this case are presented and discussed.

Psychological effects of illness in adolescence. I. Anxiety, self-esteem, and perception of control.

Three hundred and forty-nine healthy adolescents were compared with 168 adolescents with various chronic or serious diseases on standardized measures of trait anxiety, self-esteem, and health locus of control (perception of self-control over health and illness). No differences in anxiety or self-esteem were found between healthy and ill groups or between various ill groups. Patients with oncologic, renal, cardiac, and rheumatologic disorders perceived significantly less control over their health than did healthy adolescents and patients with cystic fibrosis or diabetes mellitus. Stability of prognosis was related to low anxiety, as was length of time since diagnosis. Other physician-rated variables including course of disease, visible signs of illness, severity, and number of hospitalizations did not relate to psychologic variables. The data are interpreted as casting doubt upon the supposition that chronic or serious disease inevitably leads to psychopathology in adolescents. The overall pattern presented was one of psychologic normalcy, and attitudes regarding control over health are seen as reflecting realistic perceptions on the part of patients. The importance of looking at the effects of serious disease upon day-to-day functioning, as opposed to emphasizing inferred psychologic deviance, is stressed.

Psychologic effects of illness in adolescence. II. Impact of illness in adolescents--crucial issues and coping styles.

Adolescent perceptions of the impact of illness were measured through the administration of an original questionnaire to 345 healthy adolescents and 168 adolescents with diabetes mellitus, cystic fibrosis, cancer, and cardiac, renal, or rheumatologic diseases. Total impact of illness (e.g., leukemia or colds) did not differ between ill and healthy respondents, and the nature of adolescent concerns were similar for both groups. Restriction of freedom was seen as the major disruption brought about by illness, with other areas of impact including relations with peers, siblings, and parents. Adolescents with cancer were most likely to view treatment as highly disruptive and, along with rheumatologic patients, expressed greatest disruption of body image secondary to disease and treatment. Perceived school disruption was most common in cardiac and oncologic patients, with the former also expressing a high degree of concern about sexuality. Females in all groups reported more impact of illness on physical appearance than did males; this difference was greatest in adolescents with cancer, rheumatologic diseases, and cystic fibrosis. The essentially healthy psychologic status of chronically ill adolescents is noted, as is the generally hopeful and positive quality of patient responses.