Vibrio alginolyticus-associated wound infection acquired in British waters, Guernsey, July 2011.

In July 2011, a Vibrio alginolyticus infection was diagnosed in a woman from Guernsey in the Channel Islands, British Isles after sea bathing and application of a natural seaweed dressing to a pre-existing leg wound. Microbiological investigation confirmed Vibrio in the wound and the species of seaweed used for the dressing. The washing of open wounds in seawater and use of unsterilised seaweed dressings should be discouraged, particularly in individuals with underlying risk conditions.

Determination of capsaicin, dihydrocapsaicin, and nonivamide in self-defense weapons by liquid chromatography-mass spectrometry and liquid chromatography-tandem mass spectrometry.

Sensitive and selective liquid chromatography-mass spectrometry (LC-MS) and liquid chromatography-tandem mass spectrometry (LC-MS-MS) methods for the analysis of capsaicin, dihydrocapsaicin, and nonivamide in pepper spray products have been developed. Chromatographic separation of the capsaicinoid analogues was achieved using a reversed-phase HPLC column and a stepwise gradient of methanol and distilled water containing 0.1% (v/v) formic acid. Identification and quantification of the capsaicinoids was achieved by electrospray ionization single-stage mass spectrometry monitoring the protonated molecules of the internal standard (m/z 280), capsaicin (m/z 306), dihydrocapsaicin (m/z 308), and nonivamide (m/z 294) or by tandem mass spectrometry monitoring the appropriate precursor-to-product-ion transitions. The plot of concentration versus peak area ratio was linear over the range of 10-750 ng/ml using LC-MS and 10-500 ng/ml using LC-MS-MS. However, to accurately quantify the capsaicinoids in the pepper spray products calibration curves between 10 and 1000 ng were constructed and fit using a weighted quadratic equation. Using the quadratic curve, the accuracy of the assay ranged from 91 to 102% for all analytes. The intra-assay precision (RSD) for capsaicin was 2% at 25 ng/ml, 10% at 500 ng/ml, and 3% at 800 ng/ml. The inter-assay precision (RSD) for capsaicin was 6% at 25 ng/ml, 6% at 500 ng/ml, and 9% at 800 ng/ml. Similar values for inter- and intra-assay precision were experimentally obtained for both dihydrocapsaicin and nonivamide. The analysis of selected pepper spray products demonstrated that the capsaicinoid concentration in the products ranged from 0.7 to 40.5 microg/microl.

Quantitative analysis of capsaicinoids in fresh peppers, oleoresin capsicum and pepper spray products.

Liquid chromatography-mass spectrometry was used to identify and quantify the predominant capsaicinoid analogues in extracts of fresh peppers, in oleoresin capsicum, and pepper sprays. The concentration of capsaicinoids in fresh peppers was variable. Variability was dependent upon the relative pungency of the pepper type and geographical origin of the pepper. Nonivamide was conclusively identified in the extracts of fresh peppers, despite numerous reports that nonivamide was not a natural product. In the oleoresin capsicum samples, the pungency was proportional to the total concentration of capsaicinoids and was related by a factor of approximately 15,000 Scoville Heat Units (SHU)/microg of total capsaicinoids. The principle analogues detected in oleoresin capsicum were capsaicin and dihydrocapsaicin and appeared to be the analogues primarily responsible for the pungency of the sample. The analysis of selected samples of commercially available pepper spray products also demonstrated variability in the capsaicinoid concentrations. Variability was observed among products obtained from different manufacturers as well as from different product lots from the same manufacturer. These data indicate that commercial pepper products are not standardized for capsaicinoid content even though they are classified by SHU. Variability in the capsaicinoid concentrations in oleoresin capsicum-based self-defense weapons could alter potency and ultimately jeopardize the safety and health of users and assailants.

Measurement of lipid peroxidation.

There is currently considerable interest in what is termed "oxidative stress," or the oxidation of biological macromolecules, with emphasis on its involvement in various diseases and toxicities and methods to limit either its occurrence or effects. This unit describes traditional methods to measure the extent or rate of lipid peroxidations, including assays for conjugated dienes, lipid hydroperoxides, the polyunsaturated lipid breakdown product malondialdehyde, and hemolysis, along with discussion of alternative methods.

Requirements development for a patient computing system.

Critical parts of the software development life cycle are concerned with eliciting, understanding, and managing requirements. Though the literature on this subject dates back for several decades, practicing effective requirements development remains a current and challenging area. Some projects flourish with a requirements development process (RDP) that is implicit and informal, but this approach may be overly risky, particularly for large projects that involve multiple individuals, groups, and systems over time. At Partners HealthCare System in Boston, Massachusetts, we have applied a more formal approach for requirements development to the Patient Computing Project. The goal of the project is to create web-based software that connects patients electronically with their physician's offices and has the potential to improve care efficiency and quality. It is a large project, with over 500 function points. Like most technological innovation, the successful introduction of this system requires as much attention to understanding the business needs and workflow details as it does to technical design and implementation. This paper describes our RDP approach, and key business requirements discovered through this process. We believe that a formal RDP is essential, and that informatics as a field must include proficiencies in this area.

A knowledge-based patient assessment system: conceptual and technical design.

This paper describes the design of an inpatient patient assessment application that captures nursing assessment data using a wireless laptop computer. The primary aim of this system is to capture structured information for facilitating decision support and quality monitoring. The system also aims to improve efficiency of recording patient assessments, reduce costs, and improve discharge planning and early identification of patient learning needs. Object-oriented methods were used to elicit functional requirements and to model the proposed system. A tools-based development approach is being used to facilitate rapid development and easy modification of assessment items and rules for decision support. Criteria for evaluation include perceived utility by clinician users, validity of decision support rules, time spent recording assessments, and perceived utility of aggregate reports for quality monitoring.

Examining the symptom experience of hospitalized patients using a pen-based computer.

The purposes of this study were to test the feasibility of using a pen-based computer to capture self-reported symptom data, to evaluate the system, and to evaluate the importance of obtaining symptom data. The sample included 72 patients who were hospitalized for a variety of medical conditions. Self-reported symptom data was obtained with the automated Sign and Symptom Checklist. The feasibility of using an automated symptom checklist to capture self-reported symptom data was demonstrated. Patients' evaluations of the ease of use and the format of the system were primarily positive; mean ratings ranged from 4.58 to 4.70 on a 5-point scale. Patients indicated the importance of documenting symptoms, with a few suggesting that the use of an automated symptom checklist may increase communication between providers and patients. Study findings support the inclusion of self-reported symptom data in electronic health records and national health care databases.

Iron loading into ferritin by an intracellular ferroxidase.

An intracellular, membrane-bound enzyme exhibiting both p-phenylenediamine oxidase activity and ferrous iron oxidase activity was isolated with the plasma membrane fraction of horse heart and studied for its ability to load iron into ferritin. The ferroxidase activity of the tissue oxidase was stimulated approximately twofold by horse spleen apoferritin, and the iron was loaded into ferritin. The loading of iron into ferritin by the tissue oxidase was inhibited by anti-horse serum ceruloplasmin antibody. The stoichiometry of iron oxidation and oxygen consumption during iron loading into ferritin by the tissue-derived oxidase and serum ceruloplasmin were 3.6 +/- 0.2 and 3.9 +/- 0.2, respectively. These data provide evidence that an enzyme analogous to ceruloplasmin is present on the plasma membrane of horse heart and that this ferroxidase is capable of catalyzing the loading of iron into ferritin. The implications of these data on the present models for the uptake and storage of iron by cells are discussed.

Evidence for a protein-protein complex during iron loading into ferritin by ceruloplasmin.

The formation of a protein-protein complex for the loading of iron into ferritin by ceruloplasmin was investigated. Ferritin stimulated the ferroxidase activity of ceruloplasmin unless the ferritin was fully loaded, in which case it inhibited the ferroxidase activity of ceruloplasmin. The apparent association constant for the interaction of ferritin and ceruloplasmin was 24 nM. Isothermal titration calorimetry indicated that the interaction of ceruloplasmin and ferritin was endothermic, driven by positive changes in entropy. The association constants for complex formation between ferritin and ceruloplasmin were 4.5 +/- 0.7 x 10(5) and 9.5 +/- 0.3 x 10(4) M-1 for the reduced and oxidized forms of ceruloplasmin, respectively. The oxidized form of ceruloplasmin was retained on an affinity column with ferritin immobilized as the ligand and remained bound to the column with mobile phases of increased hydrophobicity, but was eluted with increased ionic strength. The ability of ceruloplasmin to remain bound to the affinity resin was affected by the species from which ceruloplasmin was isolated. Gradient ultracentrifugation also provided evidence that the two proteins were associated, since ferritin promoted migration of ceruloplasmin through the gradient. Including ferrous iron in the gradient resulted in reduction of ceruloplasmin and increased the mobility of ceruloplasmin with ferritin. These data provide evidence that ferritin and ceruloplasmin form a protein-protein complex during iron loading into ferritin, which may limit redox cycling of iron in vivo.

Assessing and managing pain in AIDS care: the patient perspective.

Although the prevalence and complexity of pain management in HIV/AIDS has been described in the literature, little is known about the management of pain from the patient perspective. This study used a set of standardized instruments, a medication chart audit, and a semistructured interview to elicit patients' self-reports of pain and patients' perceptions of nursing and self-care pain management strategies and examined potential physiological and psychosocial correlates of pain. The sample of 249 AIDS patients from three types of care settings (hospital, home care, skilled nursing facility) reported a modest overall current pain intensity (M = .14, range = 0-1). They reported experiencing pain in all body parts as measured by a body outline and characterized their pain with an average of 8.96 words from a list of 67 words. A lower pain rating was correlated with higher ratings on quality of life and perceived psychological support. An audit of the medication record revealed that the study sample received the following medications: narcotic analgesics (49%), nonnarcotic analgesics (47%), and antidepressants (22%). In a semistructured interview, medications were rated as effective by 80% of patients experiencing pain who stated that their health care providers included pain medications as part of the patient's pain management plan. Patients reported few nonpharmacologic self-care or health care provider interventions to manage their pain, and the effectiveness ratings of the interventions demonstrated wide variability. The study findings suggest that because pain was related to quality of life ratings and the pain management strategies reported by patients were not completely effective, further work is needed to examine pain management strategies that incorporate both pharmacologic and nonpharmacologic interventions with particular attention to self-care interventions. In addition, the data suggest that nursing assessments should include questions aimed at eliciting potentially harmful (e.g., street drugs, self-prescribed medications) strategies that patients may be using to manage their pain.

Stimulation of the ferroxidase activity of ceruloplasmin during iron loading into ferritin.

Ceruloplasmin purified from horse serum was rapidly reduced upon addition of increasing equivalents of ferrous iron, generating an electronically and conformationally distinct form. This form of ceruloplasmin was characterized by significant (80%) loss of EPR detectable type I and type II copper(II), complete loss of visible absorbance at 610 nm, as well as decreased hydrophobic surface area. The reduced form of ceruloplasmin slowly reduced molecular oxygen to complete its catalytic cycle. The presence of varied concentrations of apoferritin, but not apotransferrin, significantly enhanced the rate of ceruloplasmin oxidation. The magnitude of this stimulatory effect increased as the molar ratio of ceruloplasmin to apoferritin approached 1.0, shown previously to be the optimum ratio for loading iron into ferritin. The rate of ferrous iron oxidation by ceruloplasmin was significantly stimulated by the presence of apoferritin; however, apotransferrin had no effect. The length of time required for ceruloplasmin to oxidize all the iron and return to the native form of the enzyme was also affected by the concentration of iron. In addition, the rate of iron loading into ferritin was dependent upon ferrous iron concentration. These results provide evidence for the formation of a specific complex between the reduced form of ceruloplasmin and apoferritin and that reduction of ceruloplasmin by ferrous iron may be the signal for complex formation.

Peroxidase substrates stimulate the oxidation of hydralazine to metabolites which cause single-strand breaks in DNA.

Hydrazines are believed to be oxidized by peroxidases to reactive intermediates responsible for a variety of adverse side effects including cancer and drug-induced lupus. However, hydrazines are regarded as a poor peroxidase substrates because inactivation of the peroxidase occurs during oxidation of these compounds. We have investigated the hypothesis that efficient peroxidase substrates, termed mediators, may stimulate peroxidase-catalyzed oxidation of hydrazines to intermediates capable of causing DNA damage. Oxidation of hydralazine by horseradish peroxidase was stimulated, enzyme inactivation was significantly decreased, and DNA strand breakage was enhanced by the addition of chlorpromazine. Similar results were obtained using other peroxidases, mediators, and hydrazine derivatives. DNA damage required the addition of a minimum of 3 equiv of hydrogen peroxide, suggesting the involvement of a three-electron oxidation product of hydralazine in DNA damage. Efficient substrates may therefore play a critical role in peroxidase-dependent oxidative metabolism and subsequent damage to biological macromolecules by certain chemicals.

A comparison of patient and nurse ratings of human immunodeficiency virus-related signs and symptoms.

Since management strategies are guided by the assessment of the symptom experience, agreement between patients' and nurses' perceptions of symptoms is central to clinical management. In this study, acquired immune deficiency syndrome patients' perceptions of 41 human immunodeficiency virus-related signs and symptoms were compared in 207 pairs of ratings by patients (n = 207) and nurses (n = 103). Ten symptoms were reported by 50% or more of the patients. Mean patient intensity ratings for all signs and symptoms, with the exception of anxiety, were higher than nurse ratings. Using patients' ratings as the gold standard, chance-corrected estimates of sensitivity, specificity, positive predictive value, and negative predictive value of the nurses' ratings suggested that nurses' ratings poorly predicted patients' symptom experiences.

Group treatment of fibromyalgia: a 6 month outpatient program.

OBJECTIVE: To evaluate the impact of a 6 month group therapy program on the treatment of patients with fibromyalgia (FM). Since FM is a common problem in rheumatology practice, a program was designed to treat patients in a group setting using allied health professionals. METHODS: The FM group (15 to 25 patients) met once a week for 6 months. The average session lasted 90 min and consisted of formal lectures, group sessions emphasizing behavior modification, stress reduction techniques, strategies to improve fitness and flexibility and support sessions for spouses/significant others. The 2 major outcome measures were the fibromyalgia impact questionnaire (FIQ) and the total tender point score. Secondary outcome measures were the quality of life scale, questionnaires to assess coping strategies and attitudes to illness, an index of aerobic conditioning, flexibility, distance walked in 6 min., Beck depression and Beck anxiety questionnaires. Patients were followed 2 years and compared to a group of patients outside the program. RESULTS: Between 1989 and 1993 170 patients were evaluated and 104 patients completed the program. At the end of the 6 months 73 (70%) of patients had <11 tender points and FIQ improved 25%. Having a pain profile on MMPI or having major depression, did not predict poorer outcome. Thirty-three patients followed for 2 years after the program continue to show improvement. A control group of 29 patients who never entered the program showed no significant improvement. CONCLUSION: The group treatment of patients with FM in an outpatient setting shows promise; a more formal controlled study is needed to confirm this impression.

Critical care information systems: essential infrastructure for critical care nursing practice.

In the three decades since the installation of the first bedside computer in the "shock ward" at the University of California and Los Angeles County Hospital, both computer technology and critical care practice have evolved rapidly. The premise of this article is that critical care information systems are an essential infrastructure for critical care nursing practice. This premise is described in terms of the critical care environment, clinical decision making in critical care, increasing demands for information about quality and costs, and national initiatives for the sharing of health care information.

Variables, variability, and variations research: implications for medical informatics.

Variations research is one important strategy in the quality management movement designed to improve the quality of health care and to control costs. Information systems are being utilized in variations research to provide an array of potential variables, to provide measures of the variability inherent in these variables, and to assist with the study of the linkages of patient and provider characteristics with interventions and outcomes. This article presents a systems model of inputs, processes, and outcomes with explication of factors related to client, provider, and setting as a heuristic strategy for variable specification. The implications of variable specification, the design and measurement of variability, and the key issue of control in variations research are linked with a discussion of the implications for medical informatics.

Problems of persons with HIV/AIDS hospitalized for Pneumocystis carinii pneumonia.

The authors of this prospective study describe the problems of persons living with HIV/AIDS hospitalized for Pneumocystis carinii pneumonia (PCP) (N = 90) and examine how the problems change over time. Data were obtained from four sources and were classified into major problem categories. The largest mean number of problems were reported in the category of PCP. Specific psychosocial problems were more likely to be reported in the patient and nurse interviews than in the chart and intershift report. The study findings validate the physical symptoms addressed in the published care plans and guidelines for caring for patients with PCP. The study identified the limitation of using the patient record as the only data source in determining nursing care needs and emphasized the importance of the patients perspective.

A comparison of nursing intervention classification and current procedural terminology codes for representing nursing interventions in HIV disease.

The purpose of this study was twofold: 1) to compare the ability of terms from the nursing intervention classification and from the current procedural terminology to represent the clinical terms used by nurses and patients to describe nursing interventions during hospitalization; and 2) to identify the strengths and weaknesses of the two classification systems for representing nursing systems. More NIC than CPT codes matched the concepts in the clinical terms used by nurses and patients to describe nursing interventions demonstrating, not unexpectedly, that NIC represents a broader scope of nursing practice. The major difficulty encountered using NIC was the lack of mutual exclusiveness of the nursing activities within the interventions. CPT codes were easy to apply to the clinical terms, but were limited in scope for nursing practice. The findings of this study demonstrate the necessity of using a nursing-specific classification system for the representation of nursing interventions. This is of particular importance for databases that will be used to examine the effectiveness of healthcare interventions and for databases related to reimbursement for healthcare interventions.

Capturing patients' perceptions in the computer-based patient record: essential prerequisites to the measurement of health-related outcomes.

The cost, quality, and outcomes of healthcare services have become the focus of national attention as providers, consumers, and payers of healthcare services grapple with healthcare reform in the United States. Given the importance of patient care data to the activities of all segments of the healthcare spectrum, the development and implementation of computer-based patient records (CPRs) has been recommended as CPRs have the potential to improve healthcare delivery, enhance outcomes research programs, and increase hospital efficiency [12]. The current paradigm shift in healthcare requires the active involvement of the patient in the delivery and evaluation of care. The patient must be considered as an essential user of CPRs in order to exploit the benefits of information technology for the purposes of outcome assessment. Research and development of the future CPRs must incorporate the needs of the patient. Systems should be designed to meet these needs in order to capture the patient's perceptions in CPRs.