No shows: a problem in health care.

No shows: a problem in health care. The mothers who kept their appointments were likely to be or have been head of household; they had to assume more responsibility and independence than the mothers in nuclear families. They were more likely to have been socialized in Michigan or Mexico than in Texas. They were more likely to have transportation available. They brought their children to the clinic to be sure they were all right. They tended to have prenatal care early and regularly for the same reason. The mothers who broke a number of appointments lived in nuclear families. They had never had to assume the total responsibility for their children. Unlike the good users, they were more likely to have been socialized in Texas. Some did not keep appointments because they did not have transportation. Some did not see any reason to take a child to the doctor unless he was sick. However, many of them did have prenatal care to be sure they were all right. "Start where the patient is" is still a good precept for public health nursing practice. Understanding where these mothers are should enable us to adapt our approach and practice to help them achieve their goal of good health care for their children.


Altering children's distress behavior during orthopedic cast removal. The hypothesis treated was that discrepancy between expected and experienced physical sensations (what is felt, seen, heard, tasted, and smelled) during a threatening experience will result in distress. The subjects were 84 children, 6 to 11 years of age, male and female. The threatening experience was orthopedic cast removal. Tape recorded preparatory information was used to vary systematically expectations about physical sensations. The children were randomly assigned to one of three information groups: 1) sensory information which described the sensory experience during cast removal, 2) procedure information which described the steps of the experience, 3) control group which heard no tape recorded information. Nonverbal and verbal signs of distress reactions and the pulse rate were observed during cast removal. Signs of distress were scaled from zero to two, with zero meaning no distress behaviors and two, high distress behavior. A two-factor analysis of variance (two levels of pre-fear and three levels of information) was used for analysis. As hypothesized, the mean distress score for the sensation group (.50) differed significantly from the control group mean (1.00 p less than .025). The procedure group distress score mean (.71) fell between the sensation and control group means but did not differ significantly from the control group mean. The no pre-fear group distress score mean (.52) was significantly lower than the some pre-fear group mean (1.00 p less than .02). Mean pulse rate changes for information groups for before to during cast removal were in the same order as the distress scores, but the differences were not statistically significant. The findings were similar to those from other tests of the hypothesis.


Delphi survey of priorities in clinical nursing research. Using the Delphi technique, a panel of 433 nurse and nonnurse experts was surveyed regarding priorities for clinical research in nursing. Of these, 341 completed all four Delphi survey rounds. Three questions were studied: 1) Is this an area in which nursing should assume primary research responsibility? 2) How important is research on this topic for the profession of nursing? 3) What is the likelihood of change in patient welfare because of research on the topic? Although the nature and amount of data produced prohibited interpretation of the data or delineation of succinct conclusions about priorities for clinical nursing research, responses to the three questions supported these statements: The majority of research areas identified in the questionnaire are areas in which nursing should take research leadership. Although there is some overlap, priorities for professional significance and social or patient welfare relevance are different. In terms of professional significance, highest priority was given to items regarding measuring the quality of care, role, nursing process, and the research process. In terms of patient welfare, several programs of research are discernible in the items ranked in the top ten percent; these include nursing interventions related to stress, care of the aged, pain, and patient education. The Delphi technique also is described.


Relationship among health habits, social assets, psychologic well-being, life change, and alterations in health status. To examine variables which may temper life change and enable individuals to withstand high degrees of life change without developing illness, a questionnaire was mailed to a systematically selected sample of the residents of Renton, Washington, of which 548 (57 percent) were returned. The major statistical analysis was linear correlation and multiple regression. When relationships between the major variables--health habits, social assets, psychologic well-being, and life change--and the dependent variable-alterations in health status--were examined, the single best predictor of subsequent alterations in health status for respondents in this study was found to be the magnitude of the life change. As the life changes increased, the risk of becoming ill also increased. The notion that health habits, psychologic well-being, and social assets might temper life change and make it possible to avoid a change in health status was not borne but strongly in the results of the analysis of data. These variables were weakly associated, however, with maintenance of health status.


Preparation of the breast for breastfeeding. To evaluate effectiveness of three commonly suggested methods of preparing the breasts for breastfeeding--nipple rolling, application of cream, and expression of colostrum--57 women volunteered to prepare one breast and not the other. One-third of the group used one each of the three methods. After delivery, the women completed data sheets on the subjective tenderness of both breasts, and an investigator visited them to evaluate objective measures of nipple irritation. When the treated and untreated breasts were compared, no significant differences in either objective or subjective measures of nipple sensitivity or trauma were found in any of the three groups. These findings imply that these traditional methods of preparing the breasts for breast-feeding are ineffective.


Cancer chemotherapy and management of patient problems. Cancer chemotherapy has made major progress over the past twenty-five years with the development of effective drugs and the application of multiple drug regimens to the treatment of cancer patients. The focus of cancer therapy today is on the cure of cancer with the introduction of multiple modality therapy incorporating surgery, radiotherapy, chemotherapy, and immunotherapy in the treatment of early disease. Thus chemotherapy is becoming commonplace and standard practice, and an awareness of the practical management of drug therapy is essential.


Flow kinetics of beta-galactosidase chemically attached to nylon tubing. Beta-Galactosidase (EC 3.2.1.23) has been attached covalently to the inner surface of nylon tubing. An experimental study has been made of the flow kinetics for the hydrolysis of o-nitrophenylgalactose, the substrate concentration and flow rate being varied. The results were analyzed in the light of the theoretical treatment of Kobayashi and Laidler, three different methods of analysis being employed. It is concluded that at the lower substrate concentrations and flow rates employed, the reactions are largely diffusion controlled; with increase in flow rate and substrate concentration the width of the Nernst diffusion layer decreases, and there is found to be less diffusion control. The values of Km(app) vary with flow rate VF, being linear in VF-1/3, and the value extrapolated to very high flow rate agrees well with the Km value for beta-galactosidase in free solution. The theory and results are shown to provide guidelines for the design of open tubular heterogeneous enzyme reactors for industrial, biomedical, and analytical applications.


[On the so-called posttraumatic headache (author's transl)]. Following an introduction on the notion of posttraumatic headache and on the etiology and pathogenesis of headache occurring after head injuries, the author discusses in detail the clinical aspects of such pain. Especially, a description of headache that can be expected in different types of head injury and posttraumatic complication, is presented. The importance of differential diagnosis of cephalea originating in the vertebro-cervical region and of atraumatic headache occurring casually some time after a head injury, is stressed. In the author's view, genuine chronic posttraumatic cephalea exists only in very rare cases and is always associated with considerable organic intracranial lesions. As to treatment, long-standing continuous medication with analgesics is strictly rejected. The usual therapeutic measures are mentioned and judged critically. For prophylaxis of chronic headache following head injuries, adequate primary treatment, early mobilization and early return to occupational activity seem most important. Long-lasting confinement to bed in the absence of objective clinical signs is considered as one the causes of obstinate cephalea after head injuries which are frequently only minor in degree. If psychoneurotic fixation of the accident sets in, psychiatric treatment should be commenced immediately as to prevent the establishment of irreversible neurotic symptoms. For the same reason, a pending procedure for recompensation should be settled as soon as possible. Observing the therapy explained, including guidance of patients, the prognosis of headache following head injuries proves on the whole to be very favourable.


Reciprocal beats initiated by artificial pacemaker. In conclusion, the underlying mechanism for this rhythm disturbance in our patient is the re-entry phenomenon,  which is dependent upon a localized unidirectional block in the A-V junction. The predisposing factors, including digoxin and Inderal which tend to prolong A-V conduction, are considered for the mechanism of the production of the reciprocal beats in our case. Upon temporary withdrawal of digoxin and Inderal, the re-entry phenomenon has disappeared.


Arrhythmias in the coronary-care unit. IV. Physiologic bases of paroxysmal tachycardia-dependent bundle branch block. Paroxysmal BBB may be either tachycardia-dependent which is referred to as "phase 3 block" or bradycardia-dependent, referred to as "phase 4 block." Tachycardia-dependent BBB is related to prolonged recovery. Bradycardia-dependent BBB is related to hypopolarization and SDD. These fundamental electrophysiological properties aid in understanding of transient BBB occurring during an acute MI.


Effect of body position upon pulmonary artery and pulmonary capillary wedge pressures in noncritically ill patients. Monitoring pulmonary artery (PA) and pulmonary capillary wedge (PCW) pressures with a Swan-Ganz catheter to detect left ventricular failure has assumed an important role in the present day management of critically ill patients. In order to obtain an accurate reading, it has been assumed that the patient must be supine and flat. This may require waking an acutely ill patient; also there are patients who cannot tolerate a flat position. The effect of position upon the PA and PCW pressures was investigated in ten cardiac out-patients who were undergoing hemodynamic studies during exercise tolerance testing. The pressures were measured with the backrest flat, then at 20 degrees, 45 degrees, and 90 degrees and with patient sitting on edge of bed with feet dangling. The only significant difference with relation to position was systolic pressure at 90 degrees in relation to  the systolic pressure in the flat position. Other pressure differences were not statistically significant and all pressure differences were of such small magnitude as not to be clinically significant. Based on these findings, it would seem that in patients with normal PA pressures, measurements can be made without lowering the backrest. Further study is needed to determine the effect of position on these pressures in critically ill patients.


Transcriptional control of peptidoglycan precursor synthesis during sporulation in Bacillus sphaericus. Synthesis of enzymes functional in the synthesis of nucleotide precursors of peptidoglycan ceases upon initiation of sporulation in Bacillus sphaericus. During sporulation, two periods of synthesis of these enzymes occur. The first starts at spore septum formation and is conincident with forespore engulfment; it involves the synthesis of those enzymes required for making the precursor of vegetative-type peptidoglycan, including L-lysyl ligase but no mesodiaminopimelyl ligase. The second period occurs shortly before the appearance of cortex. It involves the synthesis of diaminopimelyl ligase and the other enzymes needed for making the precursor of cortical peptidoglycan, but not lysyl ligase. Both events are a consequence of derepression at the level of transcription. Neither period of synthesis occurs in asporogenous mutants whose morphological block is at the point of spore septum formation.


Eight steps to inpatient cardiac rehabilitation: the team effort-methodology and preliminary results. The effects of a team approach in cardiac rehabilitation were investigated in 89 postmyocardial infarction patients. Team members followed an eight-step protocol in caring for the patients during the hospitalization phase. Risk factor modification data were collected at a mean time of 13.5 months after hospitalization. The investigated parameters included work, dietary and exercise habits, body weight, high blood pressure and cigarette smoking. Fifty-six per cent (42 of 75) of the survival group were actively working, 66 per cent (49 of 75) were adhering to a fat-controlled diet, 77 per cent (58 of 75) continued an exercise regime, 70 per cent (40 of 57) lost excess body weight, 91 per cent (21 of 23) had their blood pressure controlled and 60 per cent (27 of 45) stopped smoking cigarettes. It is concluded that an in-hospital team approach in rehabilitation of postmyocardial infarction patients is beneficial in long-term risk factor modification.


Maximal-stress, multiple-lead exercise testing: the significance of ST-segment changes in the detection of coronary arterial occlusive disease. Recognition of the value of objective parameters in the diagnostic evaluation for coronary arterial occlusive disease had led to increased application of maximal-stress multiple-lead electrocardiography. Changes in the ST-segment during and immediately following exercise are the most significant electrocardiographic indicators of myocardial ischemia. When such causes of ischemia as congenital anomalies, embolism, and arteritis have been excluded, exercise testing is a sensitive and specific means of detecting coronary arterial occlusion. The sensitivity and specificity of this parameter are evaluated in terms of long-term morbidity and mortality and, more recently, through correlation of electrocardiographic results with angiographic evidence. In our series of 308 patients undergoing both exercise testing and coronary arteriography, the sensitivity factor for 80 negative stress tests approached 95 per cent, with only four false-negative resting and exercise electrocardiograms. For 129 patients with ST-segment changes indicative of myocardial ischemia, angiography demonstrated significant coronary stenosis in 84 per cent of the cases. Of the twenty patients with false-positive stress electrocardiograms twelve were females, wich correlates with the generally higher rate of false-negative stress-electrocardiographic response among women.


Distribution of beta-lactamases A and B in some groups of Yersinia enterocolitica and their role in resistance. Yersinia enterocolitica W222 (serological group 3) synthesized two different intracellular beta-lactamases, called A and B. Enzyme B was more sensitive than A to inhibition by cloxacillin. The minimum inhibitory concentrations of various beta-lactam antibiotics for strains of Y. enterocolitica of groups 3 and 9 and the effect of cloxacillin on these concentrations suggested differential roles for beta-lactamases of types A anb B in penicillin and cephalosporin resistance. Type B enzymes protected Y. enterocolitica against cephalothin and cephalosporin C, wheras type A enzymes protected very efficiently against carbenicillin. Protection against other beta-lactam antibiotics was exerted by both enzymes. However, while both enzymes readily hydrolysed cephaloridine and showed no crypticity with this substrate, they only conferred a very weak protection against it. This may be because cephaloridine reached its target quickly, before it was degraded. The resistance of strains of Y. enterocolitica from groups I, 2 and I6 was also explicable in terms of a two-enzyme system, whereas strains belonging to group 5b produced only a type B lactamase and were sensitive to carbenicillin.


Beta-lactamases in hospital strains of gram-negative bacteria. A collection of 98 strains of enteric Gramnegative bacteria isolated in routine investigations in a hospital laboratory all showed beta-lactamase activity, and 39 of them (40%) produced sufficient enzyme to allow determination of their relative activities against benzylpenicillin, ampicillin and cephaloridine (substrate profiles). The commonest type of beta-lactamase, detected in 33 of the 39 strains, was an "all-purpose" enzyme that showed similar activity against the penicillins and the cephalosporins. All 39 were resistant to multiple antibiotics. They were examined for their ability to transfer the beta-lactamase gene during R-factor transfer, and transferability of the beta-lactamase gene was demonstrated in 13 strains out of 32.


The psychodynamics of the "holiday syndrome". The holiday season is clearly a time of great emotional conflict, especially for schizophrenics. Both the occurrence of the holiday season and the psychoanalytic group process itself stimulate regression in the schizophrenic which uncovers the frustration and anger associated with dependency needs. The therapist who understands the pychodynamics set in motion by the holidays and by psychoanalytic group pschotherapy can utilize the content of group interaction during the holiday season to stimulate group process, the expression of mutual concerns, and cohesion among the members.


Depression: adaptation to disruption and loss. Assisting the depressed person to cope with disruption and loss and the experiences associated with each stage of his recovery is usually a long-term process involving concerted efforts to promote a restoration of self-worth, personal control, and organization. In this article the authors have attempted to elucidate the problem of depression as a clinical phenomenon, to explore its predisposition, and, through the use of a conceptual model, to discuss its psychodynamics. The processes involved in coping with disruption and loss -- processes which tend to be evoked repeatedly during recovery and resolution since each failure or delay encountered is experienced as another loss and disruption by the individual -- were described and illustrated schematically.


Clean technique for intermittent self-catheterization. Seven patients with neurogenic bladder dysfunction who ranged in age from 16 to 54 years, and who had been on sterile intermittent self-catheterization, were changed to clean intermittent self-catheterization. Urine was monitored for one year after changing to clean technique. Urine specimens obtained while on clean technique were bacteriologically equivalent to urine specimens examined while patients were on sterile technique; the only exception to equivalent urine results were in patients who did not catheterize themselves at frequent intervals. Renal function tests on all patients were also normal. The clean, intermittent self-catheterization technique was effective, since infection did not seem to be caused by introducing bacteria into the bladder via the urethra.


Reestablishing self-feeding in a nursing home resident. An attempt was made to teach an elderly person to reacquire and maintain self-feeding skills. A single-subject ABAB reversal strategy, including assessment for generalization, was planned as experimental design. The treatment procedure consisted of a continuous, immediate reinforcement program contingent on self-feeding responses. Fast and stable control of self-feeding was obtained. A drop in feeding behavior resulted when the patient returned to base-line procedures. The patient died before the second treatment procedure could be carried out. The study found, however, that nursing home staff could facilitate healthy behavior through better use of behavioral management skills.


Patients' dependence and independence levels on the prehospitalization-postdischarge continuum. Levels of dependence and independence were studied in 26 patients who had total hip or total knee replacement procedures. Four instruments--a three-situation questionnaire, Beller's Behavioral Checklist, the D-I Scale, and the Navran Dy portion of the Minnesota Multiphasic Personality Inventory--were administered. Tests were given at five times: prehospitalization, presurgery, postsurgery, predischarge, and postdischarge. Dependence and independence levels were found to change along the prehospital-postdischarge continuum, according to the stress of hospitalization and surgery. There was, however, no significant difference in dependence scores between the prehospitalization and postdischarge administrations of the scales.


Selected National League for Nursing achievement test scores as predictors of state board examination scores. In a study to formulate regression equations which could be used to predict performance on the licensing examinations of graduates of an associate degree nursing program, selected sets of National League for Nursing achievement test scores were found to be effective predictors of state board examination (SBE) scores. When test score records of graduates for the years 1969-1974 were subjected to stepwise multiple regression analysis, prediction equations were empirically validated by correlation of predicted SBE scores with actual SBE scores obtained by graduates of the program.


Effect of cigarette smoking on postural muscle tremor. In a study of the effect of smoking on postural reflexes--specifically postural muscle tremor--in man, amplitude of postural muscle tremor, when tested in 30 subjects, was increased to a significant degree immediately following the smoking of one cigarette. Tremor amplitude continued to be significantly increased one-half hour after smoking ceased. There was no significant change in the frequency of tremor. Measurement was made using a piezo crystal accelerometer attached to the third fingers of both hands. Effects were recorded with a Sanborn Twin Viso Recorder. The findings, that smoking does affect postural reflexes, have implications for the formulation of nursing therapies, particularly in areas such as rehabilitation nursing, where the use of postural reflexes is the primary mode of intervention.


Selected factors associated with professional attitude of baccalaureate nursing students. To examine the association between professional attitude and selected situational and demographic factors of baccalaureate nursing students, 157 female students from an upper division major who had not had other college or nursing education answered a questionnaire which incorporated Osgood et al.'s Semantic Differential Test, Hogan's Professional Attitude Test, and an adaptation of the Dawson et al. instructor-leader behaviors. Eight hypotheses were tested. Professional attitude was found to be highest for students 24 to 26 years of age, who saw nursing as highly positive and highly active, had most formal and informal nursing experience, and perceived teachers as taking strong positions on their beliefs and relating to them with high consideration throughout their program and with low structuring when they were seniors. Professional attitude of students was not associated significantly with potency attributed to nursing, career choice, parents' level of education, or placement in sibling group.


Utilization of reinforcement contracts to increase written evidence of the nursing assessment. This study investigated if nursing personnel would increase written evidence of the nursing process if favorable consequences were arranged. The charting of 23 nurses was observed and tabulated for a three-week period. These base-line data were averaged and shared with each nurse, at which time each nurse set a goal (relative to increased charting) and chose a reward contingent upon achieving that goal. During the next three weeks the nurses were again observed, at the end of which results were tabulated and rewards given. The two periods were repeated. Results showed a sharp increase in charting during each reinforcement phase and a fall off during the second base-line period that was lower than the first base-line. The target behavior, therefore, was found to be increased by systematic reinforcement.


A cross-validation study for predictors of scores on state board examinations. Regression equations were computed and cross-validated for predicting nurses' scores on each of the five state board examinations (SBEs). Scores on five National League for Nursing (NLN) achievement tests of 101 nurses who graduated from a baccalaureate program between 1968 and 1972 were used as predictor variables. Stepwise regression analysis was used to compute the equations which were, in turn, used to predict the SBE scores for an independent sample of nurses who graduated in 1973. Cross-validation correlations between the predicted and actual obtained scores of the 1973 graduates ranged from .64 to .81. For each equation, the NLN test scores in Nursing of Children and Obstetric Nursing were consistently the best indicators of performance on the SBEs. Additionally, a factor analysis indicated that the SBEs do not measure independent entities, but that all five examinations have high loadings on the same factor. The results suggest that nursing programs should develop and validate prediction equations to assist nurses in preparing for SBEs.


Nursing students' knowledge about diabetes mellitus. This study investigated whether senior nursing students about to graduate from baccalaureate programs were knowledgeable enough about diabetes mellitus to teach diabetic patients and their families. The sample consisted of 144 volunteer subjects from four colleges in a metropolitan area. A student was considered eligible to teach diabetic patients if he could answer all questions correctly on a 34-item instrument. Three additional questions dealt with extracurricular contact with diabetes: was the student diabetic? Had he a diabetic in the immediate family? Had he taught diabetics? None of the participants answered all questions correctly; one student scored 31 correct answers. Only two questions were answered correctly by all students. The study indicated that the graduating students were not prepared to do diabetic teaching.


Cefamandole: antimicrobial activity in vitro of a new cephalosporin. Cefamandole, a new cephalosporin derivative, was found to have a broad spectrum of activity against a cross-section of both gram-positive and gram-negative bacteria isolated from clinical material. Gram-positive cocci, except for Streptococcus faecalis, were very susceptible. Penicillin G-resistant Staphylococcus aureus also was susceptible to cefamandole. Minimal bactericidal concentrations for gram-positive cocci approximated the minimal inhibitory concentrations. Strains of Haemophilus influenzae were very susceptible to the drug. Most strains of Escherichia coli, Klebsiella sp., and Proteus sp. were inhibited by low concentrations. Increasing resistance occurred with larger inocula. Strains of Pseudomonas sp. were resistant to cefamandole.


Hydrolysis of D-galactosides in an open tubular lactase reactor. Lactase (beta-galactosidase) was attached to the inner surface of nylon tubing. Tubes of various lengths were used to bring about the hydrolysis of o-nitrophenyl-beta-D-galactoside and of lactose in skim milk. The results with the former substrate were analyzed in the light of a theoretical treatment of Kobayashi and Laidler (Biotechnol. Bioeng., 16, 99, 1974), with the conclusion that the reaction is intermediate between diffusion-free and completely diffusion-controlled behavior. The results with skim milk show that with a single 46 m tube and continuous circulation, 90% of the lactose is removed within 20 hr. A battery of ten such tubes, with single passage, at a flow rate of 2 cm/sec, would remove more than 99% of the lactose in less than 40 min.


Kinetic studies of alpha-galactosidase-containing mold pellets on PNPG hydrolysis. Little is known about techniques for applying untreated microbial cells containing enzymes directly to industrial processes as a biocatalyst. The kinetic behavior of alpha-galactosidase-containing spherical pellets which are formed naturally under given conditions in a submerged culture of Mortierella vinacea was studied on the hydrolysis of PNPG (p-nitrophenyl-alpha-D-galactopyranoside). The effect on intraparticle diffusion on the overall reaction rate was assessed by the use of an effectiveness factor, which was calculated by the approximate solution to the equation derived from the mass balance within a pellet. The experimental effectiveness factors were found to be represented as a single function of the modified Thiele modulus, including such parameters as pellet size, enzyme concentration in the pellet, and substrate concentration. As the diffusional effect became more significant, the marked substrate inhibition as seen for a free enzyme disappeared gradually. The effect of product inhibition on the pellets was much weaker than that for a free enzyme at a given substrate concentration. In the region of diffusion controlled reaction, it was found that the rate is proportional to the square root of the enzyme concentration in the pellet. In addition, similarly to what was reported previously for a free enzyme,the reaction in a batch system was found to be approximately representable as simple first-order kinetics in which the rate constant was dependent on the initial substrate concentration.


[Disturbances of orientation with functional psychoses (author's transl)]. It was supposed by clinical impressions that disturbances of orientation do not appear only in severe degrees of a transit-syndrome, but also in the light stadium of such a physically founded psychosis. In order to verify these impressions, a questionnaire was developed which permitted an objective scoring. This Q-Test consists of 37 questions (items), which measure the orientations of time, space, situation, and person. On the base of this questionnaire two samples were tested, the one consisting of 50 patients with functional psychoses (reversible physically founded psychoses), the other consisting of 50 patients with only neurological disturbances. The degree of the functional psychoses was determined by the "Syndrome-Test" (F. Bocker, 1959). The range of the scores corresponded with the clinical categories from a low degree of the transit-syndrome to a medium degree of disturbances of consciousness. The scoring was based on an standard system derived from the results of the control group (patients with only neurological disturbances). The clinical impressions could be verified by empirical and statistical methods. According to the test results, disturbances of orientation already appear during the light stadium of the transit-syndrome. Furthermore there is a high significant correlation (p. less than 001) between the degree of the functional psychoses and the degree of the disturbances of orientation. This applies to all categories of orientation. The orientation concerning time, space and situation proved to be more susceptible to disturbances than the orientation concerning the person. The very close correlation between the degrees of the functional psychoses and the degrees of the disturbances of orientation make it possible to determine the stadium of the functional psychoses promptly. The complete and very handy "short-time-test" will be published in a special paper.


Chronic cannabis users: Further analysis of objective test results. Twelve objective tests, generating 16 psychological test variables were administered to 850 chronic cannabis takers and 839 non-takers, all Egyptian males, ranging in age between 15 and 50 years, and representing various positions on continua of literacy-illiteracy and urbanism-ruralism. The tests were intended to assess different modalities of 5 broad psychological functions: speed of psychomotor performance, estimation of moderate distances, estimation of a few minutes time interval, immediate memory for digits and designs and visual-motor co-ordination. Analysis of variance based on 3 x 3 x 2 factorial design was carried out and revealed statistically significant differences between the two groups of subjects on most of the test variables. Detailed analyses showed that controls displayed better performance than drug users on the majority of the variables. Significant second order interaction effects emerged in a big number of cases denoting that, under certain conditions relating to literacy-illiteracy and urbanism-ruralism, the superiority of controls over cannabis users became much more impressive. Our findings were discussed in the light of investigations which were conducted on the psychological correlates and/or effects of long term and short term cannabis consumption. The clinical psychological literature was cited where slowness of psychomotor performance, defective visual-motor co-ordination and impaired memory for designs were reported to be associated with psychiatric disorder. It is suggested that our results point to meaningful associations between chronic cannabis consumption and manifestations of psychopathology.


[Pathological-anatomical aspects of vagabondage (author's transl)]. Autopsies of 65 agabonds including 2 females are evaluated. Dwarfism, kyphoskoliosis and other skeletal deformities, malformations, disfigurations of the face and tatoo-marks are frequent exteriors. Compared with autopsies in other grous of population there are also numerical differences in internal diseases: In equivalent age groups ulcers of the stomach, duodenum or gastric resection respectively are found in 35,4% of our colective, in 8, % of clinical autopsies and in 4,8% of epileptic patients. Furthermore hypertension, myocardial infarction, chronic emphysema of the lungs and active tuberculosis of the lung are more frequent than in control groups...


Trends in reported illegal narcotic use in Canada: 1956-1973. Information on reported narcotic users aids in the development of drug control policy as well as programmes of prevention, treatment, and rehabilitation. In Canada, such information may be obtained from a narcotic users index which classifies known narcotic drug users into three categories: "illicit", "licit", and "professional". This paper presents trend data on known narcotic users in Canada from 1956 to 1973 by category, location, initially reported drug, sex and age. Between 1956 and 1973, the number of known "licit" and "professional" narcotic drug users steadily decreased, while the number of "illicit" narcotic drug users increased by 283 per cent, with the greatest increase taking place after 1969. Heroin was the most frequent initially reported drug (representing between 80 per cent and 89 per cent of known "illicit" narcotic drug users). Cocaine, as an initially reported "narcotic", had the largest proportional increase from 1956 to 1973. There were generally more reported male users than female in all age groups, a trend that increased over the time span considered. There were recent dramatic increases in the numbers and rates of reported users in the 20-24 year-old group, which has become the dominant pattern among new cases in recent years. Although the index on which this paper is based does not provide figures on total narcotic use in Canada, it is a valuable resource for epidemiologic research. This narcotic user index may be used to make minimum estimates of the extent and geographic and social distribution of narcotic-related problems in Canada.


The criminal histories of male non-medical opiate users in the United Kingdom. Although there is general agreement that there is some association between non-medical opiate use and criminality the nature, extent and significance of the association remains controversial. The most plausible explanation for an association is that crime becomes an economic necessity for the opiate user where there is, as in most countries, a legislative prohibition on licit supplies of the drugs. In the United Kingdom, however, opiate users may be prescribed the drugs and may also qualify for social security benefits. The criminal histories of three series of United Kingdom male non-medical opiate users are described. A somewhat higher proportion of the series had criminal convictions before any admitted drug misuse when compared with that expected from a general population sample. When age and the number of convictions before identification as opiate users were taken into account, there was no consistent evidence that they were more likely than expected to be convicted of further offences during the two-year period following identification. When the proportion found to have been convicted during this period was greater than expectation, it was due to the proportion convicted exclusively of drug offences. The criminal histories showed a decrease in the number of convictions for theft and other offences and an increase in the number of convictions for, and the number of users convicted of, drug offences during the stages of the drug using history, most particularly during the two years following identification as opiate users. The majority of the drug offences during this period involved opiates when most of the users were, or had been, in receipt of prescriptions for these drugs. It was concluded that the pattern of criminality of male non-medical opiate users was related both to the type of national drug control legislation and to their individual criminal histories.


Effects of maturity and plant spacing on the morphine content of two varieties of Papaver somniferum L. Two varieties of opium poppy were grown under irrigation for one season and their capsules analysed for morphine content by gas chromatography. Harvest of the capsules at 29-33 days after flowering (mature seed) gave 6.70 kg/ha morphine as compared to 5.36 kg/ha morphine in capsules harvested at 4-6 days after flowering. With constant row spacing (30 cm between double rows on ridges 102 cm apart), a plant spacing of 6 cm gave 20 per cent more morphine than either 12- or 18-cm spacing. There was no statistical difference in morphine content between a blue- and a white-seeded variety.


Microwave drying of microorganisms: I. Influence of the microwave energy and of the sample thickness on the drying of yeast. The use of microwave energy for the rapid drying of yeasts is described. The influences of the microwave energy and of the sample thickness are studied. The advantages of the method over the conventional drying techniques are presented.


Ovicidal levels of 2.45 GHz electromagnetic energy for the southern corn rootworm. Eggs of southern corn rootworm (Diabrotica undecimpunctata howardi Barber) were subjected to electromagnetic energy at 2.45 GHz in slotted waveguide applicators to determine ovicidal threshold levels. Ovicidal levels at different intensities and exposure times are presented. Infrared measurements of temperature changes and estimates of the heating produced at the mical.


Cochlear microphonics generated by microwave pulses. Oscillations at 50 kHz have been recorded from the round window of guinea pigs during irradiation by 918-MHz pulsed microwaves. The oscillations promptly follow the stimulas, outlast it by about 200 musec and measure to 50 muV in amplitude. They precede the auditory nerve's response and disappear with death. They are interpreted to be a cochlear microphonic and hence to demonstrate that the microwave auditory effect, in the guinea pig at least, is accompanied by a mechanical disturbance of the hari cells of the cochlea.


Dose rate distribution in triple-layered dielectric cylinder with irregular cross section irradiated by plane wave sources. Previous investigations have shown that absorptions of microwave energy in biological bodies depend, in part, on the size and shape of the biological bodies. Calculations of dose rate distributions in regularly-shaped biological tissues have been reported. In this investigation, dose distributions are calculated for a human thigh simulated by a dielectric cylinder with irregular cross section. Method of moments is used in the investigation. The results indicate possibility of using method of moments to calculate dose distribution in a two-dimensional irregularly-shaped biological body. It is concluded that additional research is needed to determine dose rate distribution in three-dimensional irregularly-shaped biological bodies.


Teratology, survival, and reversal learning after fetal irradiation of mice by 2450-MHz microwave energy. In the first of two factorially designed studies, 80 primigravid mice of the C3H-HeJ strain were subjected to 2450-MHz sinusoidally modulated microwave radiation or to sham radiation (with or without an accompanying injection of 5 mg of cortisone as a teratological marker) on the 11th, 12th, 13th or 14th day of gestation. The radiation treatment consisted of a single intense dosing of microwave energy (38 mW/g for 600 sec.= 22.8 J/g) in a multi-mode cavity. On the 19th day of gestation fetuses were taken via Caesarean section and were observed for gross structural abnormalities. While radiation of dams failed reliably to increase the incidence of fetal mortality or morbidity above that of controls, the dams treated with cortisone gave birth to reliably greater numbers of stillborn and deformed fetuses. In the second experiment and during their 14th day of gestation 60 primigravid mice received the radiation of sham-radiation treatment, half with, half without, the accompanying injection of cortisone. A virtually complete failure to survive to weaning characterized the pups born of the sham-radiated cortisone-treated group of dams, but the incidence of cortisone-induced mortality was reliably reduced in pups whose dams were also radiated by microwave energy. Pups sampled from all but the depleted group were observed later as young adults for competency in mastering a series of reversal habits in a water maze. No differences in maze performances were observed in the mice as a function of their placement in the control or the radiation condition, but offspring of cortisone-treated, radiated dams made reliably more errors. Careful measurement of elevations of colonic temperatures of radiated dams shortly after treatment with cortisone revealed an averaged deltaT that is close to that observed in a comparably radiated volume of water of equivalent mass. If the finding has generality beyond the gravid mouse-it, that is, cortisone effectively and reversibly renders the mammal ectothermic-an important advance in biological dosimetry of non-ionizing radiation may be at hand.


[Bacteria and resistance examination in bacterial conditions of the conjunctiva (author's transl)]. The optimal treatment of any inflammation within the area of conjunctiva, after recognition of pathogen and determination of resistance, is not always feasible in the daily practice of the ophthalmologist because usually immediate treatment is necessary. To test the (in vitro) efficacy of the medications available, determinations of pathogen and resistance were made in 100 conjunctival swabs taken from patients with inflammations of the conjunctiva and lacrimal duct. The relatively high incidence of resistance to penicillin, chloramphenicol and tetracycline should be the reason for using more effective substances such as gentamycine and rifamycin. The pathogens and resistance found at present are important criteria for the selection of appropriate chemotherapeutic agents.


An evaluation of the epidemiology of atherothrombotic brain infarction. Review of the epidemiology of atherothrombotic brain infarction (ABI) based largely on 18 years of prospective data from the Framingham cohort reveals that stroke is a potent force in morbidity and mortality, that hypertension is its dominant precursor, that it can be predicted and suggests that only a preventive approach can substantially reduce stroke morbidity. Data from Framingham on the relative frequency of the major types of stroke found in the community reveal that 57 percent are due to ABI and only 17 percent to intracranial hemorrhage--two-thirds of which is subarachnoid. Lacunar infarcts are common accounting for 13 percent of ABI's in men and 23 percent in women. Despite the sizeable geographic, seasonal and secular trends in stroke mortality, few environmental determinants of stroke have been uncovered. However, established hallmarks of the candidate for an atherothrombotic stroke include: hypertension (systolic or diastolic), glucose intolerance, high normal hemoglobin, the cigarette habit (men only), abnormal lipids (under age 60) and cardiac impairments. Many unresolved issues remain. Nevertheless, it is possible to identify a tenth of the general population from which half the strokes will emerge. This provides a rational basis for establishing a program of prevention.


Factors associated with patient evaluation of health care. The purpose of this paper is to study the relationships among patient characteristics, characteristics of a health care encounter, and patients' evaluation of that encounter. On the basis of 1739 patient-provider encounters in eleven ambulatory care settings, three relatively independent correlates of patient satisfaction were found: age; community satisfaction; and the nature and degree of continuity of care which characterized the visit. Patients' sex, marital status, religion, and the number and kind of services provided were not related to the evaluations patients made. Greatest differences in patient satisfaction were from setting to setting, and these differences probably can be attributed to the types of patients which they recruit or service (i.e., age, level of community satisfaction) and setting policy and procedures regarding continuity of care.


Foreign medical graduates and their impact on the quality of medical care in the United States. The literature on the level of quality of care delivered by foreign medical graduates (FMGs) has been reviewed in order to derive policy recommendations concerning their use in the United States. This review revealed a paucity in information on direct measures of the level of quality of care provided by FMGs. Differences between U.S. medical graduates (USMGs) and FMGs, especially with regard to the less than fully licensed FMGs and those FMGs at the start of graduate training, were found on examining proxy measures of quality, such as achievement of standard professional credentials or the quality of clinical training. Given this lack of evidence as to differences in performance between FMGs and USMGs, it is difficult to formulate recommendations, but four are advanced. These include (1) acknowledgment of the crucial significance of their heterogeneity, especially in regard to the quality of care provided, (2) assurance of the principle that peer-review activities are administered even-handedly to FMGs and USMGs alike, (3) improvement of the medical care capabilities of the less able provider, and (4) performance of quality of care studies, in both hospital and office practice settings, which compare FMGs with USMGs, not to ideal standards.


[Detection of Staphylococcus aureus A protein by conditioned hemagglutination]. The presence of A-protein was sought in strains of S. epidermidis and S. aureus, sensitive or resistant to methicillin. The technique used was that of passive hemagglutination of red cells of sheep, either normal or formolated and sensitised by anti-erythrocyte antibodies. A-protein was not found in any of the 157 strains of S. epidermidis. It was found in 82.5 p. cent of 360 strains of S. aureus. The methicillin resistant strains seemed less rich than the protein A-sensitive strains, which was detected more frequently when formolated red cells were used. The interest of this test for bacteriological diagnosis is discussed.


[Memory disorders in parkinsonism patients]. The experience of memory and retention weaknesses in Parkinsonian patients led us to question if these are only due to age-specific deteriorations, and if these weaknesses change during the L-Dopa therapy of the underlying disease. For this reason 30 Parkinsonian patients and 30 normal subjects of a matched control group took part in five different tests of retention and memory: digit span (Wechsler), visual retention test (Benton), Wechsler Memory Scale (subtests 4 and 7), delayed recall (Williams). The results (including some further samples of the test literature) gave some evidence of test-material-specific weaknesses in Parkinsonian patients: especially such memory decay as is dependent on the interval of retention. An organic deterioration of the intermediate term memory is suggested. This result could not be fully explained by known psychological or neurological characteristics of the underlying disease.


Knowledge, behavior, and attitudes of sixth-grade students toward family life education. Although certain exceptions may be noted with respect to sex and type of school, generally lower socioeconomic students obtained lower mean scores on the knowledge and attitude sections of the survey instrument than their counterparts from the higher economic strata. Disadvantaged children from lower socioeconomic levels are reared in an atmosphere hardly conducive to study. Their homes are overcrowded; the children are often hungry, obtain insufficent rest, and possess little interest or motivation for the future--they just live for today. The lower socioeconomic child suffers most when he comes to school. His experiences in living have not prepared him for the demands of the typical school. Shaped by his environment, seeing himself as a person of little worth, he is called upon to conform and communicate. His value system that was bred in deprivation shows sharp contrast to the established "middle class" value system held by the school. Furthermore, disadvantaged children enter school with habits and attitudes that may conflict with many of the traditional modes of teaching. They have had few opportunities to learn the relationship between effort and achievement or to observe that learning has its own reward. Educators have a responsibility to provide the best type of family life education program to meet the needs of all youth. Innovative and challenging ways must be found to make family life education programs relevant to all socioeconomic strata. It would appear essential that educators should possess a thorough knowledge of the economic, social, and cultural conditions that exist in the area in which the educational process is to be conducted.


What the schools can do to promote mental health. The schools can help to ease mental health problems in several ways--preventing them from occurring and minimizing their severity and chronicity, and in assisting with the management of students who have problems. However, the most important role of the school lies in providing the best possible education. A given purpose must be examined to see where it falls  within educative, socializing, classifying, or therapeutic roles. Some tasks, such as drug education, have been poorly, carried out because they are called "education," although actually they involve socialization. The school must be an integrated institution providing the best environment for the development of its pupils. This aim means providing the best education, but it also requires roles be clearly defined and followed out with a minimum of convert conflict.


Foundations of health education.

Foundations of health education. Health education is "the process of providing or utilizing experiences for favorably influencing understanding, attitudes, and practices relating to individual, family, and community health. As an applied science it draws its content from a variety of sources. The paradigm which depicts the foundations of health education can be visualized as five vertical pillars consisting of sociocultural, educational, psycho-behavioral, legal, and scientific foundations supporting the work of the health educator. While the components within each pillar may be altered with new developments and advances over time, the model is broad enough in scope to incorporate the changes without altering its purpose. The foundations of health viewed in this light can easily display the depth of the health education profession and will serve to orient the novice and future health educators of the underpinnings of their profession. This framework could easily be adapted for study on the college level and should serve as an orientation to those students planning to major in health.


Physician participation in health service management: expectations in United States and experiences in England. Increasing governmental regulation such as called for in PSRO and health planning legislation, pressures to contain rising costs, physician strikes, and other manifestations of change suggest that traditional hospital organization and management patterns ought to be re-examined. Moreover, as the United States moves toward a governmentally financed and regulated system, experiences in Great Britain and other nationalized systems become more pertinent to us. The 1974 major reorganization of the British National Health Service provides for considerable physician participation in management. A similar participative approach to the management of the hospitals in the United States is worthy of consideration as a way to meet increasing challenges of a governmentally financed and controlled health care system.


The generation of a ColE1-Apr cloning vehicle which allows detection of inserted DNA. A 3.2 Mdal sequence of DNA, TnA, which contains the ampicillin (Ap) resistance determinant has been translocated from an R plasmid to the plasmid ColE1. A total of 12 isolates were studied. There are at least 8 sites in ColE1 at which TnA has inserted. Insertion at five of these has resulted in a Col-phenotype. One ColE1-Apr plasmid, RSF2124, was examined further and its replication properties are found to be similar to that of the parent plasmid. RSF2124 appears to be a useful plasmid vehicle for the molecular cloning of DNA from diverse prokaryotic sources: it codes for readily detectable Ap resistance and contains a single EcoRI site in a gene affecting colicin biosynthesis so that it is unable to produce colicin upon ligation to other DNA.


The erosion of professional authority: a cross-cultural inquiry in the case of the physician. The extent to which the erosion of professional authority observed in the United States is also occurring in the United Kingdom and the U.S.S.R. is examined in the case of the primary care physician. Informal interviews with health practitioners in these diverse societies revealed that the model of the professions which bases physicians' autonomy and authority on the occupational characteristic of a monopoly of specialized knowledge is subject to some revision. Education of the patient emerged as a critical factor in eroding physician authority in both countries, while patient age affected authority relations differentially in the two societies. Despite variations in the level of bureaucratization of health care, the role of the physician, as gatekeeper to non-medical benefits, served to counteract the erosion trend in both. The legacy of deference to the upper classes in Great Britain and in the U.S.S.R., an ideology of health as a citizen's obligation plus the "mothering' ambience of a largely female personnel are varying societal characteristics which also affect physician authority.


Decision making about patient care.

Decision making about patient care. Written descriptions of four patient situations and a table of nursing actions and outcomes were presented to 47 registered nurses to investigate quantification of 185 nursing decisions about patient care. The nurses ranked the actions according to that which they considered best for the patient described, gave probabilities of the occurrence of outcomes, and assigned values to outcomes. The probability of an outcome's occurring, multiplied by the value of that outcome, and added for all outcomes of an action constituted the expected value (EV) of an action in achieving a goal. Significant agreements between the EVs and ranking of actions were obtained. The preferred action had the highest EV for 109 of the 185 decisions studied. Most decisions were justifiable in that chosen actions were desirable for achieving goals, were consistent with the nurses' knowledge of the probability of the outcomes' occurring, and were in keeping with the nurses' values for the outcomes. The findings indicated that decision theory is applicable to nursing practice, that nursing decisions can be adapted to analytical models, and that nurses can order outcomes of their actions according to their desirability and likelihood of occurrence.


An alcoholism training program: its effect on trainees and faculty. Evaluation of the effect of a three-year specialized training program in alcoholism on opinions and attitudes of trainees and faculty members at the University of Washington School of Nursing showed that the program influenced both trainees and faculty in a positive direction. Trainees were found to be more accepting of alcoholism as a disease and an increasing number of faculty believed alcoholism-related courses should be a part of the curriculum.


Registered nurses' opionions on an extended role concept. Using a Likert-type questionnaire, opinions of 800 professional registered nurses in Texas, selected at random, were surveyed on the extended role concept as reflected by the family nurse clinician (FNC). Thirty percent of the questionnaires were returned and used for data analysis. The survey found that the nurses' years of nursing experience, employment status, field of employment, and education background influenced their opinions on the extent they thought the FNC could assume the defined responsibilities, the areas of the health care delivery system in which the FNC could exert a positive influence, and anticipated problem areas for the practicing FNC. Strongly supportive of the role, the nurses favored the FNC's assuming considerable responsibility in the delivery of primary health care.


Factors that influence attraction and retention of qualified nurse educators. In a study to determine factors that influence attraction and retention of nurse educators, 92 faculty members in Iowa institutions of higher learning reported that the work itself was most important in attracting them to and holding them at the institution. Recognition was least important in attracting them, and salary was least important in retention.


The collaborative process in generating a nursing research study. The chronicle of a cooperative research venture is presented in three sections: the sequence of events and the system within which the collaboration was sponsored, the pilot study and the actual cooperative research proposal, and the stresses and strains of the collaborative process. The vagaries of events, people, and places leading to the scientific review are described. Previous research on which the study proposal was based is described so that the natural evolution of a study which extends previous work may be depicted. Interpersonal problems, opportunities, and challenges of collaboration in research are described.


Social and psychologic influences on employment of married nurses. Seven summary factors were obtained from a principal components factor analysis and Varimax rotation of 21 variables, based on 145 pieces of information given by 1,998 nurses in metropolitan Detroit, Michigan, in 1973. Study nurses were under 60 years of age, were married and living with spouse, and had at least one child 18 or younger. The factors were: career desirability, professional attitude, professional behavior, achievement personality, conducive home situation, economic value of work, and satisfaction with nursing. When these factors were compared with employment status-1) current employment activity of all subjects, 2) subjects whose employment status was constant for five years, highest scores were registered in both categories on career desirability, professional behavior, and economic value of work. Both groups of nurses scored lowest on satisfaction with nursing, with the five-year employees scoring lower. When the seven factors were correlated with employment status while controlling financial need and age of youngest child at home, highest correlation scores resulted for professional behavior, career desirability, and, in the case of those with financial need, on the economic value of nursing.


Relationship between nurses' opinions about mental illness and experience. To examine the effect of long-term experience on a psychiatric ward on nurses' opinions about mental illness, experimental groups of nursing students (N = 11) and experienced psychiatric nurses (N = 8) and a control group of medical-surgical nurses (N = 8) were compared along the five dimensions of the Opinions about Mental Illness Scale. The medical-surgical and psychiatric nurses were matched for age and education. The experienced psychiatric nurses were found to hold significantly more authoritarian opinions about mental illness; they adhered less to a belief in interpersonal etiology than the other two groups. Compared to the nursing students, the psychiatric nurses held significantly more socially restrictive opinions about mental illness; they adhered less to current mental health ideology. However, age could not be ruled out as a variable in the latter two opinions. Factors which may contribute to opinion change in psychiatric nurses are discussed.


Relationship of staff development activity to opinions about mental illness. When 1971 and 1974 student psychiatric aides, staff psychiatric aides, and professionals at Topeka State Hospital in Kansas were given the five-factor Opinions about Mental Illness Scale as pre- and posttests, no significant differences were found in scores of the student aide groups. Significant differences, however, were found among 1974 student aides, staff aides, and professionals, with students scoring higher than professionals (p less than .05) on factors A-authoritarianism, D-social restrictiveness, and E-interpersonal etiology. Staff aides scored higher than professionals on factor B-benevolence, factor A-authoritarianism (p=.005), and factor D-social restrictiveness (p=.05). Implications for nursing are discussed.


Nurse practitioner management of common respiratory and genitourinary infections, using protocols. Included in this study were all patients with symptoms of respiratory tract infection and female patients with symptoms of urinary tract and vaginal infections who sought care from a hospital-based outpatient department walk-in unit which was operated in two different modes: experimental (the "nurse-protocol mode")-in which a nurse practitioner guided by a protocol initially evaluated all such patients and independently managed many patients- and traditional-in which only physicians managed patients. Safety, effectiveness, efficiency, and cost of care rendered for these tracer conditions in the two modes were compared. No serious illnesses were overlooked by practitioners in either mode. Eighty-six percent of patients in the nurse-protocol mode and 73 percent of patients in the traditional mode reported good symptom relief. Patients reported equivalent satisfaction with care. The time physicians spent managing patients with these complaints was reduced by 91 percent from 15.5 minutes to 1.4 minutes per patient. Personnel costs were equivalent in the two modes. Costs of laboratory tests and medications ordered were 27 percent less in the nurse-protocol mode. The study indicated that care in the nurse-protocol mode was of equivalent quality, led to equivalent patient satisfaction, allowed a substantial reduction in physician time, and reduced overall costs of care.


Diabetes mellitus in elderly persons.

Diabetes mellitus in elderly persons. The person who develops diabetes late in life needs carefull assessment of his abilities to assume the new self-care activities required by the advent of a chronic disease. Knowledge of both the aging process and the complications and management of diabetes is needed to assist him toward this goal. His commitment may have to be to a part of the whole plan, but to the elderly person, any participation will provide a measure of independence and control over his life.


A behavioral therapy approach to bladder retraining. In summary, emphasis has been given to the following essential points: incontinence is a difficult problem for many elderly persons and those who are responsible for their care; the concepts of bladder retraining are simple and few in number-communication, fluid intake, and habit; contingency management is applicable to the problem of urinary incontinence and consists of a reward system not only for the patient but also for the staff. An attempt has been made to break down the necessary components that are required in a bladder retraining program that relies on contingency management. In order to institute such a program, further study and/or consultation probably should be sought.


Delivering health care to the elderly in a high-rise: a learning experience. Students in a gerontological nursing program can gain measningful experience in a metropolitan high-rise for the elderly, as well as provide needed services to the residents. Being involved in the planning stage for the experience proved to be almost as valuable as the experience itself. Working with well and not so well elderly persons in their own homes gives the student the experience she needs in looking for alternatives to institutional care. It also points out to the student the need for a "preventive" approach to health care. We found that it takes at least two quarters to solve problems that residents want settled. After their immediate needs were met, we could become more involved in increasing physical assessment skills. This is not to say that we could lose sight of the broad day-to-day problems that arose and had an effect on the residents. We learned not to plan any programs for the days when government checks or food stamps arrived, as most people left the building on those days. This experience was gratifying educationally as well as personally for both students and instructor.


[Typhoid fever in south Vietnam to day (author's transl)]. In South Vietnam, the first Salmonella typhi resistant to chloramphenicol were isolated at the end of 1971; this resistance spread rapidly to two-thirds of S. typhi isolated; it is due to resistance plasmids which parasite most strains of S. typhi identified in Vietnam. The typhoid endemy turned into an epidemic en 1972. The clinical symptoms of typhoid fever remained just as few as before: often only a high temperature; splenomegaly is rare, hepatomegaly more frequent. Complications, specially associated ones, have been more frequently observed since 1972; the evolution of the disease is slower. Although costly, a high dose of ampicillin often proves clinically active. For the moment, an association of trimethoprime and sulfamethoxazole remains the least expensive of efficient treatments.


Multiple drug-resistance in staphylococci, an analysis of all-nation computer-processed data. In a previous communication from this Institute it was assessed that multiple drug resistance plays a decisive role in overall antibiotic resistance of staphylococci and that true data of the extent of multiresistance depend decisively on sufficient number of antibiotics toward which strains of a given species is tested. It was found, by analysis of more than 60 000 staphylococcal strains isolated by Public Health Laboratories in the Slovak Socialist Republic (S.S.R.) during the period of one year, that triple and quadruple resistance is the most prevalent one in staphylococci - not regarded, however, the penicillin resistance which is absolutely predominant. Present analysis also shows that resistances to streptomycin, tetracyclines, erythromycin and kanamycin (STEK type) are both most frequent and mutually selective, i.e. strains resistant to any of these drugs (and also to penicillin, i.e. PSTEK type) show resistance also to other antibiotics of this group. In contrast, chloramphenicol resistance seems not to be connected with resistance to these substances nor is resistance to newer specific anti-staphylococcal antibiotics, used only recently in this country, as is oxacillin, lincomycin and cefaloridin. Nevertheless, lincomycin seems to select a co-resistance as many lincomycin-resistant strains were resistant also to oxacillin but not vice versa. Increasing resistance of staphylococci in S.S.R. to kanamycin and particularly to erythromycin, and their frequent occurrence in multiresistance types is a warning feature which might lead to an increase of therapeutic crisis in staphylococcal infections.


Clindamycin therapy of Staphylococcus aureus endocarditis. Clinical relapse and development of resistance to clindamycin, lincomycin and erythromycin. A 42 year old heroin addict with Staphylococcus aureus endocarditis of the mitral valve was treated with clindamycin phosphate, 600 mg intramuscularly, every 6 hours. The initial clinical response was excellent and blood cultures became negative. On the 26th day of clindamycin therapy, fever developed and six blood cultures taken during a 72 hour period grew Staph. aureus. The patient was subsequently cured with a six week course of nafcillin plus gentamicin followed by cloxacillin. The Staph. aureus isolated before clindamycin therapy and during relapse phage-typed 29/52/52A/79/80 and was resistant to penicillin G. The susceptibility of both Staph. aureus isolates to 19 antibiotics was unchanged. However, the Stahph. aureus developed marked resistance to clindamycin, lincomycin and erythromycin, to which the original isolate was susceptible. The resistance to clindamycin and lincomycin was heterogeneous whereas the entire cell population became homogeneously highly resistant to erythromycin. These antibiotics were not inactivated in vitro by the rapidly growing resistant Staph. aureus. The most likely site of resistance was at the 50 S subunit of the bacterial ribosome.


Effects of ampicillin-amikacin and ampicillin-rifampin on enterococci. Fifty-seven clinical isolates of enterococcus were tested for susceptibility to 10 antibiotics in a microtiter broth dilution system. Amoxicillin, ampicillin, vancomycin, and rifampin inhibited all strains at concentrations easily achievable in blood. Resistance to rifampin developed rapidly. Of the aminoglycosides, gentamicin was most active, followed in decreasing order by tobramycin, amikacin, kanamycin, and streptomycin. High-level resistance to streptomycin was present in 26% of the strains and to kanamycin in 23% of the strains. Growth curve studies of selected strains revealed synergy with ampicillin-amikacin and antagonism with ampicillin-rifampin. It is suggested that ampicillin-gentamicin constitutes adequate initial therapy for enterococcal infections until the results of tests for high-level resistance to kanamycin and streptomycin are known and that clinical trails of ampicillin-amikacin are warranted.


[Considerations on the antibiotic activity (M.I.C.) revealed in 247 serotypes of Salmonella]. 247 strains of Salmonella, isolated in Brescia province duriing 1973-1974 have been typed by serological methods. The MIC has been determined, using the following antibiotics: chloramphenicol, tetracycline HCL, ampicillin, doxycycline, rifampicin, cephazolin, carbenicillin, nifuratel, gentamicin, aminosidine, trimetho-prim-sulphamethoazole, nalidixic acid. The pattern of resistence of the various serotypes is quite constant. The relationship between diffusion and epidermiological factors are discussed.


Antibiotic susceptibilities of 120 strains of Staphylococcus aureus isolated from patients at a Children's Hospital. Decline of hospital staphylococci as compared with staphylococci in outpatients. A reversal. The antibiotic sensitivities of 120 strains of Staphylococcus aureus isolated from both hospitalized patients and outpatients at Children's Memorial Hospital, Oklahoma City were studied. The proportions of strains resistant to the commonly used antibiotics were considerably lower than that found by other workers in earlier years, except for penicillin G. Of the 120 strains, 98 (81.7%) were resistant to penicillin G, 13 (10.8%) to tetracycline, 9 (7.5%) to erythromycin, and 3 (2.5%) to clindamycin. No strains resistant against cephalothin, chloramphenicol, gentamicin, or oxacillin were found. Sixteen strains (13.3%), of which 5 were inpatient  strains and 11 were outpatient strains, were found to be resistant to more than one drug. Phage group 1 or type 80/81 staphylococci were not found among multiple resistant strains from hospitalized patients.


Olfaction in the development of social preferences in the human neonate. Olfactory perception in the human neonate has been largely ignored. The present experiments examine the possibility that neonates can use smell to locate a food source and that they can differentiate between their own mother and another mother on the basis of smell. Head-turning to breast pads was used in perference tests. Although the neonate did not appear to be able to use smell to localize a food source, significantly more babies spent more time turning towards their own mother's breast pad than towards a clean breast pad at five days of age. By six days of age babies were showing a differential response between their own mother's breast pad and another mother's breast pad, although this differentiation was not present at two days of age.


Breathing and sucking during feeding in the newborn. Eighteen normal full-time infants aged from 1-10 days were fed both normal saline and distilled water from a conventional feeding bottle. Fifty-four sets of observations were made when 44 infants were fed both cow's milk (Half Cream Cow & Gate) and expressed human milk. During feeding, measurements were made of breathing, sucking, and the flow of milk from a feeding bottle which incorporated an electromagnetic flowmeter transducer. Integration of the flow of milk measured the volume of milk swallowed by the baby. The results suggest that the patterns of feeding and breathing differ in some infants when different fluids are given to them.


Early mother-infant reciprocity.

Early mother-infant reciprocity. By three weeks of age, the human neonate demonstrates behaviours which are quite different with an object and with a human interactant. He also demonstrates an expectancy for interaction with his caregiver which has clearly defined limits, as demonstrated behaviourally. In microanalysis of videotape, we saw regularly a set of interactive behaviours which were demonstrable in optimal face-to-face interaction between infants and their mothers. All parts of the infant's body move in smooth circular patterns as he attends to her. His face-to-face attention to her is rhythmic with approach-withdrawal cycling of extremities. The attention phase and build-up to her cues are followed by turning away and a recovery phase in a rhythm of attention-non-attention which seems to define a cyclical homeostatic curve of attention, averaging several cycles per minute. When she violates his expectancy for rhythmic interaction by presenting a still, unresponsive face to him, he becomes visibly concerned, his movements become jerky, he averts his face, then attempts to draw her into interaction. When repeated attempts fail, he finally withdraws into an attitude of helplessness, face averted, body curled up and motionless. If she returns to her usual interactive responses, he comes alive after an initial puzzled period, and returns to his rhythmic cyclical behaviour which has previously characterized their ongoing face-to-face interaction. This attentional cycling may be diagnostic of optimal mother-infant interactions and seems not to be present in more disturbed interactions.


Consistency and change in styles of mothering. The idea that the immediate postpartum period is particularly important for the developing relationship between mother and child is being increasingly discussed; however, little is known of the long-term significance of the individual differences in adjustment found in this period. A longitudinal study of 70 mother-baby pairs showed that difficulities during feeds were related to longer labour and to measures of the baby's state at birth. Differences between babies in the latency with which they responded by crying to interruption of sucking (in tests of non-nutritive sucking) were also related to the smoothness of the feed. Measures of affectionate maternal behaviour were associated with differences between babies in sucking rate, and were not influenced by labour and delivery. During later observations (8-30 weeks), strong consistency in individual differences across age was found in the levels of maternal touching, vocalizing, and responsiveness to baby's vocalizing. Maternal affectionate contact during early feeds (babies up to 10 days old) was related to these later maternal measures for breast-fed babies. Other aspects of coordination and warmth in the early feeds did not correlate with later measures, which suggested that predictions based on observations early in the neonatal period should be made with caution. Measures of maternal response to crying showed little consistency across the first seven months and were influenced by how much the baby cried at earlier ages.


Prepartum and postpartum regulation of maternal behaviour in the rat. Maternal behaviour in the rat consists of four principal components: nursing or crouching over the young, retrieving pups to the nest, body and genital licking of pups, and nest-building. Normally the onset of maternal behaviour occurs at parturition but studies reveal that the true onset is somewhat earlier, around 24 hours pre partum. The onset of maternal behaviour is hormonally determined and it is most likely that the ovarian hormone oestradiol plays a major role under the specific conditions that exist pre partum. The onset of maternal behaviour requires the resolution of tendencies of fear-avoidance of pups, based on their olfactory characteristics, and attraction to them and response to the pup stimuli that elicit maternal behaviour. In most animals this resolution occurs almost immediately but in some animals several hours of contact with the pups is required for maternal behaviour to be firmly established. After parturition, maternal behaviour appears to be regulated chiefly by stimuli from the pups, and hormones do not play a role apart from their role in lactogenesis. Size of litter, age of pups, amount of externally induced stress and other factors can affect the mother-young interaction: there is a period of special vulnerability to disruption of the mother-young interrelationship shortly after parturition which corresponds, we believe, to the period of transition from hormonal to non-hormonal regulation of maternal behaviour. Weaning and the decline of maternal behaviour is a specific phase of maternal care. Maternal behaviours gradually decline as avoidance behaviours increase.


How a rejecting baby affects mother-infant synchrony. In any mother-infant relationship, characteristics of both the mother and infant contribute to an ongoing process of mutual modification of behaviour. With intensive observation and objective recording of behaviours, it is possible to describe individual infants, depict patterns of interaction with their mothers, and identify some of the consequences of interaction for both the mother's and the infant's developing behaviours. Even a normal infant can have behaviour patterns that play a disruptive role in the relationship. For example, an infant has been observed who, from birth through the first weeks of life, showed avoidance responses to being picked up and held. The infant's behaviour was a source of frustration and confusion to the unsuspecting parents. It is obviously difficult for the parents to respond appropriately to the needs of such an infant. And, in turn, the resulting interaction affects the infant's developing behaviours. The theme of this paper is to emphasize, though each relationship is unique, that observations made from the first days of life can permit the infant's contribution to the mother-infant relationship, and the manner in which that relationship influences his development, to be assessed.


Mother-infant neonatal separation: some delayed consequences. An earlier study of mothers of premature and full-term infants showed that the type and amount of social interaction between a human mother and her infant in the immediate postpartum period can influence the mother's subsequent behaviour and attitude towards the infant. Separation of a mother from her infant for as short a time as three weeks in the immediate postpartum period can lead to lowered feelings of maternal competency and decreased amounts of attachment behaviour, sometimes continuing for as long as one month after the pair have been reunited. Follow-up of these mothers and infants at 11, 12 and 15 months after discharge from the hospital showed that the effects of separation on maternal attitude and behaviour had disappeared, except that non-separated mothers continued to touch their infants more than separated mothers. Differences in maternal behaviour varied with birth order and sex of the infant and social class membership of the family. These findings are discussed in terms of ethological and social learning theories as they apply to matenal 'social attachment' in the neonatal period. The importance of considering the consequences of neonatal separation for the entire family rather than mother alone is emphasized.


Cognitive aspects of preverbal social interaction between human infants and adults. Our previous studies on learning and on cognitive development in preverbal human infants indicated that motor activity and social interaction played particularly important roles in the cognitive development of infants. Closer analysis has revealed that motor activity and social interaction have some underlying common regulatory mechanisms. These mechanisms can be detected more easily in infants than in older subjects. An attempt to synthesize our observations led us to the concept that there is a fundamental cognitive process in the integration of adaptive behaviour. This concept may help to elucidate the motivational and emotional aspects of social interaction, the role of mothers or other caretakers in their interactions with infants, and the unfavourable effects of early social deprivation of different types on cognitive development. Some of the assumptions on which this concept is based have been corroborated by analyses of adult-infant interaction.


Parents of babies of very low birth weight: long-term follow-up. On hundred and sixty babies of birth weight less than or equal to 1500 g who survived after perinatal intensive care have been followed up and observations have been made on their parents. In spite of attempts to minimize maternal separation and the distressing aspects of the birth and management of a baby of very low birth weight, an emotional crisis was observed in the mothers which was not fully resolved until the parents had been looking after the baby at home. The duration and degree of the crisis varied but the mothers who received sympathy and support from the baby's father appeared to have least difficulty. A rigid maternal personality and circumstances surrounding the birth which predisposed to feelings of failure and guilt appeared to prolong the crisis. Nevertheless, most of these parents subsequently formed satisfactory relationships with their children, although they tended to be over-protective and anxious. Failure to establish an adequate relationship was rare and occurred only among mothers with personality or psychiatric disorders. Although serious behaviour disorders among the children were rare, more children than would be expected were mildly over-dependent, shy and anxious at follow-up.


Does human maternal behaviour after delivery show a characteristic pattern? Specific kinds of maternal behaviour such as nesting, retrieving, grooming and exploring, are seen in non-human mammalian mothers immediately before, during and after delivery. In this study 22 human mothers were filmed during the first 10 minutes of contact with their normal nude full-term infants, who were placed beside them in private rooms in hospitals in Guatemala and the US; and nine mothers of premature infants were filmed on their first three visits to the nursery. Another 10 Guatemalan mothers and infants were observed for 10 minutes almost immediately after delivery in hospital. These observations were compared to maternal behaviour after home deliveries in California. After hospital delivery all US mothers, but only half of the Guatemalans, began touching their infants' extremities with their fingertips and proceeded within a few minutes to palm contact on the trunk. US mothers had an intense interest in eye-to-eye contact. Mothers of premature infants showed only fragments of this behaviour. In home births when the mothers are active participants in delivery, they pick up the infant immediately after birth, stroke its face with their fingertips and start breast-feeding within the first minutes after delivery. Initially the infant only licks the nipples. there is striking elevation in mood in the parents. These observations focus attention on reciprocal behaviour patterns that develop early between mother and infant and which serve to unite them.


Evidence for a sensitive period in the human mother. In certain animal species immediate separation of a mother from here young for a brief period after deliver (the sensitive period) may result in aberrant maternal behaviour. In the human, disorders of mothering, including child abuse, increase disproportionately in situations associated with early neonatal separation of mother and infant, such as prematurity. Mothers in the United States who were offered early contact with their premature infants showed differences in attachment behaviour when compared with mothers whose first contact with their infants was three weeks after delivery. Mothers who had one hour of close physical contact with their nude full-term infants within the first two hours after delivery and who had 15 extra hours of contact in the frist three days behaved significantly differently during a physical examination of the infant at one month and one year, and in their speech to their infants at two years, from a control group of mothers who had only routine contact. In a similar study in Guatemala, mothers who had 45 minutes of early extra contact showed significantly more attachment behaviour at the time of the first breast-feeding (12 hours). These and other studies in the human suggest that shortly after birth there is a sensitive period which appears to have long-lasting effects on maternal attachment and which may ultimately affect the development of the child.


Can one predict outcome of medical coma? The combined evaluation of the motor response to stimulation and the oculovestibular (OV) reflex gives useful indicants to the outcome of medical coma. We examined 48 patients during the first 12 h and at 24 h after the onset of medical coma. We excluded patients who had ingested drugs or who had hypothermia. Motor responses to a noxious stimulus were scored on a 6 'best' and 1 'worst' scale, and the presence or absence of oculovestibular responses to icewater irrigations was recorded. Subjects were divided by outcome at three months into three groups: death or persistent vegetative state, severe disability, and moderate disability or good recovery. On the basis of the present series it was often possible to distinguish among the outcomes at or before 24 h. The patient's age and the presence or absence of pupillary responses, spontaneous eye movements and oculocephalic responses were not predictive of outcome, nor were the respiratory pattern, blood gases, blood pressure, heart rate and temperature. A minimal motor score and an absence of oculovestibular responses at 12 h always were assoicated with death. With higher motor scores, the absence of oculovestibular responses at either 12 or 24 h implied an outcome no better than severe disability. The results of the present study imply that early bedside assessments can yield accurate predictive information in medical coma.


Assessment of the psychosocial outcome after severe head injury. Rehabilitation services for the severely brain injured are often inadequate and one of the chief factors responsible is undue emphasis on the contribution of physical disability with scant attention to the serious emotional and intellectual handicaps incurred. Weakness, spasticity and dysphasis tend to recover eventually to a variable extent but mental handicap is often the cause of serious and lasting disablement. For a determination of the outcome of severe brain injury in terms of its effect on daily living, the relation between physical disability, mental handicap and social reintegration has been assessed quantitatively. Three assessment scales have been constructed and used in a study of 58 severely brain damaged patients. This revealed that the duration of post-traumatic amnesia correlates highly with the degree of social, mental and physical disability incurred. Daily living was affected primarily by impairment of intellect and personality and, to a lesser extent, by physical incapacity, but only rarely by the developments of symptoms of mental illness. Using the Wechsler Adult Intelligence Scale, the time course of cognitive recovery was also assessed. Recovery curves and the relation of cognitive impairment to social and physical handicap will be demonstrated.


Recovery of function after brain injury in man. Late after-effects of cerebral trauma are difficult to study because patients tend to be seen for persisting symptoms, and not simply for their lesions. We have tried to avoid this bias by recalling periodically, over the years, 520 men with known brain injuries incurred in World War II or in Korea or Vietnam. These men are seen irrespective of clinical need and all undergo intensive behavioural and neurological assessment, which still continues. For such groups, recovery is impressive, though one third shows persistent intellectual loss. In addition, some tasks reveal specific deficits enduring unchanged, after th first 2-3 yr, for the 20-30 yr of follow-up (e.g. visual field defects, certain auditory discrimination losses, trouble on various complex perceptual tasks). These lasting deficits are linked to the site and size of focal injury, often representing remnants of more severe initially-present disorders. The extent of recovery is correlated with age at the time of trauma, the youngest faring best. Extension of such studies to cases of early brain damage (birth to five years), as indicated by hemiparesis, shows the familiar 'escape' of language after early left-hemisphere lesions but this is achieved at a price, the price being borne by non-verbal functions that normally depend on the integrity of the right hemisphere.


Acquired dyslexia: patterns of deficit and recovery. These preliminary results are concerned with the quantitative description of recovery of function and the shape of the recovery curve. Four patients, in whom dylexia was the salient residual symptom of cerebral damage, are described. Individual differences in the pattern of dyslexic error and the time course of recovery are discussed; and recovery--as measured by longitudinal studies of performance in reading tasks--is analysed in terms of a model which takes into account rate of learning and the eventual asymptote. It is suggested that these or analogous techiques may be relevant both for the design of remedial programmes and for problems of prognosis.


Fact and theory in recovery from the aphasias. Clinical evidence has suggested that the form of an aphasia--and perhaps potential for recovery therefrom--can be related to an exceedingly wide range of variables. Such anatomico-physiological considerations as size, depth, location and nature (e.g. penetrating missile injury, stroke, tumour, closed head injury) of the injury are frequently held to be crucial correlates, as are associated neurological deficits (e.g. presence of hemiplegia, sensory and visual field defects). Subject variables, such as age, sex and 'handedness" (including familial handedness), complicate the picture still further, as may differences in education personality and cognitive style. Given a multidimensional problem of this magnitude the first objective of theory is to indicate putative constrainst on patterns of impaired performance. Studies of the normal population--that is, the population from which cases of brain injury are later drawn--may, we believe, aid in the elucidation of individual differences seen after injury. A more detailed knowledge of the range of possibilities concerning cerebral specialization of function and variations in task strategies seems to be required. In this context we shall review some recent reports on dichotic listening and split visual field experiments with both normal and brain-damaged subjects and also consider the role that linguistic descriptions of aphasic impairment could play in suggesting retraining procedures appropriate to the individual patient.


Early neurophysiological assessment after insult to the central nervous system. Cerebral insult is a generic term which includes many causes of altered cerebral function. Neurophysiological investigations, closely integrated with clinical and metabolic studies, should begin at an early stage after any such insult (namely in the first few hours) to provide information on the type, severity and evolution of latered brain function. The present contribution is based on prospective studies on 200 children with closed head injuries and 500 children who had been resuscitated following cardiocirculatory or respiratory arrest. In addition to electroencephalography, other neurophysiological investigations may be carried out whenever necessary including electroretinography, evoked potential studies and polyelectromyography at the patient's bedside, whether or not in the intensive care situation. The rapid evolution of metabolic events and of both clinical and neurophysiological features characterizes the acute initial phase, in marked contrast to the more static features of long term sequelae to a cerebral insult. Experience over the past 25 yr has shown that no rule is applicable to every case because of the diversity of individual circumstances. However, a well planned early neurophysiological assessment after insult to the central nervous system has given reliable prognostic criteria for the subsequent management of each patient and for the evaluation of any complications during the first few weeks of treatment.


Prognostic factors in stroke.

Prognostic factors in stroke. Prognostic factors in 137 patients with acute ischaemic infarction of the cerebral hemisphere were examined in a prospective study with particular reference to acute mortality, delayed mortality and the ability to regain independent living. Adverse factors in the examination on admission to hospital with regard to all these aspects were found to be a reduction of the level of consciousness to any degree and paralysis of conjugate gaze. A severe hemiplegia and advancing age indicated a bad prognosis for delayed mortality and severe disability in survivors, but did not affect acute mortality. At three weeks after the onset, inability to walk unaided, a useless hand and or urinary incontinence was associated with an increased probability of death in the next few months and of failure to regain independence in the survivors. These adverse factors appeared to correlate with infarction extending beyond the middle cerebral artery territory, severe brain swelling and recent occlusion of the internal carotid artery.


Development of a formal structure for clinical management decisions: a mathematical analysis. Decision theory and the calculating power of the computer now enables us to contemplate the development of formal methods for making decisions about clinical management. In the simplest  model, it is first necessary to define all treatment decisions as an exhaustive and mutually exclusive set and similarly to define the set of consequences or outcomes of treatment. The probability of each outcome conditional on treatment has to be estimated and this consequent state of health has to be quantified as a utility. Possible methods of estimating utilities of states of health are discussed and the construction of a unidimensional utility function based on a sequence of wagers. The states of health consequent on severe brain damage can only be described multidimensionally and the model has to be extended to include this case. While such a model would allow simple treatment decisions to be formalized, it could not decide whether the cost of treatment was worth while nor whether it would pay to carry out further investigative tests and thus buy more evidence. If these additional variables are to be included in the model, it is necessary to introduce the motion of an equivalence between monetary values and utilities. This implies attaching a monetary value to any given state of health.