Maintaining prevention in practice: survival of PPIP in primary care settings. Put Prevention Into Practice

INTRODUCTION

Put Prevention Into Practice (PPIP) consists of a kit of office-based tools intended to support the provision of preventive services by primary care providers. The purpose of this study was to examine the institutionalization of PPIP within five primary care clinics funded by the Texas Department of Health to implement PPIP, and to examine the organizational determinants of program institutionalization.

METHODS

We utilized an adaptation of the Level of Institutionalizaton (LoIn) scales for qualitative data collection and for development of an institutionalization score for each site. The determinants of institutionalization were derived from the organizational behavior and health promotion literatures and used as categories for analysis. In addition, for purposes of triangulation, chart audit data for three documentation behaviors were also collected.

RESULTS

PPIP has been maintained--at varying degrees of integration--in four of the five sites studied, for 6 years after adoption. Organizational factors that facilitated the institutionalization process were the site's institutional strength, the integration of PIPP within extant programs and services, visibility of the program within and outside the site, planning for the termination of grant funding, and presence of a program champion with mid- to upper-level managerial authority. Successful initiation of the program was not a predictor of institutionalization outcomes.

CONCLUSIONS

We have highlighted the need to consider organizational determinants of institutionalization in relation to their specific sociopolitical contexts, and in relation to each other, not in isolation.

Sutureless mechanical anastomosis of a saphenous vein graft to a coronary artery with a new connector device

Construction of vascular anastomoses by manual suturing is a highly skilled and time-consuming procedure. The St Jude Medical Anastomotic Technology Group has developed a sutureless mechanical anastomosis device, which, when tested in animals, produced anastomoses in less than 3 min and with little training. Here we present the results of the first clinical saphenous-vein to coronary-artery anastomosis by means of this device.

Left posterior BA37 is involved in object recognition: a TMS study

Functional imaging studies have proposed a role for left BA37 in phonological retrieval, semantic processing, face processing and object recognition. The present study targeted the posterior aspect of BA37 to see whether a deficit, specific to one of the above types of processing could be induced. Four conditions were investigated: word and nonword reading, colour naming and picture naming. Repetitive transcranial magnetic stimulation (rTMS) was delivered over posterior BA37 of the left and right hemispheres (lBA37 and rBA37, respectively) and over the vertex. Subjects were significantly slower to name pictures when TMS was given over lBA37 compared to vertex or rBA37. rTMS over lBA37 had no significant effect on word reading, nonword reading or colour naming. The picture naming deficit is suggested to result from a disruption to object recognition processes. This study corroborates the finding from a recent imaging study, that the most posterior part of left hemispheric BA37 has a necessary role in object recognition.

Negative childhood accounts, sensitivity, and pessimism: a study of avoidant personality disorder features in college students

Theory suggests that individuals with avoidant personality disorder (APD) may have experienced rejection or isolation during childhood, that they may be temperamentally hypersensitive, and that they may hold pessimistic expectancies. In a sample of 127 undergraduates, negative childhood memories, sensory-processing sensitivity, and pessimism were assessed. To measure childhood memories, participants wrote open-ended narratives that were evaluated for valence by independent raters. To measure APD features, participants rated the degree of which verbatim DSM-IV criteria were descriptive of themselves. Negative childhood accounts, self-reports of sensory-processing sensitivity, and pessimism were correlated with DSM-IV APD features, even after controlling for the influence of present negative mood. Interactions suggested that pessimism was more strongly related to APD features among participants who were either highly sensitive or recalled adverse childhood experiences (e.g., isolation, rejection, conflict). Implications for theory and intervention are discussed.

Increases in manic symptoms after life events involving goal attainment

Bipolar disorder has been conceptualized as an outcome of dysregulation in the behavioral activation system (BAS), a brain system that regulates goal-directed activity. On the basis of the BAS model, the authors hypothesized that life events involving goal attainment would promote manic symptoms in bipolar individuals. The authors followed 43 bipolar I individuals monthly with standardized symptom severity assessments (the Modified Hamilton Rating Scale for Depression and the Bech-Rafaelsen Mania Rating Scale). Life events were assessed using the Goal Attainment and Positivity scales of the Life Events and Difficulties Schedule. As hypothesized, manic symptoms increased in the 2 months following goal-attainment events, but depressed symptoms were not changed following goal-attainment events. These results are congruent with a series of recent polarity-specific findings.

Responsiveness to threats and incentives, expectancy of recurrence, and distress and disengagement: moderator effects in women with early stage breast cancer

Models of neurobiological systems linking personality, motivation, and emotion can be integrated with the expectancy construct to suggest hypotheses about distress and giving up in response to adversity. In 220 women with breast cancer, threat responsiveness-sensitivity of the behavioral inhibition system (BIS)-and incentive responsiveness-sensitivity of the behavioral activation system (BAS)-and expectancies about cancer recurrence were measured. It was predicted and found that high BIS sensitivity interacted with recurrence expectancy to predict elevated distress and disengagement. Low BAS sensitivity (reward responsiveness) also interacted with expectancy of recurrence to predict elevated disengagement. In contrast, high BAS sensitivity (fun seeking) interacted with recurrence expectancy to predict elevated distress. Discussion centers on theoretical implications and possible applications.

Influence of transcranial magnetic stimulation on pupil size

In 22 healthy subjects, painless repetitive transcranial magnetic stimulation (rTMS) was used to investigate the role of the cortex in the regulation of pupil size and the influence of TMS on the central autonomic nervous system. RTMS was performed over three brain regions of each hemisphere (frontal, central, parieto-occipital), over cervical nerve roots and in front of the ear (sham stimulation) while the size of the pupil was measured by infrared oculography. rTMS always elicited a dilatation of both pupils, with its maximum after approximately 1.5 s and without significant R-L difference in latency or amplitude of pupillary response. No differential effects were observed for stimulation over different cortex regions of one hemisphere, but stimulation over the right central region evoked a larger dilatation of the pupil than stimulation over the left. Pupillary dilatation was larger for cervical nerve root stimulation (+13.2+/-8.3% (S.D.) of baseline) than for suprathreshold cortex stimulation (+8.4+/-4.5%, five 10-Hz stimuli). Pupillary dilatation in response to magnetic cortex stimulation appears to reflect a mainly unspecific activation of the sympathetic system rather than an activation of a cortical pupillomotor centre. Sympathetic activation following rTMS of the cortex does not limit its experimental and therapeutic application.

A fractal approach to the features of speech consonants

Fractal dimension (D) quantifies the roughness of a temporal signal and estimates its degree of freedom, allowing a good approach for its fluctuations. This present study of consonants follows the D-assessment of vowels which was presented at the Copenhagen Collegium Meeting. Using a 16 kHz time sampling the D-values of consonants were studied in the consonant-vowel context of the French language. Each consonant was pronounced four times by six males and six females. For D-measurement of long consonants the same method was used, i.e. the dyadic box-counting method and its 10 points of D-measurement (10pD) as that used for vowels. In the aim to approach infinitely small time scales, and to appreciate at least the tendency of the 10-point set, i.e. the D value to which tends this set, the slope of the three last points (3pD) was also calculated. For the plosion part of plosive consonants, a semi-continuous box-counting method devoted to the D-measurement of a short, single-dimension temporal signal was designed. This study consistently demonstrates that (i) there is a significant difference between males and females, as far as voiced and non-plosive consonants are concerned; (ii) plosive consonants are not fractal; (iii) among long consonants, D-value of fricatives are significantly different (p < 0.01), as far as 3pD measurement is considered; and (iv) in the case of nasal consonants [m] and [n], this categorization is efficient for both 3pD and 10pD measurements (p < 0.05). There results will be commented on and discussed with the aim of clinical use.

Cholesterol lowering benefits of soy and linseed enriched foods

Foods such as breads and breakfast cereals enriched with a combination of soy protein (soy grits and/or soy flour) and whole linseed are gaining popularity. Regular consumption of either whole grains or soy protein can lower risk factors for coronary heart disease. Furthermore, linseed is a rich source of the omega-3 fatty acid. alpha-linolenic acid (LNA), with purported cardiovascular benefits. The aim of this study was to determine the effect of daily consumption of soy and linseed containing foods and Canola (as an added source of LNA) on plasma lipid concentrations in 20 mildly hypercholesterolaemic postmenopausal women. Fasted blood samples were taken initially and after 3 and 8 weeks to assay plasma lipids and both plasma and erythrocyte membrane fatty acids. Urinary isoflavones were also measured. Data from 18 subjects were used for analysis. Plasma total, low-density lipoprotein (LDL) and non-high-density lipoprotein (HDL) cholesterol concentrations fell significantly (10, 12.5 and 12%, respectively) within 3 weeks. Although attenuated, there were still significant reductions in total and non-HDL cholesterol (5 and 6.5%, respectively) after 8 weeks of intervention. These reductions were associated with increases in urinary isoflavone excretion. This pilot study indicates that regular inclusion of foods containing soy and linseed in the diet may improve plasma lipids in subjects with hypercholesterolaemia.

Loss of N-linked glycans in the V3-loop region of gp120 is correlated to an enhanced infectivity of HIV-1

We describe mutants of human immunodeficiency virus type-1 (HIV-1) strain NL4-3, which are lacking the thirteenth, fifteenth, or seventeenth sites for N-linked glycosylation (g13, g15, g17) of the envelope protein gp120. All three sites are located within the hypervariable V3 loop region of gp120. Those mutants lacking carbohydrates g15 or combinations of g15/g17 showed markedly higher infectivity for GHOST cells (human osteosarcoma cells) expressing CXCR4 (GHOST-X4), compared to the fully glycosylated NL4-3 wild type virus. In addition, these mutants could also infect cells which exhibits low background expression of CXCR4, corresponding to <10% of that observed for GHOST-X4 cells. In addition to the enhanced infectivity observed, mutants lacking g15 and g17 showed increased resistance to inhibition by SDF-1, the natural ligand of CXCR4. Thus, loss of the oligosaccharides g15 and g17 in the V3 region of gp120 markedly influences CXCR4-specific infection.

Characterization of intracellular bacteria in the freshwater dinoflagellate Peridinium cinctum

Intracellular bacteria belonging to two phylogenetically different groups of eubacteria were found in cultures of the freshwater dinoflagellate Peridinium cinctum (O.F. Müller) Ehrenberg isolated from the eutrophic lake Plusssee (Federal Republic of Germany). The phylogenetic relationships of the bacteria were studied with fluorochrome-conjugated oligonucleotides specific for archaebacteria, eubacteria, alpha-, beta- and gamma-proteobacteria, complementary to 16S rRNA and 23S rRNA sequences, respectively. The bacteria are members of the eubacterial alpha- and gamma-subgroups of proteobacteria.

Responsiveness to threats and incentives, expectancy of recurrence, and distress and disengagement: moderator effects in women with early stage breast cancer

Models of neurobiological systems linking personality, motivation, and emotion can be integrated with the expectancy construct to suggest hypotheses about distress and giving up in response to adversity. In 220 women with breast cancer, threat responsiveness-sensitivity of the behavioral inhibition system (BIS)-and incentive responsiveness-sensitivity of the behavioral activation system (BAS)-and expectancies about cancer recurrence were measured. It was predicted and found that high BIS sensitivity interacted with recurrence expectancy to predict elevated distress and disengagement. Low BAS sensitivity (reward responsiveness) also interacted with expectancy of recurrence to predict elevated disengagement. In contrast, high BAS sensitivity (fun seeking) interacted with recurrence expectancy to predict elevated distress. Discussion centers on theoretical implications and possible applications.

Increases in manic symptoms after life events involving goal attainment

Bipolar disorder has been conceptualized as an outcome of dysregulation in the behavioral activation system (BAS), a brain system that regulates goal-directed activity. On the basis of the BAS model, the authors hypothesized that life events involving goal attainment would promote manic symptoms in bipolar individuals. The authors followed 43 bipolar I individuals monthly with standardized symptom severity assessments (the Modified Hamilton Rating Scale for Depression and the Bech-Rafaelsen Mania Rating Scale). Life events were assessed using the Goal Attainment and Positivity scales of the Life Events and Difficulties Schedule. As hypothesized, manic symptoms increased in the 2 months following goal-attainment events, but depressed symptoms were not changed following goal-attainment events. These results are congruent with a series of recent polarity-specific findings.

Conformational preferences of a synthetic 30mer peptide from the interface between the neck and stalk regions of kinesin

The conformation of a synthetic peptide, consisting of 30 amino acids spanning the neck and hinge regions of rat brain kinesin, was investigated by NMR spectroscopy. The peptide extends from K357 to D386 and has the sequence KSVIQHLEVELNRWRNGEAVPEDEQISAKD. A total of 82 distance range constraints and 23 dihedral angle constraints could be obtained from NOESY and E.COSY spectra, respectively. These were used to calculate 500 structures by applying the REDAC algorithm of the software package DYANA. The first half of the peptide matched the helical structure of the neck determined from an X-ray crystal structure of kinesin. This part normally dimerizes into a coiled-coil by virtue of a leucine zipper interaction, but it is alpha-helical even in the monomeric state. The second half (not visible in the X-ray structure because of disorder) contains locally defined structure elements (extended chain, helical loop) connected by flexible joints. This is consistent with the "hinge" function postulated for this domain which is important for kinesin's motility and orientation.

Changes in cerebral hemodynamics during simple partial motor seizures

Changes in cerebral perfusion were studied during nine short-lasting simple partial motor seizures (SPS) in an 11-year-old girl. Blood flow velocity changes in both middle cerebral arteries (MCAs) were assessed by transcranial Doppler sonography during simultaneous EEG monitoring. Within 7.4 +/- 1.4 s after electroencephalographic seizure onset, flow velocity in the MCA ipsilateral to the electrical discharges started to increase and then gradually rose up to 70% above baseline values. Spread of the epileptic activity to the other hemisphere in the late stage of seizure was associated with a slight increase in blood flow velocity (<30%) in the contralateral MCA. After the end of the seizure, flow velocities returned to baseline within 47 +/- 7 s. Our findings indicate that focal epileptic seizures evoke asymmetric perfusion increases which are closely related to the onset and cessation of the electroencephalographic seizure activity.

MADS-Box gene diversity in seed plants 300 million years ago

MADS-box genes encode a family of transcription factors which control diverse developmental processes in flowering plants ranging from root development to flower and fruit development. Through phylogeny reconstructions, most of these genes can be subdivided into defined monophyletic gene clades whose members share similar expression patterns and functions. Therefore, the establishment of the diversity of gene clades was probably an important event in land plant evolution. In order to determine when these clades originated, we isolated cDNAs of 19 different MADS-box genes from Gnetum gnemon, a gymnosperm model species and thus a representative of the sister group of the angiosperms. Phylogeny reconstructions involving all published MADS-box genes were then used to identify gene clades containing putative orthologs from both angiosperm and gymnosperm lineages. Thus, the minimal number of MADS-box genes that were already present in the last common ancestor of extant gymnosperms and angiosperms was determined. Comparative expression studies involving pairs of putatively orthologous genes revealed a diversity of patterns that has been largely conserved since the time when the angiosperm and gymnosperm lineages separated. Taken together, our data suggest that there were already at least seven different MADS-box genes present at the base of extant seed plants about 300 MYA. These genes were probably already quite diverse in terms of both sequence and function. In addition, our data demonstrate that the MADS-box gene families of extant gymnosperms and angiosperms are of similar complexities.

Capillary oxygen saturation and tissue oxygen pressure in the rat cortex at different stages of hypoxic hypoxia

The objective of this study was to generate data that allow for estimation of the validity of oxygen saturation (SO2) values in superficial cortical capillaries as calculated by a microreflectometric system (EMPHO II). Capillary SO2 and tissue oxygen pressure (PtO2) were measured simultaneously in the cortex of n = 13 Wistar rats under normocapnic (PaCO2 = 36 mmHg) arterial normoxia (PaO2 = 92 mmHg), moderate (paO2 = 53 mmHg) and severe hypoxic hypoxia (PaO2 = 31 mmHg) with microreflectometry and multiwire surface electrodes. Values were pooled according to arterial oxygenation levels, displayed as frequency histograms and compared via ANOVA (p < 0.05). In a Hill-plot (log PtO2 versus log SO2/(100 - SO2)) an in vivo tissue oxygen dissociation curve was obtained and a linear regression/correlation analysis performed. Mean +/- SD values of SO2 respectively PtO2 decreased from 45.6% +/- 14.6% resp. 26.8 +/- 8.2 mmHg during arterial normoxia to 32.6% +/- 10.2% resp. 20.2 +/- 6.6 mmHg during moderate and to 12.3% +/- 11.1% resp. 8.7 +/- 5.0 mmHg during severe hypoxic hypoxia. Linear regression analysis in the Hill-plot of values between 1% and 65% SO2 and 0.1 and 41 mmHg PtO2 revealed an excellent correlation (r2 = 0.88) with an increase of scatter below 10% SO2 or 1.5 mmHg PtO2. We conclude that SO2 values calculated by the algorithm of the applied microreflectometric system reflect very accurately cortical oxygen supply over a very wide range of oxygenation levels when compared to a gold standard reference. Only at extremely low levels (e.g. below 10% SO2) did we find possible inaccuracies with regard to truly absolute saturation values.

[Tumor surgery of the upper cervical spine]

Our own series of tumors of the upper cervical spine was analyzed retrospectively. The standard treatment strategies were reevaluated. A total of nine patients (mean age 61 years, metastasis 4, plasmocytoma 3, chordoma 1, histiocytosis 1) were treated between 1/92 and 2/99. A total of 12 operations were carried out. One-step procedures (6): Three extraoral, one transoral, one dorsal and in one case combined dorsal and extraoral tumor removal were performed. Three dorsal occipitocervical or atlantoaxial stabilizations, one ventral plating and two combined ventral plating plus dorsal three-point fixations, and four vertebral body replacements were carried out. Two-step procedures (3): three extraoral tumor removals with ventral plating plus dorsal three-point fixation, in combination with vertebral body replacement in two cases. The neurological status and the quality of life (Karnofsky performance status, pain levels) were analyzed preoperatively and at the follow-up outpatient examinations (mean follow-up: 18 months). Flexion-extension radiographs were performed at the follow-up. There was no operative mortality. The transient morbidity was 11%. The operative intervention improved the quality of life in all patients. Three patients died within 27 months of operation. Tumor resection at the upper cervical spine using individually modified surgical strategies over an approach corresponding to the tumor location, stabilization and vertebral body replacement increases significantly the time of survival and quality of life with an acceptable surgical risk for complications.

Coping and medication adherence in bipolar disorder

BACKGROUND

Effective treatment of bipolar disorder depends on medication adherence, yet few correlates of adherence have been identified. The pleasure experienced during some manic episodes may render some individuals reluctant to adhere to medications that reduce these 'highs'. Clinical observers identify denial of the severity or existence of illness as common to both bipolar disorder and addiction. The Alcoholics Anonymous model promotes acceptance as a pathway to abstinence adherence. This report hypothesized that acceptance coping would correlate positively and denial coping would correlate inversely with adherence to mood-stabilizing medication among individuals with bipolar disorder.

METHODS

Thirty-two participants diagnosed with bipolar I disorder were administered scales from the Brief COPE and an adherence self-report measure.

RESULTS

Consistent with hypotheses, curvilinear relationships between acceptance and denial with adherence were detected, suggesting that low levels of acceptance and high levels of denial undermine medication adherence.

LIMITATIONS

Given the cross-sectional, naturalistic design of the study, no causal inferences can be made.

CONCLUSIONS

The results uncover links between coping styles and adherence in a psychiatric population. The link between acceptance-denial coping, and mature, self-supportive behavior may point the way towards more effective psychosocial interventions.

Differential treatment in acute upper cervical spine injuries: a critical review of a single-institution series

BACKGROUND

A single-institution series of injuries of the upper cervical spine are analyzed retrospectively and the literature relevant to the topic is reviewed.

METHODS

Seventy patients (34 female, 36 male, mean age 47 years) were admitted during a 5-year period for injuries of the upper cervical spine. Sixty-five were followed for a mean time of 18 months. Three isolated ligamentous instabilities, 6 isolated C1 fractures, 3 complex C2 fractures, 10 combined C1/C2, and 48 C2 fractures (17 hangman's, 31 odontoid) were diagnosed. Twenty-nine patients were treated conservatively and for 41 patients surgery was the primary treatment. Twenty-three ventral odontoid screw fixations, 8 ventral platings and 10 dorsal stabilizations were performed. Stability was evaluated using flexion-extension radiography. Pain levels and neurological outcome were assessed.

RESULTS

Operative mortality and neurological morbidity were 0%. Two wound infections and 3 instabilities (17%) in odontoid Type II fractures primarily treated with ventral odontoid screw fixation needed dorsal restabilization. During follow-up examinations the neurological status of three patients was improved. In 62 patients preoperative status was attained. Six patients evaluated their pain as severe, two as disabling.

CONCLUSIONS

Candidates for surgery as the primary treatment include those with isolated ligamentous instabilities, Type III hangman's fractures and Type II odontoid fractures with dislocation more than 5 mm. In combined C1/C2 fractures the axis fracture dictates the treatment strategy. Patients who undergo dorsal procedures and have involvement of C1 have a greater chance of developing persistent pain.

Image guided microsurgery with a semifreehand neuronavigational device

There is only limited experience with neuronavigators among the neurosurgical community so far. We evaluated such a prototype system in order to define indications for its succinct future use and to adjust it to daily clinical practice. We have employed an infrared light-linked computerized system (SPOCS; Aesculap/ISG) for preoperative planning and intraoperative navigation according to digitized images. A wired, penlike sensor-located "pointer" is used for navigation. Forty-eight patients (22 females, 26 males; aged 7-74 years) with a total of 53 intracranial lesions are included in the study. Fourteen lesions were smaller than 2 cm (26.4%), 33 were 2-4 cm (62.3%), and 6 were greater than 4 cm (11.3%). The documented accuracy was in the range of 3 mm or better in 33 patients throughout the whole operation and in an additional 7 through the most important surgical steps, with satisfactory results in all types of patient positioning except for the sitting position. In one patient the accuracy level decreased too early to perform useful intraoperative navigation. Technical dropouts early in the series led to abortion of the navigation in 7 instances but would currently no longer lead to abortion. There was no additional surgical morbidity associated with the use of the system. With more convenience in instrument design and development of techniques for real-time intraoperative reregistration, this kind of navigational device will play an increasingly important role for assistance during intracranial surgery. It proved to be helpful for planning of the craniotomy, intraoperative guidance on occasions of limited exposure and narrow visual field, localization and resection of small lesions in critical areas, and border definition of large lesions and for pure image guided resection of previously marked regions.

Compositional inversion symmetry breaking in ferroelectric perovskites

Cubic perovskite compounds of the form (A(1/3)A(')(1/3)A(")(1/3))BO3 and A(B(1/3)B(')(1/3)B(")(1/3))O3, in which the differentiated cations form an alternating series of monolayers, are studied using first-principles methods. Such compounds are representative of a possible new class of materials in which ferroelectricity is perturbed by compositional breaking of inversion symmetry. For isovalent substitution the ferroelectric double-well potential becomes asymmetric, so that minority domains may no longer survive. The symmetry breaking is enormously stronger for heterovalent substitution; here the double-well behavior is destroyed. Tuning between these behaviors may allow for the optimization of desired materials properties.

Mapping the active site of angiotensin-converting enzyme by transferred NOE spectroscopy

The interaction of five furylacryloyl (fa)-amino acid derivatives, fa-Phe, fa-Phe-Phe, fa-Gly-Leu-NH(2), fa-Ala-Lys, and fa-Trp, with angiotensin-converting enzyme (ACE), a protein of MW = 130 kDa, was studied by transferred NOESY experiments. Identification of fa derivatives binding to ACE as well as determination of their relative affinities could be accomplished directly from the compound mixtures. Of the five fa derivatives we found that fa-Phe, fa-Trp, and fa-Gly-Leu-NH(2) bind more strongly to ACE than the other two. The dissociation constant of fa-Phe was determined from NMR spectra to 5 x 10(-4) M. A large excess of dipeptides competitively displaced fa-Trp and fa-Phe-Phe from the receptor pocket, allowing the binding site to be mapped. Also, the relative affinities of the fa-Phe, fa-Ala-Lys, and fa-Gly-Leu-NH(2) changed after addition of the dipeptides with fa-Gly-Leu-NH(2) showing the strongest binding. In addition, the presence of a strong inhibitor of the S1' and S2' sites, namely captopril, resulted in the same transferred NOE intensities of fa-Phe, indicating that it binds solely to the S1 and S2 subsites. A rapid screening of binding specificity from mixtures is possible by using a large excess of ligand(s) in transferred NOE studies, even when relatively small amounts of protein are present.