Alcohol problems as a risk factor for postdisaster depressed mood among U.S. veterans

Alcohol problems may impede adaptive, proactive responses to disaster-related injury and loss, thus prolonging the adverse impact of disasters on mental health. Previous work suggests that veterans of the U.S. armed forces have a relatively high prevalence of alcohol misuse and other psychiatric disorders. This is the first study to estimate the impact of predisaster alcohol problems on postdisaster depressed mood among veterans, using data that were collected before and after the 1994 Northridge, CA, earthquake. The authors assessed the impact of alcohol problems on postdisaster depressed mood in an existing clinical cohort of veterans who experienced the 6.7-magnitude earthquake that struck Northridge in January 1994. One to 3 months after the disaster, interviewers contacted participants by telephone to administer a follow-up questionnaire based on a survey that had been done preearthquake. Postearthquake data were obtained on 1,144 male veterans for whom there were preearthquake data. We tested a predictive path model of the relationships between latent variables for predisaster alcohol problems, functional limitations, and depressed mood on latent variables representing postdisaster "quake impact" and depressive mood. Results showed that veterans who had more alcohol problems before the earthquake experienced more earthquake-related harms and severely depressed mood after the earthquake, compared with those who had fewer alcohol problems. Programs serving veterans with a high prevalence of alcohol problems should consider designing disaster response protocols to locate and assist these patients in the aftermath of disasters.

Prospective analysis of human cytomegalovirus DNAemia and specific CD8+ T cell responses in lung transplant recipients

In lung transplant recipients (LuTRs), human cytomegalovirus (HCMV) DNAemia may be associated with HCMV disease and reduced survival of the allograft. Because T cells are essential for controlling HCMV replication, we investigated in this prospective study whether the kinetics of plasma HCMV DNA loads in LuTRs are associated with HCMV-specific CD8+ T cell responses, which were longitudinally assessed using a standardized assay. Sixty-seven LuTRs were monitored during the first year posttransplantation, with a mean of 17 HCMV DNA PCR quantifications and 11.5 CD8+ T cell tests performed per patient. HCMV-specific CD8+ T cell responses displayed variable kinetics in different patients, differed significantly before the onset of HCMV DNAemia in LuTRs who subsequently experienced episodes of DNAemia with high (>1000 copies/mL) and low plasma DNA levels (p = 0.0046, Fisher's exact test), and were absent before HCMV disease. In HCMV-seropositive LuTRs, high-level DNAemia requiring preemptive therapy occurred more frequently when HCMV-specific CD8+ T cell responses fluctuated, were detected only after HCMV DNA detection, or remained undetectable (p = 0.0392, Fisher's exact test). Thus, our data indicate that HCMV-specific CD8+ T cells influence the magnitude of HCMV DNAemia episodes, and we propose that a standardized measurement of CD8+ T cell immunity might contribute to monitoring the immune status of LuTRs posttransplantation.

Potential safety gaps in order entry and automated drug alerts: a nationwide survey of VA physician self-reported practices with computerized order entry

OBJECTIVE

Understanding provider perceptions of and experiences with order entry and order checks (drug alerts) in an electronic prescribing system may help improve medication safety technology.

DESIGN

Cross-sectional, national survey of Veterans Administration physicians practicing in various specialties.

MEASUREMENT

Thirty-five question instrument was divided into 4 content domains. Response options included dichotomous, numeric, multiple choices, and Likert-like scales. Statistical methods included logistic regression.

RESULTS

The adjusted response rate was 1543 of 3588 (43%). Almost all providers (90%) felt that the VA electronic prescribing system, including its order checks, improved prescribing safety to some degree. Most respondents (72%) reported that they always or almost always document outside medications in a clinic note, although only 44% always or almost always entered outside medications in the non-VA medication data field. Most physicians (88%) who encountered serious allergic or adverse drug reactions reported either notifying a pharmacist or entering the information in the allergies/adverse reactions field. Generalists and physicians with higher numbers of prescriptions were more likely to enter relevant data into the electronic medical record (or notify a pharmacist, in the case of adverse reactions). In addition, 48% of providers described critical drug-drug interaction alerts as very useful; medical specialists found these less useful, whereas surgical specialists found these more useful when compared with generalists.

LIMITATIONS

Survey was conducted within a single healthcare system.

CONCLUSION

Computerized provider order entry and related order checks are perceived to improve prescribing safety; however, provider entry of some relevant information into the appropriate electronic fields may not be optimal.

[Study of treatment adherence by patients living with HIV in 2009 at the outpatient care and treatment center of Brazzaville, Congo]

OBJECTIVES

The purpose of this study was to evaluate treatment adherence and its determinants in patients living with HIV followed up at the outpatient care and treatment center in Brazzaville, Congo.

METHODS

This cross-sectional study included patients who attended the center from July to October 2009. Adherence was evaluated using a self-administered questionnaire, 5 distinct measurement tools, and global adherence index. Correlations between patient characteristics and adherence data were analyzed.

RESULTS

A total of 214 patients were enrolled in the study. Mean patient age was 42 years. The female-to-male ratio was 2. There were 6 children. Most patients (92.5%) were receiving a first-line antiretroviral regimen; it consisted of a combination of zidovudine, lamivudine and nevirapine in 53.3% of cases. Adherence was estimated at 55.4-86.9% depending on the measurement tool. The global adherence index was significantly higher in patients who achieved their pre-defined life project (OR 4.33, p = 0.04) and in those who spoke lingala (OR 3.99, p = 0.01). After 6 months of antiretroviral therapy, mean weight gain was 4.8 kg; mean increase in CD4 was 104/mm3 (262 versus 158); and viral load was undetectable in 89.4% of patients.

CONCLUSION

This study in Brazzaville (Congo) confirms that antiretroviral treatment adherence is satisfactory in sub-Saharan Africa. Adherence was mainly correlated with structural factors, e.g. language and life project, and with the patient friendliness of the regime. Most patients had favourable responses based on clinical, immunological, and virological criteria.

Impact of dementia on caring for patients' diabetes

OBJECTIVE

To explore caregivers' challenges and quality-of-life issues managing diabetes in patients with dementia.

METHOD

We conducted six focus groups with 21 caregivers of patients with dementia and type 2 diabetes. Focus groups were digitally recorded, transcribed, and translated using a software coding system. Emergent themes were identified and confirmed.

RESULTS

Three themes emerged. (1) Memory loss was the first identified cause of self-care neglect leading to caregiver intervention. (2) Behavioral and psychological symptoms of dementia (BPSD) disrupted the daily diabetes care routine, with 'denial' of having diabetes or memory loss (anosognosia) being the most disruptive. (3) Caregivers reported that caring for both diabetes and dementia was highly burdensome, felt overwhelmed with BPSD, and wanted more support from family and patients' healthcare providers.

CONCLUSION

Caregivers of patients with dementia and diabetes face extraordinary challenges managing both conditions and the accompanying BPSD. Their identified need for a greater response from the healthcare system should be tested in quality improvement programs for this overlooked yet rapidly growing population.

Human cytomegalovirus infection in lung transplant recipients triggers a CXCL-10 response

Human cytomegalovirus (HCMV) causes significant morbidity in lung transplant recipients (LTRs). The clinical effects of HCMV replication are determined partly by a type 1 T-helper cell (Th1) response. Because the chemokine interferon-inducible protein of 10 kilodaltons (IP-10, CXCL-10) induces a Th1 response, we investigated whether HCMV triggers IP-10 in LTRs. The IP-10 concentration and HCMV DNA load were determined in 107 plasma and 46 bronchoalveolar lavage fluid (BALF) samples from 36 LTRs. Initial HCMV detection posttransplantation was significantly associated with increased plasma IP-10, regardless of whether the patients showed HCMV DNAemia (p = 0.001) or HCMV replication only in the allograft (p < 0.0001). In subsequent episodes of HCMV detection, plasma IP-10 increased regardless of whether HCMV was detected in blood (p = 0.0078) or only in BALF (p < 0.0001) and decreased after successful antiviral therapy (p = 0.0005). Furthermore, levels of HCMV DNA and IP-10 correlated statistically (p = 0.0033). Increased IP-10 levels in HCMV-positive BALF samples were significantly associated with severe airflow obstruction, as indicated by a decrease in forced expiratory volume in one second (FEV1). Our data indicate that HCMV replication in LTRs evokes a plasma IP-10 response and that, when an IP-10 response is observed in BALF, it is associated with inflammatory airway obstruction in the allograft.

Dynamics of Elementary Processes At Surfaces: Nitric Oxide Scattered From A Graphite Surface

Molecular beam scattering from solid surfaces has long been recognized as a powerful means for investigation of gas-surface reaction dynamics. With the help of the recently developed laser-induced fluorescence and ionization techniques for state-selective detection, one can now measure the angular and velocity distributions of the scattered molecules together with their internal energy distributions. Such measurements fully describe the average energy and momentum exchanges between molecules and surfaces and give thus full information on the dynamics of the interaction. Recently, also the scattering of vibrationally excited NO molecules was investigated. The paper gives a review of new experiments with emphasis on the investigation of the scattering of NO molecules from a pyrographite surface. A simple model using transport properties of the solid is presented which accounts surprisingly well for the observed features.

An inequality among determinants

WE PROVE THAT FOR ANY TRACE CLASS OPERATORS, [FORMULA: see text].

[2007 cholera epidemic in Comoros islands: a step towards endemisation?]

In 2007, a cholera epidemic occurred on two of the three islands of the Comoros archipelago: Grande Comore and Moheli. This study is based on data from the files of the 1571 patients admitted to five cholera treatment centers (CTC). The outbreak lasted for ten months. A dramatic peak was observed in July and August corresponding to the traditional wedding season during which hundreds of guests including returning diaspora gather to celebrate "Grand Marriages". Initial stool cultures identified Vibrio cholerae O1, Ogawa serotype. The in-center fatality rate was 1.85%. Poor socio-economical conditions combined with a rapid turnover of health personnel and delayed response of the health authorities could lead to endemisation.

High-resolution three-dimensional tomographic diffractive microscopy of transparent inorganic and biological samples

We have developed a tomographic diffractive microscope, equipped with a fluorescence confocal scanner. We measure experimentally the lateral resolution using an edge method and by comparing tomographic images of the same samples with wide-field and laser scanning confocal microscopy images; a scanning electron microscope image serves as a reference. The experimental resolution is shown to be to about 130 nm, or lambda/(3.5 NA). This instrument also permits one to measure 3D, complex index of refraction distributions, a quantity that is not accessible to conventional microscopes, and we show how this feature may be used to observe KCl crystals, absorption of which is very weak.

A comparison of glycaemic variability in CSII vs. MDI treated type 1 diabetic patients using CGMS

OBJECTIVE

To evaluate and compare glucose variability, hypoglycaemic events and daily glycaemic control in well-controlled (HbA1c <or= 7%), type 1 diabetic patients treated with either continuous subcutaneous insulin infusion (CSII) using lispro or multiple daily insulin injection (MDI) using glargine once daily and lispro with meals.

RESEARCH DESIGN AND METHODS

A total of 16 patients with type 1 diabetes receiving treatment with either CSII (eight patients) or MDI (eight patients), all with HbA1c levels < 7%, wore a continuous glucose monitoring system sensor for 3 days to compare the number, duration, timing and severity of hyperglycaemic and hypoglycaemic episodes.

RESULTS

There were several more episodes of hyperglycaemic [blood glucose (BG) >or= 180 mg/dl] and hypoglycaemic (BG <or= 60 mg/dl) excursions observed in patients treated with CSII than MDI. Glycaemic exposure over 150 mg/dl was similar between the two groups. Maintenance of near-euglycaemia as determined by the average amount of time spent within the glucose range of 80-140 mg/dl was marginally significantly better for the MDI than for the CSII group. Although the CSII group had significantly more hypoglycaemic episodes below 60 mg/dl, the average duration of hypoglycaemia was not significantly different for the two groups. Similar percentages of nocturnal hypoglycaemia were seen. There were no reported major adverse events throughout the duration of the study.

CONCLUSION

Well-controlled type 1 diabetic patients treated with MDI had fewer hyperglycaemic and hypoglycaemic excursions than patients treated with CSII.

A structure refinement protocol combining NMR residual dipolar couplings and small angle scattering restraints

We present the implementation of a target function based on Small Angle Scattering data (Gabel et al. Eur Biophys J 35(4):313-327, 2006) into the Crystallography and NMR Systems (CNS) and demonstrate its utility in NMR structure calculations by simultaneous application of small angle scattering (SAS) and residual dipolar coupling (RDC) restraints. The efficiency and stability of the approach are demonstrated by reconstructing the structure of a two domain region of the 31 kDa nuclear export factor TAP (TIP-associated protein). Starting with the high resolution X-ray structures of the two individual TAP domains, the translational and orientational domain arrangement is refined simultaneously. We tested the stability of the protocol against variations of the SAS target parameters and the number of RDCs and their uncertainties. The activation of SAS restraints results in an improved translational clustering of the domain positions and lifts part of the fourfold degeneracy of their orientations (associated with a single alignment tensor). The resulting ensemble of structures reflects the conformational space that is consistent with the experimental SAS and RDC data. The SAS target function is computationally very efficient. SAS restraints can be activated at different levels of precision and only a limited SAS angular range is required. When combined with additional data from chemical shift perturbation, paramagnetic relaxation enhancement or mutational analysis the SAS refinement is an efficient approach for defining the topology of multi-domain and/or multimeric biomolecular complexes in solution based on available high resolution structures (NMR or X-ray) of the individual domains.

Nonclassic presentation of pheochromocytoma: difficulties in diagnosis and management of the normotensive patient

OBJECTIVE

To report an unusual presentation of pheochromocytoma along with challenges in diagnosis and management.

METHODS

We report a clinical case history and describe diagnostic methods and pitfalls. The preoperative medical preparation in a normotensive patient is described.

RESULTS

A 33-year-old man fell off a ladder, resulting in C6 paraplegia. After C7-T1 laminectomy, he was transferred to a rehabilitation center where he reported lightheadedness, shortness of breath, and chest pain during therapy sessions. A left adrenal mass was incidentally discovered during the workup to rule out a pulmonary embolism. He reported no history of hypertension, and no elevated blood pressure readings had been documented. Magnetic resonance imaging of the adrenal glands showed a well-defined left adrenal mass measuring 3.9 x 3.2 x 3.3 cm, which was hyperintense on T2-weighted images. Twenty-four hour urinary catecholamine concentrations were unremarkable; urinary metanephrines were markedly elevated. During hospital admission, blood pressure was in the low to normotensive range, requiring a cautious approach to alpha-adrenergic blockade and surgical preparation. He under-went uneventful laparoscopic left adrenalectomy; surgical pathology was consistent with pheochromocytoma.

CONCLUSIONS

This case illustrates a nonclassic presentation of pheochromocytoma and demonstrates that urinary catecholamines alone are not sufficient for a biochemical diagnosis of large pheochromocytomas. Preoperative preparation in normotensive patients can be achieved with alpha-adrenergic blockade, hydration, and liberal salt intake.

What the Resident Meant to Say: Use of Cognitive Interviewing Techniques to Develop Questionnaires for Nursing Home Residents

Purpose:  Emphasis on consumer-centered care for frail and institutionalized older adults has increased the development and adaptation of surveys for this population. Conventional methods used to pretest survey items fail to investigate underlying sources of measurement error. However, the use of the cognitive interview (CI), a method for studying how respondents answer survey items, is not well established or documented in this population. This study demonstrates how CIs can be used to improve questionnaires intended for nursing home residents. Design and Methods: CIs were conducted with 29 nursing home residents in order to identify potential problems with prospective survey items. We used scripted probes to standardize the interviews and adapted the Question Appraisal System to enumerate and classify the problems discovered. Results: We fielded between one and five versions of each item in an iterative process that identified 61 item-specific problems. Additionally, residents' cognitive responses suggested that some screened their answers on the basis of perceived physical and environmental limitations, and some had difficulty answering items about preferences that fluctuate day to day. These findings led us to modify the items and response set to simplify the respondents' cognitive task. Implications: This study illustrates how CI techniques can be used to understand residents' comprehension of and response to survey items.

Evaluation of the VIA Blood Chemistry Monitor for Glucose in Healthy and Diabetic Volunteers

BACKGROUND

Manual methods of blood glucose monitoring are labor-intensive, costly, prone to error, and expose the caregiver to blood. The VIA(R) blood chemistry monitor for glucose can automatically measure plasma glucose (PG) every 5 minutes for 72 hours using blood sampled from a peripheral vein/artery or a central vein.

METHODS

VIA performance was evaluated in eight normal and five type 1 diabetic (T1DM) subjects in 15 separate experiments. The VIA device was connected to a peripheral vein and reported a PG value every 5 minutes during each 510-minute experiment. Blood samples were collected manually every 10 minutes and assayed using a HemoCue(R) beta-glucose analyzer (HC). Whole blood HC measurements were corrected to PG values. Paired HC/VIA measurements (n = 717) were analyzed.

RESULTS

Mean PG was 90 +/- 14 and 96 +/- 12 mg/dl in normal subjects and 194 +/- 64 and 173 +/- 48 mg/dl in T1DM subject as measured by the HC and VIA, respectively. Clark error grid analysis revealed 86% points in zone A, 11% points in zone B, and 2% points in zone D. Linear regression analysis yielded the following equation: VIA = 0.732 x HC + 30.5 (r(2) = 0.954). Residual analysis revealed a glucose-dependent bias between the HC and the VIA. VIA data were transformed using the linear regression equation to correct for bias. After the correction, the mean absolute relative difference between the VIA and the HC was less than 10%, and 99.6% of data were in zones A and B. The VIA was able to sample blood automatically every 5 minutes for more than 8 hours in the laboratory setting. On average, the VIA reported glucose values for 94% of the samples it attempted to obtain.

CONCLUSIONS

This study demonstrated that the VIA blood chemistry monitor for glucose can reliably sample blood frequently for a prolonged period of time safely and effectively in diabetic and nondiabetic volunteers. Agreement between the two devices was the closest at normal glucose concentrations. After correcting for a glucose-dependent bias between the devices, the MARD was consistently less than 10% for all glucose ranges.

An accelerated vaccine schedule with a poly-antigenic hepatitis C virus MVA-based candidate vaccine induces potent, long lasting and in vivo cross-reactive T cell responses

We designed and evaluated in HLA-class I transgenic mouse models a hepatitis C virus (HCV) T cell-based MVA vectored vaccine expressing three viral antigens known to be targets of potent CD8+- and CD4+-mediated responses. An accelerated (3 week-based) vaccination induced specific CD8+ T cells harboring two effector functions (cytolytic activity - both in vitro and in vivo- and production of IFNgamma) as well as specific CD4+ T cells recognizing all three vaccine antigens. Responses were long lasting (6 months), boostable by a fourth MVA vaccination and in vivo cross-reactive as demonstrated in a surrogate Listeria-based challenge assay. This candidate vaccine has now moved into clinical trials.

The utility of adding retrospective medication profiling to computerized provider order entry in an ambulatory care population

BACKGROUND

We assessed whether medication safety improved when a medication profiling program was added to a computerized provider order entry system.

DESIGN

Between June 2001 and January 2002 we profiled outpatients with potential prescribing errors using computerized retrospective drug utilization software. We focused primarily on drug interactions. Patients were randomly assigned either to Provider Feedback or to Usual Care. Subsequent adverse drug event (ADE) incidence and other outcomes, including ADE preventability and severity, occurring up to 1 year following the last profiling date were evaluated retrospectively by a pharmacist blinded to patient assignment.

MEASUREMENTS

Data were abstracted using a study-designed instrument. An ADE was defined by an Adverse Drug Reaction Probability scale score of 1 or more. Statistical analyses included negative binomial regression for comparing ADE incidence.

RESULTS

Of 913 patients in the analytic sample, 371 patients (41%) had one or more ADEs. Incidence, by individual, was not significantly different between Usual Care and Provider Feedback groups (37% vs. 45%; p = 0.06; Coefficient, 0.19; 95% CI: -0.008, 0.390). ADE severity was also similar. For example, 51% of ADEs in the Usual Care and 58% in the Provider Feedback groups involved symptoms that were not serious (95% CI for the difference, -15%, 2%). Finally, ADE preventability did not differ. For example, 16% in the Usual Care group and 17% in the Provider Feedback group had an associated warning (95% CI for the difference, -7 to 5%; p = 0.79).

CONCLUSION

Medications safety did not improve with the addition of a medication profiling program to an electronic prescribing system.

Cerebral embolism with interventional closure of symptomatic patent foramen ovale: An MRI-based study using diffusion-weighted imaging

Paradoxical embolism via patent foramen ovale (PFO) is an important cause of stroke, especially in younger patients. Transcatheter PFO closure is considered to bear a low risk and to be technically feasable with a high primary success rate. There are no data for the rate of procedure-associated silent embolic events. The present study sought to analyze the total number of cerebral ischemic complications with interventional PFO closure. Thirty-five symptomatic PFO patients (15 male, 26-71 years) with cerebral infarctions proven by magnetic resonance imaging (MRI) were examined by diffusion-weighted imaging (DWI) before and after PFO closure. In the MRI examinations following the intervention, new microembolic lesions were found in three of 35 (8.6%) patients. The lesions were located in the right and left thalamus and the left frontoparietal white matter respectively. Two of three infarcts were clinically inapparent, whereas the third patient suffered from a transient right-sided hemihypaesthesia for 12 h. If the prevention of recurrent cerebrovascular events associated with the presence of PFO is necessary, a low frequency of closure associated silent cerebral embolisms was documented after interventional PFO closure. The rate of microembolic events with neurological deficit was 1/35 (approximately 2.8%).

Perceived barriers to weight management in primary care--perspectives of patients and providers

BACKGROUND

Despite the consequences of overweight and obesity, effective weight management is not occurring in primary care.

OBJECTIVE

To identify beliefs about obesity that act as barriers to weight management in primary care by surveying both patients and providers and comparing their responses.

DESIGN

Anonymous, cross-sectional, self-administered survey of patients and providers of a Veteran's Administration Primary Care Clinic, distributed at the clinic site.

SUBJECTS

Forty-eight Internal Medicine providers and 488 patients.

MEASUREMENTS

Beliefs, attitudes, and experiences with weight management as well as demographic characteristics were collected through a questionnaire.

RESULTS

Providers and patients differed significantly on many beliefs about weight. Providers were more likely than patients to perceive that patients lack self-control to stay on a diet and that fattening food in society and lack of time for exercise were prime factors in weight gain. They also expressed more interest in helping patients with weight management than patients desiring this. Patients were more likely to state that weight problems should be managed on one's own, talking to a provider is not helpful, providers blame them for their weight problem, and that appointments contain sufficient time for weight discussion.

CONCLUSION

Providers and patients emphasize different barriers to weight management. Providers need to be aware of the beliefs that their patients hold to improve weight management discussions and interventions in primary care.

What are the current possibilities in treating peptic ulcer disease?

There are two major principles of ulcer therapy. Today, the most widely accepted drugs are those which substantially reduce aggressive factors (i.c. acid and pepsin), namely histamine H2-receptor antagonists, antimuscarinics and antacids. Less frequently applied are mucoprotective agents like colloidal bismuth compounds and sucralfate. Prostaglandins both reduce acid secretion substantially and are believed to enhance mucosal resistance. Their anti-ulcer efficacy, however, is solely explicable by their antisecretory activity. Although mucosa-strengthening agents and H2-receptor blockers have nearly identical healing rates, mucosa-strengthening agents have inconvenient dosage regimens (four times or twice daily) and are probably less effective in relieving pain. The same holds true for antacids. Prostaglandins, antimuscarinics and antacids have dose related side effects. In contrast, H2-receptor blockers are characterized by a clear mechanism of action, convenient dosage regimens, good tolerance and a low incidence of side-effects. H2-receptor antagonists are the most effective anti-ulcer drugs presently available.

VA emergency health care for women: condition--critical or stable?

BACKGROUND

Veteran's Affairs (VA) facilities have reconfigured themselves to address the health care needs of the growing number of women veterans. However, the challenge of providing comprehensive care to a group that is an extreme minority within VA may still leave gaps in the delivery of necessary health care services.

OBJECTIVES AND METHODS

We sought to assess the availability of women's health care specialists for emergency gynecologic problems (emergency-GYN) and for emergency mental health conditions specific to women (emergency-WMH), we surveyed the Chief of Staff and senior clinician at each VA site serving 400 or more women veterans.

RESULTS

Emergency-GYN expertise was usually available at all times for 39.8% of sites, and only during usual clinic hours for 24.6% of sites. An emergency-WMH specialist was available at all times for 51.7% of sites, and only during usual clinic hours for 31.0% of sites. VA sites that had a separate women's health clinic were more likely to have emergency-GYN expertise available. Sites in regions with higher managed care penetration were less likely to have emergency-WMH specialist availability.

CONCLUSIONS

Our data suggest a limited availability of specialists for gynecologic and women's mental health emergencies at some VA sites. How this may affect overall quality of care for women in the VA system is unknown. Further work is needed to determine actions clinicians take when expertise is emergently needed for health care issues unique to women. Options for expanding VA availability of such expertise include internal development of women's health expertise and telemedicine access to experts to aid in emergency women's health care decision making.

[The French Red Cross: a network of care centers dedicated to HIV-AIDS]

The commitment of the French Red Cross Society to the fight against HIV/AIDS in Africa and Asia is based on day care centers (DCC) set up and operated within public hospitals. These outpatient facilities offer global care including clinical and biologic follow-up for patients undergoing anti-retroviral treatment. In most countries these DCC have become reference centers providing support for national decentralization policies. To reinforce the impact of their activities, centers offer regular educational programs and provide extensive training for medical personnel.

Optimizing the design and distribution of clinical trial information via handheld devices

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Background: The timely identification of available clinical trials by an oncologist for a patient represents a critical initial step in the research process. The challenges in supporting this step are threefold: (1) Large cancer centers may have more than 200 active clinical trials; (2) The accrual status of any particular clinical trial can change frequently; (3) Oncologists have limited time in their schedule to seek out clinical trial information. We hypothesized that delivering up-to-date clinical trial information directly to a handheld device would address the combination of these three challenges, and we utilized an iterative design process to refine the format and organization of this information. Methods: Web pages containing clinical trial information and optimized for a handheld display were created using an existing database and standard web development software. AvantGo software was utilized for transferring these web pages to handheld devices upon synchronization. Feedback on the initial design was obtained from four oncologists based in our community network locations. Two subsequent designs were developed based on both this feedback and encountered technical constraints. Results: Four major design changes emerged during our iterative design process. These changes included: (1) The organization of trial information based on network location; (2) The improvement of trial disease categories; (3) The shortening of trial titles; and (4) The inclusion of descriptive trial summaries for all trials. Conclusions: A demonstration of the handheld clinical trial information that is available to over 60 oncologists in our extended network will be provided. The merits of this approach as well as the lessons learned from our design process should be considered by other cancer centers seeking new methods for the distribution of clinical trial information.

No significant financial relationships to disclose.

Post-training lesions of the medial prefrontal cortex interfere with subsequent performance of trace eyeblink conditioning

Rabbits were trained on trace eyeblink (EB) conditioning until they reached a criterion of 10 consecutive EB conditioned responses (CRs). Electrolytic lesions were made in the medial prefrontal cortex (mPFC) centered on the prelimbic area (Brodmann's area 32), at five different intervals after training. These included immediately, 24 h, 1 and 2 weeks, and 1 month after training. Separate groups of animals received sham lesions at these same intervals after training. After a 2 week postoperative recovery period, all animals were retested for 3 d on trace conditioning, using the same parameters used during preoperative training. Mean EB conditioning performance deficits occurred in the animals with mPFC lesions compared with sham-lesioned animals on the first day of retesting in all five groups. However, by the second or third day of retesting, the rabbits with lesions were performing at a level that was comparable with that of sham animals. Rabbits that received more posterolateral lesions of the neocortex did not, however, show postoperative conditioning deficits. A comparison of percentage EB CRs of animals with postoperative training with that of animals that received mPFC lesions before training suggests that the mPFC post-training lesions produce damage to a retrieval process and not to a storage site or an acquisition process.

Exposure to Automated Drug Alerts Over Time

OBJECTIVE

We tested whether interval exposure to an automated drug alert system that included approximately 2000 drug-drug interaction alerts increased recognition of selected interacting drug pairs. We also examined other perceptions about computerized order entry.

RESEARCH DESIGN

We administered cross-sectional surveys in 2000 and 2002 that included more than 260 eligible clinicians in each time period.

SUBJECTS

We studied clinicians practicing in ambulatory settings within a Southern California Veterans Affairs Healthcare System and who responded to both surveys (97 respondents).

MEASURES

We sought to measure (1) recognition of selected drug-drug and drug-condition interactions and (2) other benefits and barriers to using automated drug alerts.

RESULTS

Clinicians correctly categorized similar percentages of the 7 interacting drug-drug pairs at baseline and follow-up (53% vs. 54%, P = 0.51) but improved their overall recognition of the 3 contraindicated drug-drug pairs (51% vs. 60%, P = 0.01). No significant changes from baseline to follow-up were found for the 8 interacting drug-condition pairs (60% vs. 62%, P = 0.43) or the 4 contraindicated drug-condition pairs (52% vs. 56%, P = 0.24). More providers preferred using order entry at follow-up than baseline (63% vs. 45%, P < 0.001). Signal-to-noise ratio remained the biggest reported problem at follow-up and baseline (54 vs. 57%, P = 0.75). In 2002, clinicians reported seeing a median of 5 drug alerts per week (representing approximately 12.5% of prescriptions entered), with a median 5% reportedly leading to an action.

CONCLUSIONS

Interval exposure to automated drug alerts had little to no effect on recognition of selected drug-drug interactions. The primary perceived barrier to effective utilization of drug alerts remained the same over time.

To use or not to use. What influences why women veterans choose VA health care

BACKGROUND AND OBJECTIVE

Effects of advances in Department of Veterans Affairs (VA) women's health care on women veterans' health care decision making are unknown. Our objective was to determine why women veterans use or do not use VA health care.

DESIGN AND PARTICIPANTS

Cross-sectional survey of 2,174 women veteran VA users and VA-eligible nonusers throughout southern California and southern Nevada.

MEASUREMENTS

VA utilization, attitudes toward care, and socio-demographics.

RESULTS

Reasons cited for VA use included affordability (67.9%); women's health clinic (WHC) availability (58.8%); quality of care (54.8%); and convenience (47.9%). Reasons for choosing health care in non-VA settings included having insurance (71.0%); greater convenience of non-VA care (66.9%); lack of knowledge of VA eligibility and services (48.5%); and perceived better non-VA quality (34.5%). After adjustment for socio-demographics, health characteristics, and VA priority group, knowledge deficits about VA eligibility and services and perceived worse VA care quality predicted outside health care use. VA users were less likely than non-VA users to have after-hours access to nonemergency care, but more likely to receive both general and gender-related care from the same clinic or provider, to use a WHC for gender-related care, and to consider WHC availability very important.

CONCLUSIONS

Lack of information about VA, perceptions of VA quality, and inconvenience of VA care, are deterrents to VA use for many women veterans. VA WHCs may foster VA use. Educational campaigns are needed to fill the knowledge gap regarding women veterans' VA eligibility and advances in VA quality of care, while VA managers consider solutions to after-hours access barriers.

Reactive Hyperaemia in the Forearm Skin of Highly Trained Windsurfers

We undertook this study to determine whether long-term high intensity exercise would modify cutaneous endothelial-dependent vasodilation. We compared a group of 9 highly trained windsurfers (mean age: 24.5 +/- 1.6 years) to a control group of 8 sedentary individuals (22.9 +/- 0.4 years, NS). Laser Doppler was used to measure cutaneous blood flow in the resting state (baseline), during post-occlusive hyperaemia (endothelium-dependent vasodilation), and local heating to 42 degrees C. Lipid profile was similar in both groups. Resting heart rate was significantly lower in windsurfers. Baseline cutaneous vascular conductance (CVC) values were similar in both groups (0.059 +/- 0.016 and 0.051 +/- 0.009). During reactive hyperaemia, normalized peak CVC value was significantly higher in the windsurfers group (1775.4 +/- 286.9 and 826.4 +/- 121.7 % baseline CVC; p = 0.01). Normalized peak CVC value in response to local heating (42 degrees C) was not significantly different between both groups (2359.4 +/- 346.1 and 1467.7 +/- 282.6 % baseline CVC). Endothelium-dependent vasodilation in cutaneous microcirculation is significantly enhanced in the forearm skin of highly trained windsurfers when compared to sedentary controls.

The PPAR(gamma) K422Q mutation does not contribute to troglitazone inefficiency in colon cancer treatment

Peroxisome proliferator-activated receptor gamma (PPAR(gamma)) ligands inhibit cell growth of colorectal cancer cells in most experimental models, but no significant effect could be observed in patients with colorectal cancer. We therefore, screened human colorectal tumors to determine the prevalence of the PPAR(gamma) K422Q loss-of-function mutation, recently identified in 50% of colonic cancer cell lines. A sensitive allele-specific real-time amplification assay was developed and 170 colorectal primary tumors and 12 liver metastasis were analyzed. We did not find the K422Q mutation in any of these samples. We can therefore exclude this alteration as a mechanism of resistance to PPAR(gamma) ligands in patients with colon cancer.

Identifizierung eines mittels Immunturbidimetrie nach Anionenaustausch-Chromatographie erhöhten Carbohydrate-Deficient-Transferrin-(CDT-)Serumspiegels als Transferrin (Tf)-D-Variante

Many studies have shown carbohydrate-deficient transferrin (CDT) to be a sensitive and specific marker of chronic alcohol abuse. We present the case of a 23-year-old, healthy professional soccer player who caused a car accident due to alcohol consumption. Several CDT test results were elevated above the laboratory reference range and were considered to be caused by alcohol intake at a level commensurate with misuse and thus license reapplication was refused. In addition, assuming chronic alcohol abuse, the young man suffered from increasing social isolation. He was finally referred to our out-patient clinic for further evaluation on the assumption of a liver disease. Since chronic alcohol consumption was denied, and there was no evidence of liver disease, a qualitative characterization of the transferrin isoforms was performed. Isoelectric focusing of serum transferrin revealed a pattern atypical for chronic alcohol intake but detected a genetically determined transferrin (Tf)-D-variant. The changed amino acid sequence caused an overlapping of transferrin isoforms with different degrees of sialylation, thus revealing false-positive serum CDT values. Determination of this Tf-D-variant heterozygosity resulted in his social rehabilitation and license reinstatement. Thus, where the evidence for alcohol dependency is either uncertain or uncorroborated, qualitative isoelectric focusing of transferrin is a useful method for analyzing unexplained CDT elevations, thus increasing the value of CDT as a marker for chronic alcoholic abuse.

Proposed recommendations for the management of HIV post-exposure prophylaxis after sexual, injecting drug or other exposures in Europe

Post-exposure prophylaxis (PEP) is the standard of care for a healthcare worker (HCW) accidentally exposed to an HIV infected source person (occupational exposure), but this is not the case for non-occupational exposures. Very few national guidelines exist for the management of non-occupational exposures to HIV in Europe, contrarily to the occupational ones. The administration of non-occupational post-exposure prophylaxis (NONOPEP) for HIV may be justified by: a biological plausibility, the effectiveness of PEP in animal studies and occupational exposures in humans, efficacy in the prevention of mother to child HIV transmission, and cost effectiveness studies. These evidences, the similar risk of HIV transmission for certain non-occupational exposures to occupational ones, and the conflicting information about attitudes and practices among physicians on NONOPEP led to the proposal of these European recommendations. Participant members of the European project on HIV NONOPEP, funded by the European Commission, and acknowledged as experts in bloodborne pathogen transmission and prevention, met from December 2000 to December 2002 at three formal meetings and a two day workshop for a literature review on risk exposure assessment and the development of the European recommendations for the management of HIV NONOPEP. NONOPEP is recommended in unprotected receptive anal sex and needle or syringe exchange when the source person is known as HIV positive or from a population group with high HIV prevalence. Any combination of drugs available for HIV infected patients can be used as PEP and the simplest and least toxic regimens are to be preferred. PEP should be given within 72 hours from the time of exposure, starting as early as possible and lasting four weeks. All patients should receive medical evaluation including HIV antibody tests, drug toxicity monitoring and counseling periodically for at least 6 months after the exposure. NONOPEP seems to be a both feasible and frequent clinical practice in Europe. Recommendations for its management have been achieved by consensus, but some remain controversial, and they should be updated periodically. NONOPEP should never be considered as a primary prevention strategy and the final decision for prescription must be made on the basis of the patient-physician relationship. Finally, a surveillance system for these cases will be useful to monitor NONOPEP practices in Europe.

Proposed recommendations for the management of HIV post-exposure prophylaxis after sexual, injecting drug or other exposures in Europe

Post-exposure prophylaxis (PEP) is the standard of care for a healthcare worker (HCW) accidentally exposed to an HIV infected source person (occupational exposure), but this is not the case for non-occupational exposures. Very few national guidelines exist for the management of non-occupational exposures to HIV in Europe, contrarily to the occupational ones. The administration of non-occupational post-exposure prophylaxis (NONOPEP) for HIV may be justified by: a biological plausibility, the effectiveness of PEP in animal studies and occupational exposures in humans, efficacy in the prevention of mother to child HIV transmission, and cost effectiveness studies. These evidences, the similar risk of HIV transmission for certain non-occupational exposures to occupational ones, and the conflicting information about attitudes and practices among physicians on NONOPEP led to the proposal of these European recommendations. Participant members of the European project on HIV NONOPEP, funded by the European Commission, and acknowledged as experts in bloodborne pathogen transmission and prevention, met from December 2000 to December 2002 at three formal meetings and a two day workshop for a literature review on risk exposure assessment and the development of the European recommendations for the management of HIV NONOPEP. NONOPEP is recommended in unprotected receptive anal sex and needle or syringe exchange when the source person is known as HIV positive or from a population group with high HIV prevalence. Any combination of drugs available for HIV infected patients can be used as PEP and the simplest and least toxic regimens are to be preferred. PEP should be given within 72 hours from the time of exposure, starting as early as possible and lasting four weeks. All patients should receive medical evaluation including HIV antibody tests, drug toxicity monitoring and counseling periodically for at least 6 months after the exposure. NONOPEP seems to be a both feasible and frequent clinical practice in Europe. Recommendations for its management have been achieved by consensus, but some remain controversial, and they should be updated periodically. NONOPEP should never be considered as a primary prevention strategy and the final decision for prescription must be made on the basis of the patient-physician relationship. Finally, a surveillance system for these cases will be useful to monitor NONOPEP practices in Europe.