Primary cutaneous Nocardia otitidiscaviarum infection: case report and review

Organisms of the genus Nocardia cause a variety of illnesses in humans and other mammals. Nocardiae normally enter the body via the respiratory tract, but they may also be directly inoculated into the skin, causing primary cutaneous disease. Nocardia otitidiscaviarum is one of the less commonly isolated species of Nocardia, but it can produce localized or disseminated infection. We report a case of primary cutaneous N. otitidiscaviarum infection and review the clinical and microbiological features of other reported cases. Cutaneous N. otitidiscaviarum infection usually occurs in the setting of trauma, most often in otherwise healthy hosts. The manifestations of N. otitidiscaviarum skin infection range from cellulitis and abscess formation to the development of mycetomas. Cutaneous infection by N. otitidiscaviarum can mimic disease caused by more common pyogenic organisms, often leading to delay in diagnosis and treatment. Appropriate antibiotic therapy, usually with a sulfa drug-containing regimen, is generally successful.

Epstein-Barr virus coinfection and recombination in non-human immunodeficiency virus-associated oral hairy leukoplakia

Human immunodeficiency virus-associated oral hairy leukoplakia (HLP) is characterized by coinfection with multiple types and strains of Epstein-Barr virus (EBV) and recombination within the EBV genome. HIV-seronegative immunosuppressed and immunocompetent patients with HLP were examined to determine the pathogenic contribution of EBV coinfection and recombination to the development of HLP. Multiple coinfecting EBV strains were detected in both HLP specimens and peripheral blood lymphocytes (PBL) of HIV-seronegative persons with HLP. One specific EBV strain was detected in HLP specimens from 3 of 4 patients. Also, viral recombination during productive replication within HLP generated variants of the latent membrane protein-1 (LMP-1) and nuclear antigen-2 (EBNA-2) genes. Some variants were also detected within PBL. Thus, EBV coinfection and recombination are consistent findings in persons with HLP regardless of immune status. Virally mediated determinants may be important features of EBV pathogenesis.

Examining a paradox: does religiosity contribute to positive birth outcomes in Mexican American populations?

A particularly interesting and consistent finding regarding the health of the Latino population is that Mexican American women, despite their relatively lower socioeconomic status, deliver significantly fewer low birth weight babies and lose fewer babies to all causes during infancy than do women of other ethnic groups. A central thesis of this discussion is that the religiosity and spirituality of many of these Latinas, a key factor in their culture, may protect them and their infants through the pre- and antenatal phases of life. We also suggest that lack of research, related to cultural similarities and differences in Hispanic/Latino subgroups, can lead to faulty or simplistic understanding regarding their health behavior and health status.

Self-management of the health care regimen: a comparison of nurses' and cardiac patients' perceptions

This study compared perceptions of 129 elderly cardiac patients regarding their health status and self-management skills with corresponding assessments by outpatient nursing staff members. Nurse-patient perceptions were most congruent on general questions regarding the heart condition. Differences were most apparent regarding how aware patients were of being asked to follow a regimen for managing their heart problems; what specific components comprised the regimens the patients were to follow; and how much confidence patients had in their ability to comply with specific components of the regimen. Congruence in perceptions of nurses and patients varied by the sex of the patient. Findings suggest that careful and continuous assessment of patients' perceptions about their condition and ongoing instruction regarding specifics of the therapeutic regimen are key elements in efforts to enhance elderly patients' self-management skills.

Management of asthma by patients and families

This paper focuses on assessment of asthma-management outcomes resulting from interventions for patients. Noted is the need to design both programs and evaluations that reflect a theoretical understanding of behavior change. For purposes of illustration, the theoretical construct of self-regulation is used. It is posited that individuals are predisposed to take action to handle asthma problems by virtue of internal (knowledge, attitudes, beliefs) and external (models of behavior, technical advice and service, money, etc.) factors. Through processes of self-regulation--that is, the ability to observe, make judgments, and react to one's own behavior--individuals learn which management strategies (prevention, symptom management, negotiation, and communication) work for them. If these management strategies are effective, one would expect certain outcomes: the patient's personal goal will be reached; physiologic and psychological health status will be maintained or improved; and health care use will be appropriate. A range of good studies of patient behavior related to asthma management and of interventions to enhance behavior are available, and provide some evidence that these outcomes can be attained. A solid foundation for the development of more sophisticated and refined self-management assessment measures is available. Objective measures have been used to verify behavior in two or three research projects. Although objective measures are costly and can be cumbersome to administer, more effort to develop and use such measures is needed. Testing of the reliability and validity of existing patient-management measures has been perfunctory, and greater attention, especially to the validity of measures, is needed. Six recommendations for better measurement are made.

Reducing tobacco smoke in the environment of the child with asthma: a cotinine-assisted, minimal-contact intervention

Children with asthma who are exposed to environmental tobacco smoke are at increased risk for adverse health consequences. An experimental design was used to evaluate a minimal-contact intervention aimed at modifying parents' smoking behavior in their homes. All subjects received counseling on the health effects of passive smoking and advice to quit smoking inside the home. Treatment subjects were also mailed the results of a urine cotinine test on their child and a self-help manual. More treatment (35%) than control (17%) subjects reported smoking outside their homes at posttest (and their children's cotinine levels were lower), but this difference was not statistically significant.

Patient and family management of asthma: theory-based techniques for the clinician

Several model asthma education programs are available to improve patient self-management, and elements of these models are discussed as they relate to the teaching role of health-care providers. Self-regulation is being explored in current asthma education research, and preliminary findings of a study are presented that show self-regulation behaviors to be associated with more frequent use of asthma management strategies by patients. Using more management strategies was associated with being observant of symptoms (p = .0001) and feeling confident to manage them (p = .01). Taking more preventive actions was associated with being observant (p = .001) and feeling confident to keep the child out of the triggering situation (p = .02) and prevent symptoms (p = .001). Important issues arising from recent psychosocial research are outlined for consideration by the clinician. These include ways that counseling by the health professional can encourage self-regulation and better at-home management of asthma.

Sustaining collaborative problem solving: strategies from a study in six Asian countries

This paper presents findings from seven case studies of collaborative problem solving. The cases represent models of large-scale collaborative effort to improve the social, economic or health status of residents in poor communities. In these examples a variety of organizations worked together: government, business, voluntary agencies, community groups and people's organizations. A range of strategies was evident as these entities tried to sustain their collaboration. Strategies identified included those deployed collectively, those used by an individual organization to maintain its ability to participate and those used to persuade or pressure needed collaborators to become involved or stay the course. Specific strategies employed and descriptions of their use are presented and comprise a compelling profile of how collaborative problem solving functions.

Activation of the human T-cell leukemia virus type I enhancer is mediated by binding sites for Elf-1 and the pets factor

Infection with human T-cell leukemia virus type I (HTLV-I) is associated with adult T-cell lymphoma/leukemia. This disease occurs in only a small minority of people infected with HTLV-I and manifests itself many years after infection. Therefore, it appears that a fine balance exists between HTLV-I and the host T-cell factors with which it interacts. HTLV-I encodes a transactivating protein, Tax, which activates viral transcription via cellular mechanisms which are incompletely understood. As viral gene expression is negligible during latency, it is doubtful that Tax controls the initial transition to the replicative state. Tax-independent cellular factors which control HTLV-I transcription, and presumably latency, have received little study. Recently, the product of the chicken proto-oncogene ets-1 has been shown to bind to the HTLV-I enhancer and modestly activate transcription in certain cell types (S. C. Gitlin, R. Bosselut, A. Gégonne, J. Ghysdael, and J. N. Brady, J. Virol. 65:5513-5523, 1991). However, the functional significance of the ets-binding site in the intact enhancer has not previously been shown. We now demonstrate that site-specific mutation of the purine-rich ets-binding site significantly diminishes inducible enhancer function, but not Tax response, in the human Jurkat T-cell line. Similarly, mutation of the peri-ets (pets) site, not previously noted in the HTLV-I enhancer, markedly inhibits inducible enhancer function but not Tax response. Further, we show that the predominant protein binding the purine-rich HTLV-I enhancer element in human T cells is not ets-1 but Elf-1, a member of the ets family which is very similar to the Drosophila morphogen E74. Regulation of HTLV-I through Elf-1/pets enhancer motifs resembles that seen with human immunodeficiency virus type 2 (D. M. Markovitz, M. Smith, J. Hilfinger, M. C. Hannibal, B. Petryniak, and G. J. Nabel, J. Virol. 66:5479-5484, 1992; J. M. Leiden, C.-W. Wang, B. Petryniak, M. Smith, D. M. Markovitz, G. J. Nabel, and C. B. Thompson, J. Virol. 66:5890-5897, 1992), another human pathogenic retrovirus with a relatively long incubation period.

Patient, professional, and public education on behavioral aspects of asthma: a review of strategies for change and needed research

Combating increases in asthma morbidity and mortality necessitates an understanding of social and behavioral aspects of the disease. Education for patients, professionals, and the public based on the most current scientific information is required. This paper reviews the existing research on patient education and management of asthma. It discusses physician and family interaction related to asthma management; identifies gaps in the current understanding of relevant patient, professional, and public behavior; outlines needed strategies to improve asthma education; and poses recommendations for further research.

Self-regulation of health behavior: the "take PRIDE" program

Social cognitive theory, in particular, the construct of self-regulation was the basis for developing an educational program for older adults with heart disease. This paper discusses the theoretical principles utilized and describes the program activities based on them. Data from an evaluation conducted with 246 older heart patients who took part in the education are used to illustrate how social cognitive theory constructs operated empirically.

The relationship between cognitive maturity and information about health problems among school age children

This study of urban, multi-ethnic children was undertaken to explore the relationships between age, cognitive developmental capability (termed 'cognitive maturity') and accuracy of information about health problems. A total of 299 children in the first, second and third grades from six public and one private school in New York City were individually interviewed using an open-ended set of questions. Findings indicated that having accurate health information is not the same as comprehending the abstract internal nature of the 'facts'. Results supported Piaget's levels of cognitive development applied to the area of health. Findings also showed that age is a better predictor of children's accuracy about health information than their cognitive maturity. The findings underscore the need for those providing health education to place emphasis on the cognitive abilities of children and not to mistake recitation of factual information for understanding of conceptual elements of a health problem.

Impact of self-management education on the functional health status of older adults with heart disease

This paper presents findings from the evaluation of a self-management education program based on self-regulation principles. Older men and women (N = 324) were randomly assigned to program and control groups. Outcomes were measured using the Sickness Impact Profile. Twelve months following baseline data collection, psychosocial functioning of program participants was significantly better than that of controls. Different program effects were noted when results were analyzed by participant gender.

Health beliefs and practices of kenyan primary school students

A study of 224 primary school students in Kenya was conducted to determine if health belief model variables predicted their health behavior, specifically, using safe drinking water. One health belief model construct, belief in benefits, was associated with the behavior (p = .05). Living in an urban environment (p = .01), and proximity to a tap (p = .004) were also significant predictors of safe water use. Implications for further research and health education programs are discussed.

Differences in the impact and management of heart disease between older women and men

Findings are presented from an exploratory study of differences in the impact and management of heart disease between men and women aged 60 and over (N = 323). The sample consisted of ambulatory, non-institutionalized, cardiac patients who had agreed to participate in a self-management intervention study. Differences between men and women were found regarding symptom experience, physical functioning, exercise compliance, use of prescribed drugs, and physician/clinic visits. Differences in emotional well-being and psychosocial functioning were not found; however, women reported more stress and limitation in the area of household management. Implications for future research and practice are discussed.

A school health education program for children with asthma aged 8-11 years

It was hypothesized that a health education program for children with asthma aged 8-11 years that was delivered in elementary schools, would increase children's asthma management skills, self-efficacy and influence on parents' management decisions; reduce school absences and improve school performance. The study population consisted of 239 low-income, predominantly Hispanic and black children from 12 elementary schools (six experimental and six control) in New York City. Parents did not attend educational sessions but received written materials. The program emphasized the child's responsibility for recognizing symptoms and taking appropriate management steps. Follow-up data obtained one year after the program showed that compared to controls experimental group children had higher scores on an index of asthma management (p less than 0.05), greater self-efficacy with respect to asthma management skills (p less than 0.05), more influence on parents' asthma management decisions (p less than 0.05), better grades in school (p = 0.05), and fewer episodes of asthma (p less than 0.01) of shorter average duration (p less than 0.01). No differences were observed for changes in number of school absences. These findings show that asthma health education designed for delivery to children can significantly increase management skills, reduce symptoms of asthma, and improve school performance.

The impact of passive smoking on emergency room visits of urban children with asthma

Baseline data obtained from a study of 276 children with asthma from 259 low income families were analyzed to test the hypothesis that passive smoking is associated with frequency of emergency room (ER) visits, hospitalizations, and impaired pulmonary function. The data were analyzed using multiple regression techniques. We controlled for other variables that might affect the frequency of ER visits, including smoking by the children themselves and the presence of other irritants or allergens in the child's home. Passive smoking was positively associated with ER visits (p less than 0.01), but not with hospitalizations or abnormalities in pulmonary function. The frequency of days with symptoms of asthma per month was also directly associated with ER visits (p less than 0.02). The estimated mean annual increase in ER visits attributable to the presence of one or more smokers in the household was 1.34 +/- 0.50, an increase of 63% over nonsmoking households. The estimated annual health care cost for emergency care of children with asthma that can be attributed to passive smoking is 92 dollars (95% confidence interval from 24 to 160 dollars) for families with 1 or more smokers.

The impact of health education on frequency and cost of health care use by low income children with asthma

A sample of 310 low income urban children with asthma from 290 families was randomized into a control group and an experimental group that received health education to improve asthma management at home. No significant decreases in subsequent health care use were observed when the experimental group was compared to the control group without regard to previous hospitalization. When the comparison was restricted to children who had been hospitalized during the preceding year, however, the experimental group was found to have decreased its use of the emergency room significantly more than the control group (p less than 0.05) and to have experienced a significantly greater reduction in the mean number of hospitalizations (p less than 0.05) during the year of follow-up. The program reduced health care costs for children with one or more hospitalizations, saving $11.22 for every $1.00 spent to deliver health education.

Managing better: children, parents, and asthma

To evaluate a health education program to improve family management of asthma, 310 children with asthma and their 290 parents were randomly assigned to a program or control group. Program families participated in health education designed to resolve specific management problems and build self-confidence in the ability to manage asthma. Following education, program parents scored better on an asthma self-management index than parents in the control group (+1.57 versus -0.83, P less than 0.0001). Program parents also scored better on two subindices of the self-management index: attack management (+0.87 vs. +0.42, P less than 0.05) and preventive measures (+0.42 vs. -0.35, P less than 0.05). Also, program parents reported significantly more use of guidelines to determine appropriate levels of physical activity for children. Following education, program children reported more use of three management steps than control children: productive cough or postural drainage (59% vs. 35%, P less than 0.004), breathing and relaxation exercises (80% vs. 65%, P less than 0.05), and attempts to stay calm (12% vs. 2%, P less than 0.05). Program children reported significantly less worry than control children about the limitations asthma imposes and about making mistakes at school.

A sense-making approach to understanding adolescents' selection of health information sources

The authors propose that information sources are best understood as constructed by individuals in an attempt to find answers to questions of immediate relevance. Contact profiles, or patterns of source use for particular information, determine what constitutes a source for an individual. The study explores how adolescents acquire and use health information. Data analyses based on a probability sample of 200 adolescents identified nine contact profiles and supported four study hypotheses. Contact profiles differ according to health topics and are related to message sending and seeking regarding human sexuality and birth control. Adolescents with peer-media, home-oriented or multi-source contact profiles about human sexuality and birth control were more likely than others to be the peer advisors on this topic, and those with peer-media and multi-source profiles the ones more likely to be the information seekers about it. Contact profiles are also related to adolescents' health decision making capacity. Adolescents with peer-media and multi-source profiles for human sexuality and birth control information and those with home-oriented profiles for alcohol and smoking information engaged in more health decision making steps than those with other profiles. Finally, contact profiles are also related to awareness and contact with new information sources. Adolescents with peer-oriented and multi-source profiles were more likely than others to be aware of and have contacted a new peer education program in the school.

Changes in children's school performance as a result of education for family management of asthma

This paper describes the impact of an asthma self-management program for parents and children on the school performance and adjustment of children with asthma. Program participants were predominantly low income, minority families enrolled in four pediatric outpatient clinics. The educational content of the program was based on a needs assessment of the participants and recommendations of medical consultants. Parents and children participated separately in group sessions that focused on the development of self-management skills and problem solving. The program was organized into six themes including "how to help your child (yourself) do well in school." The program was evaluated with an experimental research design and yielded significant school related benefits. Children participating in the program maintained better grades. Math, reading and science grades were higher relative to control group children in the year following the program. Within a subgroup of children who received care from private practitioners, program children exhibited better social adjustment to school than did control group children.

Patient consent in seven medical-care institutions

An exploratory study of the patient consent process was conducted in seven large medical-surgical institutions. Analysis of the most recent literature on consent and of data provided by knowledgeable persons in each facility led to the conclusions that (1) the primary intent of obtaining patient consent is to legally protect the hospital and the physician, (2) legal and educational objectives are confused and entangled in the consent process, (3) legal objectives are not adequately met in any facility, and (4) the potential for sophisticated patient education is dim given existing procedures.

The effectiveness of education for family management of asthma in children: a preliminary report

This paper reports preliminary findings in a convenience sample of one half the population enrolled in a study of self-management in low income families where a child has asthma. In initial evaluation data, parents participating in self-management education reported significantly less fear and anxiety associated with their children's wheezing episodes than did control families. They also reported that their children exhibited fewer signs of stress during wheezing episode. A trend toward reduced school absences and emergency room visits was noted among participating families. The actions taken by a family to manage the illness increased with the number of sessions attended.

Developing education for children with asthma through study of self-management behavior

Bronchial asthma is the major cause of disability in childhood. Among its effects are impaired levels of physical activity and self-esteem, reduced school attendance and performance, and increased utilization of emergency health services. This paper describes the development of a health education program designed to test the hypothesis that better family self-management of asthma can reduce the negative impact of the disease. Three hundred low income Black and Hispanic families were enrolled in the study. Children and primary caretakers were interviewed separately to obtain baseline data on current levels of self-management and to assess needs for educational intervention. Data have been accumulated on a variety of topics concerning asthma self-management, including health practices and beliefs, coping skills, asthma knowledge, and locus of control. An Asthma Self-Management Index was developed to measure positive management behaviors by the family. The needs assessment indicated that six core themes were priorities for these families in terms of relevant skills and behaviors. These topics were incorporated as lesson plans in the intervention.

Knowledge-informed behavior and the nursing culture: a preliminary study

The pilot study reported in this article was undertaken to identify roles that nurses perform in actual practice and factors and behaviors that enable or prevent them from resolving practice problems in a knowledge-informed way. It was theorized that if nursing roles based on actual practice can be described and if behaviors which enhance knowledge-utilization can be identified, nurses can learn to implement the specific activities needed to ensure the full application of professional knowledge in the practice setting. This preliminary study uncovered six intersecting roles assumed by nurses in the practice of their profession and identified nine categories of behavior and their influence on the ability to use knowledge in carrying out each role. The findings provide additional insight into the nursing culture and suggest the need for changes for education and service.

Spanning the boundary between agency and community: a study of health planning staff and board interaction

This paper suggests that planning staff and board members function as boundary spanners between the agency and various interests which must be considered in health planning. The study outlines communication behaviors which, in the view of board members, appear to influence decision making and effective performance as boundary spanners collaborate in planning.