Implementation of on-site screening sigmoidoscopy positively influences utilization by primary care providers

BACKGROUND & AIMS

Sigmoidoscopy is an effective screening strategy for colorectal cancer that is not widely used by primary care providers. The aim of this study was to assess the impact of "academic detailing" in the form of an outreach educational seminar combined with implementation of on-site sigmoidoscopy services performed by university-based gastroenterologists on provider compliance.

METHODS

A controlled trial was initiated at 9 urban neighborhood health centers, including 4 intervention and 5 comparison sites. Baseline data on provider attitudes and practice patterns were collected using a validated questionnaire. Outcome measures included a year 1 follow-up survey of provider attitudes and quarterly review of screening sigmoidoscopy referrals using appointment logs to assess utilization.

RESULTS

Overall self-reported compliance rates for screening sigmoidoscopy increased by 36% (baseline, 24%; year 1, 60%) for the intervention group vs. only 7% (baseline, 19%; year 1, 26%) for the comparison group (P = 0. 001). When stratified by site, compliance rates increased at each intervention site (range, 7%-92%) but at only 2 control sites. Use of screening sigmoidoscopy was also significantly greater at the intervention sites (47% vs. 4%; P </= 0.001).

CONCLUSIONS

An outreach educational seminar combined with implementation of on-site sigmoidoscopy services is an effective strategy for enhancing provider utilization of screening sigmoidoscopy.

Convergent inductive signals specify midbrain, hindbrain, and spinal cord identity in gastrula stage chick embryos

In the chick embryo, neural cells acquire midbrain, hindbrain, and spinal cord character over a approximately 6 hr period during gastrulation. The convergent actions of four signals appear to specify caudal neural character. Fibroblast growth factors (FGFs) and a paraxial mesoderm-caudalizing (PMC) activity are involved, but neither signal is sufficient to induce any single region. FGFs act indirectly by inducing mesoderm that expresses PMC and retinoid activity and also directly on prospective neural cells, in combination with PMC activity and a rostralizing signal, to induce midbrain character. Hindbrain character emerges from cells that possess the potential to acquire midbrain character upon exposure to higher levels of PMC activity. Induction of spinal cord character appears to involve PMC and retinoid activities.

Organochlorine contaminants in Caspian and harbour seal blubber

Organochlorine contaminants (pesticides and individual polychlorinated biphenyl congeners, PCBs) were measured in Caspian (Phoca caspica) seal blubber and compared with concentrations in Harbour (Phoca vitulina) seal blubber. Concentrations of total dichlorodiphenyltrichloroethane (DDT) and its metabolites were significantly higher in Caspian seal than Harbour seal samples, whereas PCB congeners were significantly higher in Harbour than Caspian seals. Our finding suggests that Caspian seals are exposed to high levels of DDT pesticides. In contrast, PCBs are circulating in this population at much lower levels than in marine mammals from the North Sea.

The long-acting beta2-agonist salmeterol xinafoate: effects on airway inflammation in asthma

Salmeterol xinafoate is an inhaled long-acting beta2-adrenoceptor agonist recently introduced for the treatment of asthma. Both in vitro and animal studies suggest that it may have anti-inflammatory activities of benefit in this disease. To assess this directly, the effects of 6 weeks' treatment with salmeterol on indices of clinical activity, airway dysfunction and inflammation in subjects with stable atopic asthma were investigated. In a double blind study, asthmatic patients were randomized to 6 weeks' treatment with either salmeterol 50 microg twice daily (n=14) or placebo (n=12). They underwent bronchoscopy with bronchoalveolar lavage (BAL) and bronchial biopsy immediately before starting treatment and again after 6 weeks. Treatment with salmeterol improved clinical indices of asthma activity, but there were no changes in BAL differential cell counts or mediator levels, and no change in T-cell numbers or activation status. In the biopsy specimens there were no changes in numbers of inflammatory cells, sub-basement membrane collagen deposition or mast cell degranulation. Regular treatment with salmeterol improves clinical indices of asthma but has no effect on the underlying inflammatory process. These findings strengthen guideline recommendations that long-acting beta2-agonists should not be prescribed as sole antiasthma medication.

Melanin-concentrating hormone is the cognate ligand for the orphan G-protein-coupled receptor SLC-1

The underlying causes of obesity are poorly understood but probably involve complex interactions between many neurotransmitter and neuropeptide systems involved in the regulation of food intake and energy balance. Three pieces of evidence indicate that the neuropeptide melanin-concentrating hormone (MCH) is an important component of this system. First, MCH stimulates feeding when injected directly into rat brains; second, the messenger RNA for the MCH precursor is upregulated in the hypothalamus of genetically obese mice and in fasted animals; and third, mice lacking MCH eat less and are lean. MCH antagonists might, therefore, provide a treatment for obesity. However, the development of such molecules has been hampered because the identity of the MCH receptor has been unknown until now. Here we show that the 353-amino-acid human orphan G-protein-coupled receptor SLC-1 expressed in HEK293 cells binds MCH with sub-nanomolar affinity, and is stimulated by MCH to mobilize intracellular Ca2+ and reduce forskolin-elevated cyclic AMP levels. We also show that SLC-1 messenger RNA and protein is expressed in the ventromedial and dorsomedial nuclei of the hypothalamus, consistent with a role for SLC-1 in mediating the effects of MCH on feeding.

The effect of orally administered midazolam on children of three age groups during restorative dental care

PURPOSE

The effects of orally administered midazolam on three groups of preschool children who differed by age only and required dental treatment were studied. Sixty-one children age 24-58 months participated in this institutionally-approved study.

METHODS

Selection criteria for the children included: demonstrated disruptive behaviors; healthy (ASA I); required at least one restorative appointment involving a posterior quadrant; no known drug allergies; were between two and five years of age; and had no prior experience with sedative trials. The children were divided into three groups according to age: Group I (24-35 months), Group II (36-47 months), and Group III (47-59 months). Each child received midazolam 0.5 mg/kg orally 15 minutes before treatment. Behavior was evaluated using the Ohio State Behavior Rating Scale (OS). Physiological parameters including heart rate, oxygen saturation, systolic and diastolic blood pressure were also evaluated. Data were analyzed using chi-square, cross tabulation, descriptive statistics, ANOVA, t-tests, and regression and correlation analysis.

RESULTS

Results indicated no statistically significant difference in behavior across all age groups as evaluated by the OS.

CONCLUSION

No significant differences of clinical significance were noted.

The role of Schizosaccharomyces pombe Rad32, the Mre11 homologue, and other DNA damage response proteins in non-homologous end joining and telomere length maintenance

The Schizosaccharomyces pombe homologue of Mre11, Rad32, is required for repair of UV- and ionising radiation-induced DNA damage and meiotic recombination. In this study we have investigated the role of Rad32 and other DNA damage response proteins in non-homologous end joining (NHEJ) and telomere length maintenance in S.pombe. We show that NHEJ in S.pombe occurs by an error-prone mechanism, in contrast to the accurate repair observed in Saccharomyces cerevisiae. Deletion of the rad32 gene results in a modest reduction in NHEJ activity and the remaining repair events that occur are accurate. Mutations in two of the phosphoesterase motifs in Rad32 have no effect on the efficiency or accuracy of end joining, suggesting that the role of Rad32 protein may be to recruit another nuclease(s) for processing during the end joining reaction. We also analysed NHEJ in other DNA damage response mutants and showed that the checkpoint mutant rad3-d and two recombination mutants defective in rhp51 and rhp54 (homologues of S.cerevisiae RAD51 and RAD54, respectively) are not affected. However disruption of rad22, rqh1 and rhp9 / crb2 (homologues of the S.cerevisiae RAD52, SGS1 and RAD9 genes) resulted in increased NHEJ activity. Telomere lengths in the rad32, rhp9 and rqh1 null alleles were reduced to varying extents intermediate between the lengths observed in wild-type and rad3 null cells.

The use of unlicensed assistive personnel and selected outcome indications

This pilot study examine the satisfaction levels of patients, RNs, and UAPs after implementing a patient care delivery system using UAPs as nurse extenders on a 41-bed short-stay medical-surgical observation unit. It also compared patient fall statistics prior to and after implementing the new care model. The convenience study sample included 40 patients, 15 RNs, and 9 UAPs and covered 2 months of unit experience in mid 1997. Risk management statistics from a comparable period 2 years prior showed no significant difference in the number of patient falls. Patient satisfaction scores on five of the seven regularly collected questions was higher in 1997 than the comparable earlier period. RN satisfaction with the care model using UAPs was above a neutral score of 3 on a 5-point Likert scale on two out of three items, but additional attention to the RN's role in effective delegation to UAPs was needed.

The reproductive performance of sows after PRRS vaccination depends on stage of gestation

In order to minimize the effects of porcine reproductive and respiratory syndrome (PRRS) on stillbirth, mummification, and neonatal mortality in swine herds, many producers have vaccinated their herds using a modified-live virus vaccine. The purpose of this study was to determine the association of the PRRS modified-live vaccine and reproductive performance by stage of gestation when the vaccine was administered. A total of 47 swine herds from Ontario and Manitoba, Canada, and from the mid-western USA were included in the study. Participating farms had vaccinated all of their sows at one point in time when they used the vaccine for the first time. The reproductive performance of sows that farrowed in the year prior to use of the vaccine was compared to that of sows vaccinated in each of five stages of gestation and in the gestation that followed the initial use of the vaccine. Sows vaccinated at any time during gestation had a reduced number of pigs born alive, a reduced number of pigs weaned per litter, and increased number of stillborn pigs and an increased number of mummified pigs compared to the sows that farrowed prior to use of the vaccine. The largest association was seen in sows that were vaccinated in the last four weeks of gestation. The largest losses were observed in those herds that were vaccinated concurrently with the initial PRRS herd outbreak. These results suggest that the modified-live vaccine should only be administered to non-gestating sows.

Mucosal inflammation in severe glucocorticoid-dependent asthma

To improve our understanding of the inflammatory mechanisms underlying severe disease, a biopsy study was performed comparing 15 clinically unstable glucocorticoid-dependent asthmatics, 10 mild asthmatics, and 10 control subjects. Compared with mild asthma, severe asthma was characterized by reduced mucosal eosinophilia. Whilst no significant differences were found in the numbers of mast cells, neutrophils, CD3+ and CD4+ T-cells between the three groups, up to a 4-fold increase In the numbers of activated T-lymphocytes bearing the interleukin (IL)-2 receptor (IL-2R) was found in the mucosa in severe asthma compared to mild asthma (p = 0.03) and control subjects (p = 0.003). Compared to control subjects, the mucosa of severe asthmatics contained significantly (p = 0.02) higher numbers of IL-5+ cells, with no differences between mild and severe disease. In contrast, staining for the anti-IL-4 monoclonal antibody 3H4 revealed that biopsies from mild asthmatics contained more IL4+ cells than biopsies from severe asthmatics and control subjects (p = 0.0008). In the severe asthmatics, a close correlation (r(s) = 0.76, p = 0.005) was found between the numbers of IL-2R-bearing cells and the variability in peak expiratory flow. In conclusion, persistent T-cell activation is a prominent feature of severe asthma. These results also indicate that interleukin-5, and not interleukin-4, is upregulated in severe disease.

Oral vaccination of mice with human papillomavirus virus-like particles induces systemic virus-neutralizing antibodies

To assess whether oral vaccination against human papillomavirus (HPV) may be feasible, we administered HPV virus-like particles (VLPs) to mice by gavage. Enzyme-linked immunosorbent assay (ELISA) results indicated that serum anti-VLP immunoglobulin G (IgG) and IgA antibodies were induced after oral vaccination, and these responses demonstrated antigenic specificities that were conformationally dependent and restricted according to HPV genotype. Importantly, orally induced postimmune sera were found to neutralize HPV-11 virions in vitro. These results indicated that the VLPs were antigenically stable in the environment of the gastrointestinal tract and were able to engage in potentially useful immune system interactions. These findings support the concept of oral vaccination against anogenital HPV disease, and suggest the possibility that this may be a useful approach to the immunization of large populations against cervical cancer and other HPV associated diseases.

Gadolinium chloride toxicity in the mouse

1. Groups of five male and five female CD-1 mice received a single intravenous injection of gadolinium chloride at dosages of 0 (saline control), 0.05, 0.1 and 0.2 mmol/ kg. All mice were necropsied 48 h post dose. 2. Plasma analysis showed increases in concentrations of lactate dehydrogenase (both sexes), aspartate aminotransferase and alanine aminotransferase (females only) in the 0.2 mmol/kg group. Cholesterol was elevated at all dosages in both sexes whilst globulin was raised in both sexes at 0.1 and 0.2 mmol/kg. 3. Histological lesions were present at all dosages and increased in severity in a dose-related fashion. The most common lesions were: mineral emboli in capillaries, accumulation of mineral in the mononuclear phagocytic system, hepatocellular necrosis, and lymphoid depletion, necrosis and mineralisation in the spleen. 4. Such observations are similar to those in rats given gadolinium chloride and should be assessed when evaluating the toxicological profile of gadolinium containing compounds being developed for nuclear magnetic resonance imaging.

Comparison of physical chemical properties of llama VHH antibody fragments and mouse monoclonal antibodies

Antigen specific llama VHH antibody fragments were compared to antigen specific mouse monoclonal antibodies with respect to specificity, affinity and stability. The llama VHH antibody fragments and the mouse monoclonal antibodies investigated were shown to be highly specific for the protein antigen hCG or the hapten antigen RR-6. The affinity of the interaction between monovalent llama VHH antibody fragments and their antigen is close to the nanomolar range, similar to the bivalent mouse monoclonal antibodies studied. Llama VHH antibody fragments are similar to mouse monoclonal antibodies with respect to antigen binding in the presence of ammonium thiocyanate and ethanol. The results show that relative to antigen specific mouse monoclonal antibodies, antigen specific llama VHH fragments are extremely temperature stable. Two out of six llama VHHs are able to bind antigen specifically at temperatures as high as 90 degrees C, whereas four out of four mouse monoclonal antibodies are not functional at this temperature. Together with the finding that llama VHH fragments can be produced at high yield in Saccharomyces cerevisiae, these findings indicate that in the near future antigen specific llama VHH fragments can be used in for antibodies unexpected products and processes.

Advanced practice nursing: opportunities and challenges

Planning for the future may not be easy but it is always worthwhile. Resources that can help in making choices include professional organizations such as the Kentucky Coalition of Nurse Practitioners and Nurse Midwives, KNA, American Academy of Nurse Practitioners, American College of Nurse Practitioners, the Internet, and the college and university Schools of Nursing. Taking control of one's destiny is the best gift that can be given to one's self. Increasing options for career development is just one of the benefits of pursuing educational goals. The first step is commitment to goal. Selecting the right specialty, planning how financial obligations will be met and choosing the program that best meets identified needs are steps that will follow. Health care changes are occurring at such a rapid pace the individual nurse may feel caught in a whirlwind without control. Making the choice to seek change will present its own challenges but without change, growth is impossible. For those considering an Advanced Practice role, making the commitment, outlining a plan with each step clearly identified, reliance on a strong support system, and maintaining a vision of the completed goal will lead to success.

Anesthesia for pediatric dentistry

The administration of anesthesia to young patients creates a unique series of problems for the anesthesiologist. This article details these various problems and tackles the primary challenge facing clinicians in this environment: providing an environment that allows technically complex dental treatment to be delivered without inflicting any adverse psychological impact on the child or physical harm to the child or others.

Recent advances in 7-transmembrane receptor research

Approximately half of the currently known drugs act on cell surface receptors, the majority of which are 7-transmembrane (7-TM) receptors. The advent of genomic technologies has provided drug discovery scientists with a plethora of fascinating challenges, in particular a large increase in the number of potential 7-TM receptor targets for which the biological role, ligands and assays need to be found. These technologies have also led to novel and puzzling insights into the complex world of structure and function. Recent advances in the identification, classification, structure and function of 7-TM receptors are reviewed, together with the latest assay methods and the identification of novel ligands.

Phase I study of combination therapy with intravenous cidofovir and oral ganciclovir for cytomegalovirus retinitis in patients with AIDS

Ganciclovir and cidofovir, two antiviral agents used in the treatment of cytomegalovirus (CMV) retinitis, have a synergistic effect inhibiting CMV replication in vitro. In a phase I study, seven patients with AIDS-related CMV retinitis were treated with cidofovir (5 mg/kg intravenously every 2 weeks) combined with ganciclovir (1 g orally three times a day). During a median of 5.5 months (range, 1-12 months) of combined therapy, only one patient had retinitis progression, and only two of 28 blood cultures (specimens of which were obtained on a monthly basis) yielded CMV. Dose-limiting adverse ocular effects (anterior uveitis [two patients] and hypotony [two patients]) occurred in three of seven patients. The results suggest that combination therapy with intravenous cidofovir and oral ganciclovir (a regimen that does not require indwelling central venous catheter access) might enhance clinical efficacy. Less frequent administration of cidofovir in combination with oral ganciclovir should be prospectively studied to determine if the incidence of treatment-associated toxicity might be reduced.

Is default from colposcopy a problem, and if so what can we do? A systematic review of the literature

It has been reported that many women referred to outpatient colposcopy clinics fail to attend for their appointments. The aim of this paper is to search the literature to assess the extent of default from colposcopy and to identify interventions, suitable for implementation within primary care, to reduce the proportion of women defaulting. Searches were performed on MEDLINE, PsychLIT, Bids and Cancerlit from 1986 to September 1997 using the terms colposcopy or cervical/Pap smear in association with default, non-attendance, adherence, patient compliance, treatment refusal, patient dropouts, attendance, barriers or intervention. The inclusion criteria for primary papers were that they contained data that enables the calculation of default rates for colposcopy or the results of interventions aimed at improving the default rates. Thirteen publications describing default rates and four describing interventions were included as primary papers. Combining the data from these studies suggests default rates of 3%, 11%, and 12% for assessment/treatment visits, first review, and second review respectively. The intervention studies suggested a need to tailor the intervention to the population and the type of information to suit the individual. Varying definitions make comparison of default rates difficult, and the use of a crude non-attendance rate may result in an overestimate of default rates. The vast majority of women invited to colposcopy eventually attend. It is questionable if there is a need for interventions to increase compliance. Where necessary, greater cooperation across the primary/secondary care interface and use of the extended primary care team may be a more cost-effective means of increasing compliance.