Do benefits and barriers differ by stage of adoption for colorectal cancer screening?

In 2003, over 148,300 people were expected to be diagnosed and 56,000 to die from colorectal cancer (CRC). First-degree relatives (FDRs) of people with colon cancer have a two- to eight-fold increased risk for CRC. Despite evidence that screening is effective, adherence with screening recommendations in this at-risk population is low. This study's purposes were to (1) identify perceived benefits and barriers of fecal occult blood testing (FOBT), sigmoidoscopy and colonoscopy, and (2) compare demographic characteristics and perceived benefits and barriers by stage of adoption for CRC screening. Participating FDRs (n = 257) completed a 40-min structured telephone interview. Despite high rates of agreement with the benefits of screening, most FDRs were not contemplating being screened. Of those 50 and older, most were in precontemplation for FOBT, sigmoidoscopy and colonoscopy. Older age was related to stage for FOBT and sigmoidoscopy, but not colonoscopy. Lack of provider recommendation also was related to stage. Consistent with theoretical predictions, precontemplators had (1) higher rates of endorsement of specific barriers to screening and (2) lower rates of endorsement of benefits than contemplators or actors. For morbidity and mortality reduction, participation in routine, periodic screening is imperative. These findings can guide development of screening-promoting interventions.

Spatial and temporal bacterial quality of a lowland agricultural stream in northeast Scotland

Stream water concentrations of the faecal coliform group of sanitary indicator bacteria were monitored in the Newmills Burn, a small agriculturally intensive tributary of the River Don in Aberdeenshire. The results indicated that during its passage through the catchment, stream water became significantly contaminated with faecal coliform bacteria from the main agricultural land use inputs of livestock grazing and organic waste applications. Point sources of faecal coliform bacteria in terms of farmyard runoff, however, also appeared to be important in contributing to the spatial pattern of contamination. Significant temporal variation was observed in response to the hydrological behaviour of the catchment. Higher flows and more frequent washout of stored bacteria in winter and spring months led to lower faecal coliform concentrations than were detected during the summer. Maximum faecal coliform concentrations were measured during rainfall events and the varying responses associated with these helped to identify the importance of different sources of bacteria in the catchment and the mechanisms transferring them. The overall impact on the water quality of the Newmills Burn was considered as having a potentially serious threat to the health of downstream recreational users of the River Don, as well as to the large proportion of the local population who rely on private water supplies.

A sharp debridement procedure devised by specialist nurses

In the clinical governance era, self-education is not adequate training for nurses to carry out sharp debridement, which is a risky process. Specialist nurses in south-east London drew up a workable procedure for training and practice.

Association of homozygous 7048G7049 variant in the intron six of Nurr1 gene with Parkinson's disease

OBJECTIVE

To determine whether the Nurr1 gene, which is critical for the development and maintenance of nigral dopaminergic neurons, is a risk factor associated with PD.

BACKGROUND

The Nurrl gene is highly expressed in the dopaminergic neurons in the midbrain. Knockout of the gene results in agenesis of nigral dopaminergic neurons and heterozygous knockout mice increases 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced neurotoxicity.

METHODS

This study included 105 patients with familial PD (fPD) and 120 patients with sporadic PD (sPD) and 221 age-matched healthy control subjects. The polymorphisms and mutations of the Nurr1 gene in patients with PD were initially examined by heteroduplex analysis and sequencing analysis from PCR-amplified Nurr1 gene fragments. A polymorphism in the BseRI restriction site was identified, and a relatively large-scale analysis then was conducted by three independent investigators who were blinded to the clinical status of the subjects.

RESULTS

A homozygous 7048G7049 polymorphism was found in intron 6 of the Nurr1 gene, which was significantly higher in fPD (10/105; 9.5%) and in sPD (5/120; 4.2%) compared with healthy control subjects (2/221; 0.9%). The mean age and the SD at onset of these homozygote patients with PD was 52 +/- 15 years for fPD and 46 +/- 7 years for sPD. The clinical features of these homozygote patients with PD did not differ from those of typical PD.

CONCLUSIONS

The homozygote polymorphism of 7048G7049 in intron 6 of the Nurr1 gene is associated with typical PD.

A double-blind, placebo-controlled and longitudinal study of riluzole in early Parkinson's disease

BACKGROUND

To the extent that excitotoxicity may play a role in the pathogenesis of certain neurodegenerative disorders, antagonists of glutamate, an excitatory neurotransmitter, should exert neuroprotective effects in these disorders, including Parkinson's disease (PD).

METHODS

Patients in early stages of PD, not previously treated with levodopa, were randomized to receive riluzole 50mg capsules orally, taken twice daily or a matching placebo. All subjects were evaluated at baseline (pre-treatment), at 1, 3 and 6 months (post-treatment), and following a 6-week washout. After the washout, all subjects were offered an enrollment in an open label, 1-year, extension study. The principal investigator (JJ), however, remained blinded to the original assignment during the entire study. The patients were assessed by the Unified Parkinson's Disease Rating Scale (UPDRS), Activities of Daily Living (ADL), Hoehn & Yahr (HY) stage, and Schwab and England (SE) ADL scale. The quantitative assessments included Movement Time (MT) and Reaction Time (RT). Additionally, the time to initiate dopaminergic therapy was assessed. Safety was determined at each visit by clinical history and examination, a panel of blood safety laboratory tests including complete blood count, chemistry profile, and liver function studies.

RESULTS

Twenty patients with a mean age of 62+/-9.02 (range: 46-73) years and mean duration of symptoms of 18+/-9.53 (range: 6-36) months were enrolled. One patient withdrew from the study because he needed more aggressive treatment of his symptoms. Analysis of the efficacy variables showed no meaningful symptomatic effect of riluzole on UPDRS score. Likewise, there was no significant change in the median HY stage, SE ADL rating, or the MT/RT. Seventeen patients (mean age 62+/-9.26) elected to continue in the open label extension study. Although the observed deterioration in UPDRS scores seemed to be more pronounced in the placebo group than in the riluzole group, the difference did not reach statistical significance. There was no statistically significant difference in the latency between enrollment and start of symptomatic therapy when patients initially treated with riluzole were compared to those initially treated with placebo (8.3 vs 9 months).

CONCLUSIONS

This pilot and extension study showed that riluzole, 100mg/day, was well tolerated in patients with early PD. No evidence of symptomatic effect of riluzole was observed. Because of the exploratory nature of the design and small size of the study, it was not possible to determine whether riluzole affected the natural history of PD. The encouraging results from our study, however, suggest that larger, longitudinal studies are warranted.

IL-12 suppression during experimental endotoxin tolerance: dendritic cell loss and macrophage hyporesponsiveness

Endotoxin tolerance, the transient, secondary down-regulation of a subset of endotoxin-driven responses after exposure to bacterial products, is thought to be an adaptive response providing protection from pathological hyperactivation of the innate immune system during bacterial infection. However, although protecting from the development of sepsis, endotoxin tolerance also can lead to fatal blunting of immunological responses to subsequent infections in survivors of septic shock. Despite considerable experimental effort aimed at characterizing the molecular mechanisms responsible for a variety of endotoxin tolerance-related phenomena, no consensus has been achieved yet. IL-12 is a macrophage- and dendritic cell (DC)-derived cytokine that plays a key role in pathological responses to endotoxin as well as in the induction of protective responses to pathogens. It recently has been shown that IL-12 production is suppressed in endotoxin tolerance, providing a likely partial mechanism for the increased risk of secondary infections in sepsis survivors. We examined the development of IL-12 suppression during endotoxin tolerance in mice. Decreased IL-12 production in vivo is clearly multifactorial, involving both loss of CD11c(high) DCs as well as alterations in the responsiveness of macrophages and remaining splenic DCs. We find no demonstrable mechanistic role for B or T lymphocytes, the soluble mediators IL-10, TNF-alpha, IFN-alphabeta, or nitric oxide, or the NF-kappaB family members p50, p52, or RelB.

Practice unwinds and disengagements

Many employed physicians are being forced to consider entering the private practice arena as physicians networks and groups are contemplating total or partial divestitures. Still other physicians are evaluating the possibility of leaving their current practice or hospital based network and opening their own practice. This article is designed to better prepare a physician for this situation ad proactively plan for their future.

NMR kinetic studies on the decomposition of beta-amidozinc reagents: optimization of palladium-catalyzed cross-coupling with acid chlorides

The decomposition of beta-amidozinc reagent 4 by beta-elimination has been shown to be a unimolecular process in both THF and DMF as solvent, with relative rates of 4:1 at room temperature, and activation parameters have been determined. These results indicate the beta-elimination is a syn-process. NMR experiments reveal that as little as 2 equiv of DMF can have a significant stabilizing influence on reagent 4. Use of a mixture of DMA and toluene as the bulk solvent, in place of DMF, has allowed successful palladium-catalyzed cross-coupling reactions of both 4 and the homologous reagent 5 with acid chlorides to yield unsymmetrical ketones (nine examples).

Accuracy of administrative data in trauma: splenic injuries as an example

BACKGROUND

Accurate data are needed to evaluate clinical outcomes, therapeutic modalities, and quality of care in trauma. Administrative data, usually used for billing, have been used to evaluate performance and assess therapy in other medical specialties. This study was performed to determine whether administrative databases are accurate in the recording of information about trauma patients with splenic injuries.

METHODS

Patients who had blunt splenic injuries were identified using a state trauma registry. The medical records of those patients were reviewed. The data collected by chart review were compared with data in the statewide administrative database of patients who had splenic injuries at the same four Level I and II trauma centers in the same 5-year period. Age, sex, admission date, and hospital were matched to assure comparison of the identical cohort. chi2 analysis was used to compare dichotomous data and Student's t test continuous data.

RESULTS

The administrative database identified 641 and the trauma registry identified 529 patients with a diagnosis of splenic injury. A total of 401 patients were found in both databases. Of these, 120 (22.7%) patients were not recorded in the administrative database. Injury Severity Score was underreported by the administrative database (25.74 +/- 14.7 vs. 19.52 +/- 11, p < 0.0001). The administrative database underreported orthopedic, chest, and head injuries (317 vs. 215, 325 vs. 228, and 234 vs. 155, respectively; all p < 0.0001). Use of abdominal computed tomographic scan and diagnostic peritoneal lavage were also underreported (260 vs. 56 and 104 vs.17, both p < 0.0001). The number of operations on the spleen and number of orthopedic procedures were underreported (259 vs. 225, p < 0.014 and 147 vs. 94, p < 0.0001). Complications were markedly underreported by the administrative database (200 vs. 47, p < 0.0001)

CONCLUSION

This study shows that administrative data lack accuracy in the recording of associated injuries, injury severity, diagnostics, procedures, and outcomes data in patients with splenic injuries. Whether these data should be used to evaluate treatment modalities or quality of care in trauma is questionable.

The relationship between body mass index and waist circumference: implications for estimates of the population prevalence of overweight

OBJECTIVE

Body mass index (BMI) based on self-reported height and weight is a systematically biased, but acceptable measure of adiposity and is commonly used in population surveys. Recent studies indicate that abdominal obesity is more strongly associated with obesity-related health problems than is adiposity measured by BMI. The purpose of this study was to determine the relationships of both measured and self-reported BMI with measured waist circumference in a randomly selected sample of Australian adults.

DESIGN

Cross-sectional survey with self-reported and laboratory-based measures of adiposity.

SUBJECTS

1140 randomly-selected Australian adults aged 18-78 y resident in the city of Adelaide, South Australia.

MEASUREMENTS

Data on self-reported and measured height and weight as well as measured waist circumference were drawn from the Pilot Survey of the Fitness of Australians database. The proportion of men and women with acceptable BMI (BMI</=25 kg/m2) and with excess abdominal adiposity (>/=94 cm for men and >/=80 cm for women) was determined. Differences in the prevalence of overweight based on BMI alone or BMI and waist circumference were also determined.

RESULTS

Compared with the prevalence based on self-reported BMI alone, the prevalence of overweight among men based on self-reported BMI and waist circumference combined was 2.4%, 5.3%, 19.1% and 7.5% greater for men aged 18-39 y, 40-59 y, 60-78 y and for all men, respectively. Among women, compared with the prevalence based on self-reported BMI alone, the prevalence of overweight based on the combined measures was 9.9%, 24.0%, 33.3% and 20.6% greater for women aged 18-39 y, 40-59 y, 60-78 y and for all women, respectively.

CONCLUSIONS

If waist circumference is used as the criterion, then the prevalence of overweight among Australian adults, and probably other Caucasian populations, may be significantly greater than indicated by surveys relying on self-reported height and weight. The development of valid self-reported measures of waist circumference for use in population surveys may allow more accurate epidemiological monitoring of overweight and obesity.

Gabapentin for essential tremor: a multiple-dose, double-blind, placebo-controlled trial

Essential tremor (ET) is a common movement disorder that often becomes refractory to conventional pharmacologic management. Open-label studies suggest that gabapentin is efficacious for ET, but the results of controlled trials have been mixed. To determine the efficacy and tolerability of gabapentin in ET, we conducted a double-blind, placebo-controlled, cross-over trial evaluating two doses (1800 mg per day and 3600 mg per day; N = 25). Patients on other ET medications were maintained on their concurrent medications for 3 months prior to study initiation and throughout the study. Twenty patients (mean age, 69.9 +/- 6.1 yrs) completed the study. Overall, patient global assessments (p <0.05), observed tremor scores (p <0.005), water pouring scores (p <0.05), and activities of daily living scores (p <0.005) significantly improved. Accelerometry scores, spirographs, and investigator global impression scores did not improve. The results were similar for high and low doses. Statistical regression models did not demonstrate any significant predictors for response. Gabapentin may be effective in some cases of ET.

Mechanical ventilation and high-efficiency vacuum cleaning: A combined strategy of mite and mite allergen reduction in the control of mite-sensitive asthma

BACKGROUND

The relationship between exposure to house dust mite (HDM) allergens and prevalence of sensitization to these allergens in patients with asthma has been confirmed in many studies. Mite population growth is regulated by humidity. Reducing humidity and removing allergen by efficient vacuuming should control mite allergen and reduce symptoms.

OBJECTIVE

We sought to investigate the effect of mechanical ventilation and high-efficiency vacuuming on HDM numbers and Der p 1 concentrations in the homes of mite-sensitive asthmatic subjects and to evaluate the effect of any reductions on symptoms.

METHODS

The homes of 40 HDM-sensitive asthmatic subjects were randomized to receive (1) mechanical ventilation and a high-efficiency vacuum cleaner (HEVC); (2) mechanical ventilation alone; (3) an HEVC alone; and (4) no intervention. Homes and patients were monitored for 12 months. Change in absolute humidity, mite numbers, Der p 1 concentrations, lung function, bronchial hyperresponsiveness, and symptom scores were analyzed.

RESULTS

Homes with mechanical ventilation achieved significantly lower humidity levels than those without (P <.001), with an associated reduction of mite numbers (P <.05) and Der p 1 concentrations (P <.001 ¿in nanograms per gram, P =.006 ¿in milligrams per square meter) in bedroom carpets and some other mite sources in the ventilated areas of the homes. The addition of a vacuum cleaner enhanced this effect. There was a trend for an improvement in histamine PC(20) (P =.085) in the patients whose homes were ventilated.

CONCLUSION

The use of a mechanical ventilation system in suitable homes resulted in some reduction in numbers of HDM and Der p 1 concentrations. The addition of an HEVC slightly enhanced the effect but not sufficiently to see an improvement in symptoms.

A novel sublingual apomorphine treatment for patients with fluctuating Parkinson's disease

We tested a novel preparation of a sublingual apomorphine hydrochloride tablet (APO) in 10 patients with advanced Parkinson's disease complicated by motor fluctuations. After a dose titration, patients took either 40 mg APO three times per day alternating with levodopa doses (eight patients) or six doses of 20 mg APO taken concurrently with levodopa doses (two patients) for 3 months. Assessments included timed tapping and ambulation tests, Unified Parkinson's Disease Rating Scale (UPDRS), and patient diaries. Tapping speed while taking only APO (12 hours after stopping levodopa) was faster than while taking only levodopa (p <0.05). The daily levodopa dose decreased by 32.1% (p <0.01), yet the total "on" time increased from 73.5% +/- 10.2% to 81.5% +/- 7.5% of the day (p <0.01) after starting APO. "On" UPDRS part II scores (p <0.05) and "on" UPDRS part III (motor examination) scores (p <0.05) also improved. Adverse events such as nausea, orthostatic hypotension, and disagreeable taste did not limit the dose of APO in any case. The short-term benefit and tolerability demonstrated in this study warrant further study of this new APO preparation.

Who gets what treatment for obesity? A survey of GPs in Scotland

OBJECTIVE

To describe the types and delivery of obesity treatment currently favoured by General Practitioners (GPs) working in Scotland.

DESIGN

Representative cross-sectional survey using a postal questionnaire which included case stories as stimuli for questions about the GPs' nutrition guidance to overweight female patients.

SUBJECTS

A systematic sample of 1400 general practitioners (GPs) from a total of 3593 GPs working in Scotland in 1997.

RESULTS

From 1363 eligible GPs, 609 returned the full questionnaire and a further 132 took part in a telephone mini-interview. Net response was 54.4% (741/1363). Almost half of the GPs (45.6%) reported that they had read the recent national clinical guideline for integrating obesity prevention with weight management (SIGN 1996). The majority of GPs (89.6%) agreed that nutrition has an important role to play in the management of disease and 82.4% agreed that they can offer healthy eating advice to patients. However, only 34.8% of GPs believed that they had been successful in treating overweight patients. Routinely used treatments involve either a dietitian, practice nurse and/or a commercial slimming group and realistic weight loss was considered one criteria of successful treatment by some GPs. Age, year qualified and location of practice were found to have little influence over variations in GP treatment while weak associations between gender of GP and treatment were found.

CONCLUSIONS

The readership of the clinical guidelines in Scotland has been moderate so far although a multidisciplinary approach to obesity treatment is recognised. Further investigations of any relationships between nutrition education-obesity treatment are needed.

Efficacy and tolerability of a novel sublingual apomorphine preparation in patients with fluctuating Parkinson's disease

We tested a novel preparation of sublingual apomorphine hydrochloride (APO) in 10 patients with advanced Parkinson's disease complicated by motor fluctuations and dyskinesias. After dose titration, patients underwent a blinded comparison of APO versus placebo, and an unblinded comparison of APO versus optimally dosed carbidopa/levodopa using timed tapping and walking paradigms. APO was significantly better than placebo in both measures: Tapping speed was 30.8% faster than with placebo (p < .0005), and ambulation speed was 45.2% faster than with placebo (p < .05). Ambulation speed with APO was also 15.9% faster than that with optimal doses of carbidopa/levodopa (p < .05). The latency to onset of clinical improvement with each APO dose was 10 to 40 minutes, and the duration of effect was 60 to 130 minutes. Adverse events included nausea, orthostatic hypotension, and disagreeable taste in the patient's mouth. Aside from the bitter taste, all other side effects resolved with continued use and did not limit dosing in any case. We feel that the good short-term efficacy and tolerability demonstrated in this study warrant further study of this new preparation, as there are several potential advantages of sublingual administration compared with traditional APO preparations.

Bifurcations of periodic orbits in axisymmetric scalefree potentials

We study orbits in potentials with central cusps, emphasizing the spheroidal equidensity (SED) potentials generated by mass distributions with spheroidal equidensity surfaces. The most prominent bifurcations are those related to 1:1 and 4:3 resonances between radial motions and motions perpendicular to the central plane. We find that 1:1 resonances can cause the thin tube orbit, as well as the equatorial plane orbit, to become unstable. We concentrate on period-tripling bifurcations because they appear to be the least understood. We study them via a class of analytic maps. This study suggests that stable period-three orbits generally arise de novo in stable and unstable pairs via a turning-point bifurcation, and not through a bifurcation from the thin tube at a 120 degree rotation angle. The stable period-three orbits typically have only a short span of existence before becoming unstable to a period-doubling instability through a supercritical pitchfork bifurcation.

Aggressiveness of colon carcinoma in blacks and whites. National Cancer Institute Black/White Cancer Survival Study Group

Black patients with colon cancer in the Black/White Cancer Survival Study were found to have a poorer survival than white patients. More advanced-stage disease at diagnosis was the primary determinant, accounting for 60% of the excess mortality. After adjusting for stage, factors such as poverty, other socioeconomic conditions, and treatment did not further explain the remaining survival deficit. This study examined the aggressiveness of colon tumors in blacks and whites to explore its role in the racial survival differences. Tumor characteristics of 703 cases of newly diagnosed invasive colon adenocarcinoma were centrally evaluated by a gastrointestinal pathologist, blinded in regard to the age, race, and sex of the patients. Blacks were less likely to have poorly differentiated (grade 3) tumors [odds ratio (OR), 0.44; 95% confidence interval, 0.22-0.88] and lymphoid reaction (OR, 0.49; 95% confidence interval, 0.26-0.90) when compared with whites. These black/white (B/W) differences remained statistically significant after adjusting for age, sex, metropolitan area, summary stage, socioeconomic status, body mass index, and health care access and utilization. In addition, blacks were less likely to have high-grade (grade 3) nuclear atypia, mitotic activity, and tubule formation, although these ORs did not reach a statistical significance level of 0.05. Similar B/W differences were observed for patients with advanced disease but not with early stage. Comparison by anatomical subsite showed that blacks had statistically significantly better differentiated tumors for cancers of the proximal and transverse colon but not for the distal. No racial differences were found for blood vessel and lymphatic invasion, necrosis, fibrosis, and mucinous type of histology. The findings, therefore, are the opposite of those hypothesized. After adjusting for stage, more aggressive tumor characteristics do not explain the adverse survival differential in blacks. This suggests that there may be racial differences in environmental exposure, and that the intensity and mode of delivery of carcinogen insult as well as host susceptibility may differ by race and anatomical subsite. Future studies should explore the B/W differences in tumor biology using molecular markers that precede the conventional histological parameters evaluated here.

Amniotic fluid interleukin-10 (IL-10) concentrations during pregnancy and with labor

To determine if amniotic fluid interleukin-10 (IL-10) concentrations are elevated in women with labor, either at term or preterm, and in the setting of infection-associated preterm labor, amniotic fluid samples were collected from women: (1) at term, not in labor (n = 42); at term, in labor (n = 56), preterm contractions, undelivered within 1 week (n = 22), and preterm labor, delivered within 1 week (n = 31). IL-10 concentrations were assayed in each sample via ELISA (Pharmingen, San Diego, CA). In a subsequent analysis, 8 women with preterm labor associated with chorioamnionitis were matched for gestational age with women experiencing preterm contractions (undelivered within 7 days) and preterm labor (delivered within 7 days) and amniotic fluid IL-10 concentrations compared. Approximately 40-70% of amniotic fluid samples obtained from women in each group had detectable IL-10. However, there were no significant differences in amniotic fluid IL-10 concentrations among the patients. While 1 of 8 patients with chorioamnionitis had amniotic fluid IL-10 concentrations greater than 300 pg/ml, there were no statistically significant differences among the matched samples. Amniotic fluid IL-10 concentrations were not elevated in women with term labor, preterm labor, or chorioamnionitis. This finding contrasts with the elevated concentrations of pro-inflammatory cytokines and chemokines such as interleukin-1, tumor necrosis factor-alpha, IL-6, IL-8, MIP-1 alpha, and GRO alpha reported in previous studies. Because we did not detect elevations of the key anti-inflammatory cytokine IL-10 in amniotic fluid of women with infection-associated preterm labor, we suggest that anti-inflammatory processes in this setting may be attenuated.