Does provider prevention orientation influence female patients' preventive practices?

BACKGROUND

Health care provider encouragement for particular preventive behaviors is associated with patient adherence, but it is unclear whether a provider's overall prevention approach influences whether patients engage in recommended preventive measures. We examined whether older women who perceived that their health care provider encouraged a particular preventive behavior were more likely to follow that recommendation if they also perceived that the provider encouraged other preventive behaviors.

DATA AND METHODS

The sample included 1119 women aged 50 to 79 enrolled in a health maintenance organization. We examined associations of reported provider encouragement for post-menopausal hormone use, physical activity, fecal occult blood testing (FOBT), and flexible sigmoidoscopy with one another and with adherence to these measures according to recommended guidelines.

RESULTS

Among women reporting provider encouragement for physical activity, the likelihood of reporting regular physical activity was greater among women who reported encouragement for one other (odds ratio [OR]=1.99; confidence interval [CI]=1.35 to 2.95) and at least two other (OR=2. 38; 95% CI=1.62 to 3.48) preventive measures compared with women who reported no other encouragement. The likelihood of reporting adequate counseling for post-menopausal hormone use was greater among women reporting encouragement for at least two other preventive measures compared with those reporting no other encouragement. The likelihood of having had an FOBT or sigmoidoscopic examination was related to encouragement for those procedures, but not with greater encouragement for other preventive measures.

CONCLUSIONS

Patient perceptions of a provider's overall preventive practice approach may influence whether patients engage in recommended preventive practices, particularly for lifestyle factors.

A novel transcriptional repression domain mediates p21(WAF1/CIP1) induction of p300 transactivation

The transcriptional coactivators p300 and CREB binding protein (CBP) are important regulators of the cell cycle, differentiation, and tumorigenesis. Both p300 and CBP are targeted by viral oncoproteins, are mutated in certain forms of cancer, are phosphorylated in a cell cycle-dependent manner, interact with transcription factors such as p53 and E2F, and can be found complexed with cyclinE-Cdk2 in vivo. Moreover, p300-deficient cells show defects in proliferation. Here we demonstrate that transcriptional activation by both p300 and CBP is stimulated by coexpression of the cyclin-dependent kinase inhibitor p21(WAF/CIP1). Significantly this stimulation is independent of both the inherent histone acetyltransferase (HAT) activity of p300 and CBP and of the previously reported carboxyl-terminal binding site for cyclinE-Cdk2. Rather, we describe a previously uncharacterized transcriptional repression domain (CRD1) within p300. p300 transactivation is stimulated through derepression of CRD1 by p21. Significantly p21 regulation of CRD1 is dependent on the nature of the core promoter. We suggest that CRD1 provides a novel mechanism through which p300 and CBP can switch activities between the promoters of genes that stimulate growth and those that enhance cell cycle arrest.

Video-assisted evacuation of empyema is the preferred procedure for management of pleural space infections

BACKGROUND

Empyema remains a cause of morbidity and mortality. Thoracoscopy has proved its versatility in the management of pleural space disorders. The suitability of video-assisted thoracic surgery (VATS) for decortication in the management of the fibrotic stage of empyema is unclear.

METHODS

VATS evacuation of empyema and decortication was performed on seventeen patients presenting with pleural space infections. A retrospective review was performed and constitutes the basis of this report.

RESULTS

VATS evacuation of empyema and decortication was successfully performed in 13 of 17 patients. Blood loss was 325 +/- 331 cc. Mean hospital stay was 18 +/- 10 days. Postoperative hospitalization was 11 +/- 7 days. Chest tubes remained in place for 7 +/- 3 days. There were no operative mortalities.

CONCLUSIONS

Video-assisted evacuation of empyema and decortication is an effective modality in the management of the exudative and fibrinopurulent stages of empyema. An organized empyema should be approached thoracoscopically, but may require open decortication.

Adapting charting by exception to the perianesthesia setting

Many acute care settings are experiencing a shift toward ambulatory patient care and are being pressured to decrease patient length of stay. Meanwhile, there is increased pressure to remain patient centered and to become more customer oriented. This article describes how the authors adapted charting-by-exception principles to develop a single ambulatory surgery nursing record for use from admission to discharge. The authors' goals were to condense documentation, to decrease time spent on documentation, and to diminish the variance in quality of documentation. This article also details how the new nursing record measures achievement of patient outcomes, with a focus of promoting street readiness.

Prevalence of and factors associated with hormone replacement therapy counseling: results from the 1994 National Health Interview Survey

OBJECTIVES

This study estimated the prevalence of and the factors associated with hormone replacement therapy (HRT) counseling.

METHODS

We analyzed the responses of 3170 women, aged 40 to 60 years, from the 1994 National Health Interview Survey.

RESULTS

The prevalence of HRT counseling was 43.6%. Women were more likely to report having received HRT counseling if they were White, older, more educated, had had a hysterectomy, had experienced menopausal symptoms, and had a regular source of care.

CONCLUSIONS

More attention should be directed at counseling non-White women and women with less formal education. Reducing the barriers to having a regular source of care appears to increase the likelihood of receiving HRT counseling.

Comparison of self-reported fecal occult blood testing with automated laboratory records among older women in a health maintenance organization

Screening guidelines for colorectal cancer recommend annual fecal occult blood (FOB) testing for adults aged 50 years and older. Self-reported history of screening is frequently the sole source of data available to researchers and clinicians. This study validated FOB testing in a sample of 1,021 older women. Testing rates based on self-reported data exceeded rates based on computerized laboratory records by 13.9%. Agreement was moderate (kappa = 0.52; 95% confidence interval 0.47, 0.58). Sensitivity was 0.92 and specificity 0.58. Logistic regression analysis showed that older age and physician encouragement for FOB testing were associated with accurate recall (p<0.05). Self-report is the most commonly available information about the occurrence and timing of cancer detection procedures. These data suggest cautious use of self-reported screening by FOB for clinical decision making and for research and surveillance.

Diabetes education needs of family members caring for American Indian elders

PURPOSE

This qualitative study investigated diabetes care management among family members of American Indian elders with self-care limitations. Focus groups were used to examine the reasons for and content of diabetes care management, the challenges faced, and the support services needed.

METHODS

Five focus groups were conducted with family caregivers from six tribes. Caregivers' responses related to care management were identified and categorized into themes.

RESULTS

Participants reported that they provided assistance with a wide range of diabetes care tasks (e.g., skin and wound care, in-home dialysis) depending on the elder's level of impairment. Caregivers described three major challenges related to diabetes care management: (1) anxiety about in-home care, (2) coping with psychosocial issues, and (3) decision making and communication problems with other family members. They emphasized the importance of developing a care routine for successful diabetes management.

CONCLUSIONS

Based on these findings, we suggest areas where diabetes educators can assist American Indian family caregivers in meeting the needs of frail elders in the home.

Perceived barriers and recommendations concerning hormone replacement therapy counseling among primary care providers

OBJECTIVE

To increase our understanding of the factors that impede or promote counseling about hormone replacement therapy, we asked clinicians to provide information concerning barriers and strategies to promote counseling.

DESIGN

We asked clinicians to consider two different scenarios: (1) what they do in they current practice and (2) what they would do if their health care systems implemented the United States Preventive Services Task Force recommendation regarding hormone replacement therapy counseling. A total of 49 of 50 invited clinicians participated in one of six focus group interviews (three women's groups and three men's groups). Our analysis consisted of four steps: (1) identifying segments and classifying them into themes, (2) categorizing themes into topic areas, (3) establishing a final consensus of themes and topics, and (4) ascertaining similarities and contrasts among groups. Transcripts of sessions were analyzed across groups for themes using a text-based analysis system. Conceptualization of themes was derived using a system model of preventive care. Interrater agreement before consensus was good: Kappa (kappa) ranged from 0.70 to 1.00.

RESULTS

For current practice, identified barriers included lack of information about risks and benefits, unique challenges of counseling, and lack of resources to conduct counseling. The major strategies suggested were to develop and distribute patient education materials. Discussions about barriers to implementing the United States Task Force recommendation focused on lack of information and resources.

CONCLUSIONS

Suggested strategies were multiple, involving individual-, relationship-, and system-level interventions. We expect the strategies identified to be supportive of future efforts to promote counseling for hormone replacement therapy.

Body size and body shape: perceptions of black women with diabetes

PURPOSE

This qualitative study was conducted to explore perceptions of body size and shape in a group of black women with Type 2 diabetes.

METHODS

Thirty-three black women with Type 2 diabetes participated in one of three focus groups to discuss perceptions about body size and body shape. Transcriptions of the discussion were analyzed for themes of participants' perceptions about their bodies, their ideas about body size and body shape, and personal and environmental influences on their preferences about size and shape.

RESULTS

Participants preferred a middle-to-small body size but indicated that a middle-to-large body size was healthier. They also said that a large body size did result in some untoward social consequences. Participants preferred a pear-shaped body (a figure without abdominal adiposity). The three major influences on body image perceptions were children, parents, and the media.

CONCLUSIONS

With these findings in mind, diabetes education programs that are geared for black women may benefit from the inclusion of key family members. Additionally, the importance of body image perceptions should be recognized in the design and implementation of weight-related diabetes education programs.

The high-resolution crystal structure of the molybdate-dependent transcriptional regulator (ModE) from Escherichia coli: a novel combination of domain folds

The molybdate-dependent transcriptional regulator (ModE) from Escherichia coli functions as a sensor of molybdate concentration and a regulator for transcription of operons involved in the uptake and utilization of the essential element, molybdenum. We have determined the structure of ModE using multi-wavelength anomalous dispersion. Selenomethionyl and native ModE models are refined to 1. 75 and 2.1 A, respectively and describe the architecture and structural detail of a complete transcriptional regulator. ModE is a homodimer and each subunit comprises N- and C-terminal domains. The N-terminal domain carries a winged helix-turn-helix motif for binding to DNA and is primarily responsible for ModE dimerization. The C-terminal domain contains the molybdate-binding site and residues implicated in binding the oxyanion are identified. This domain is divided into sub-domains a and b which have similar folds, although the organization of secondary structure elements varies. The sub-domain fold is related to the oligomer binding-fold and similar to that of the subunits of several toxins which are involved in extensive protein-protein interactions. This suggests a role for the C-terminal domain in the formation of the ModE-protein-DNA complexes necessary to regulate transcription. Modelling of ModE interacting with DNA suggests that a large distortion of DNA is not necessary for complex formation.

Ischemic venous thrombosis: its hidden agenda

Ischemic venous thrombosis (IVT) is the most severe form of venous thrombosis. The purpose of this article is to describe this rare clinical condition and to review 14 cases of IVT that involve the lower extremities, emphasizing its association with cancer. Between September 1995 and November 1997, 9 women and 5 men, ranging in age from 37 to 75 years (mean 58.6 years), were treated for IVT. Malignancy was the most prevalent risk factor, occurring in 86% (12 of 14) of the patients, and was not diagnosed in 58% (7 of 12) of the cases until after IVT occurred. A postoperative state and a previous history of thrombophlebitis were the next most common risk factors and were equal in frequency (39%). Venous gangrene was present in 79% (11 of 14) of the cases, resulting in 11 amputations in 9 patients. The mortality rate was 71% (10 of 14) of the patients, with 40% of the deaths occurring within 2 months of the diagnosis of IVT. These data support the belief that a strong association exists between IVT and cancer and that IVT may precede the diagnosis of cancer, representing a potential marker for an undiagnosed malignancy. Furthermore, the combination of extensive venous gangrene and disseminated cancer has a poor prognosis.

Implementing preventive services: to what extent can we change provider performance in ambulatory care? A review of the screening, immunization, and counseling literature

Strategies to improve the delivery of preventive care often consist of office-based interventions, which are designed to modify provider behaviors or practice patterns. We report on a meta-analysis of 117 behavioral outcomes extracted from 43 studies. Meta-analytic techniques were used to express the results in a common metric, which allowed quantitative comparisons across outcomes. Studies were examined by domains of preventive care (screening, immunization, and counseling) and divided into two groups based on unit of analysis (provider or patient categories). The mean effect size reflects the difference in proportion of physicians providing the targeted behavior between the experimental and comparison groups. In the provider category, the weighted mean effect size for screening was .14, for immunization was .18, and for counseling was .28. In the patient category, the weighted means for screening and immunization were .12 and .15, respectively, but were smaller for the counseling (.08). Because tests for homogeneity of effect sizes were rejected in the patient category, caution in interpreting mean effect sizes is warranted because of variability across individual values. In summary, office-based interventions were found to have positive effects on providers' adherence to preventive recommendations. We discuss the methodological issues and needs for future work to enhance the delivery of preventive services.

Two crystal forms of ModE, the molybdate-dependent transcriptional regulator from Escherichia coli

The molybdenum-responsive ModE regulatory protein from Escherichia coli has been purified and used in crystallization trials. Two crystal forms have been observed. Form I is tetragonal, P41212 (or enantiomorph), with a = b = 72.3, c = 246.2 A and diffracts to medium resolution. Form II is orthorhombic, P21212, with a = 82.8, b = 127.9, c = 64.0 A and diffraction has been observed beyond 2.8 A resolution. Structural analysis, in combination with ongoing biochemical characterization, will assist the elucidation of the structure-activity relationship in regulating the uptake of molybdate in bacteria.

The physician's role in women's decision making about hormone replacement therapy

OBJECTIVE

To ascertain the sources of information women use when making decisions about hormone replacement therapy (HRT).

METHODS

A cross-sectional, population-based computer-assisted telephone survey of 1082 randomly selected women aged 50-80 years (80.3% response rate) was conducted at Group Health Cooperative of Puget Sound, a large staff-model health maintenance organization in Washington state.

RESULTS

Overall, 460 participants (42.5%) were current HRT users, 226 (20.9%) were past users, and 396 (36.6%) were never users. Discussions with physicians dominated as the major source of information used in decision making by current (83.4%) and past (65.5%) users, but were less often cited by never users (44.4%); printed material was used by 44.5% of women. Although 72.1% of current users reported that the amount of information received from their physician about the benefits of HRT was about right, only 48.2% of past users and 33.6% of never users shared this view (P < .001 current versus never), and 13.3% of current users, 32.6% of past users and 58% of never users reported receiving no information from their physician about HRT's benefits.

CONCLUSION

Hormone replacement therapy use is strongly related to interactions between women and their physicians. Many women use written materials to make decisions about HRT. A large proportion of women feel inadequately informed about HRT's risks and benefits. Much work remains to be accomplished toward meeting the goal of the US Preventive Services Task Force that all perimenopausal and postmenopausal women be counseled about the potential benefits and risks of HRT.

Role dimensions of patient and physician in medical interviews: relationship to patients' satisfaction

We applied the Verbal Response Mode coding system to 80 medical interviews to characterize role dimensions of patient and physician and to assess the relation between physicians' role dimensions and patients' satisfaction. Role dimensions conformed closely to prior work. Physicians' acquiescence was positively correlated with satisfaction. This study suggests that the role dimensions generated by the Verbal Response Mode taxonomy are a useful measure of patients' and physicians' relationships.

Participation in a diabetes education and care program: experience from the diabetes care for older adults project

There is very little reported information concerning the participation of older adults in diabetes education and care programs, factors related to their attendance, and the influence of attendance on program outcomes. In this study, which was part of a larger study of insulin therapy, subjects (> or = 65 years old) assigned to the intensive management group (n = 53) were provided with educational sessions during the 18-month study period. Data for this group were examined to determine factors that influenced enrollment and attendance. Attendance rates for individual participants averaged 72% during the first 6 months and 68% during the subsequent 12 months. Demographic factors, baseline knowledge test scores, and baseline glycosylated hemoglobin levels did not significantly influence participation. Greater distance from the clinic and shorter time using insulin were significantly related (P = .05) to attendance. Perceived benefits of the program included diabetes education (45%), glucose control (23%), and interacting with others who have diabetes (23%).

Zinc acetate treatment in Wilson's disease

OBJECTIVE

To briefly review the pathophysiology and diagnosis of Wilson's disease, and to evaluate the pharmacology, pharmacokinetics, clinical utility, adverse effects, dosing regimens, and pharmacoeconomics of zinc acetate therapy in Wilson's disease.

DATA SOURCES

A MEDLINE search (December 1966-December 1996) of the English-language literature using the terms zinc and Wilson's disease was conducted to identify pertinent clinical trials, review articles, and case reports. Additional articles were selected from bibliographies of the reviewed literature.

STUDY SELECTION AND DATA EXTRACTION

Due to the rarity of the disease, all articles were considered for possible inclusion in this review. Single case reports are referenced, but were not selected for evaluation.

DATA SYNTHESIS

Wilson's disease, an inherited disorder of copper metabolism, is fatal if untreated. The chelating drugs penicillamine and trientine have been the mainstay of therapy; however, adverse reactions of chelators often interfere with successful treatment. Recently, zinc acetate was approved in the US for maintenance therapy in patients initially treated with a chelating agent. Although studies evaluating large populations are lacking zinc therapy has demonstrated exceptional safety and efficacy over a period of 40 years. Zinc acetate can be used during pregnancy and for the treatment of presymptomatic patients, although data do not support its use as monotherapy in patients with acute neurologic or hepatic disease.

CONCLUSIONS

Zinc acetate is an effective maintenance therapy for patients with Wilson's disease. Negligible toxicity, compared with that of previously approved treatments, is a major advantage.

Leukocyte activation and flow behavior in rat skeletal muscle in sepsis

In animal models of endotoxemia, sepsis is associated with the accumulation of leukocytes and altered microvascular perfusion. In order to test the hypothesis that bacterial sepsis upregulates leukocyte-endothelial adhesion, we used intravital microscopy to examine the flow behavior of leukocytes in the postcapillary venules (PCV) of rats made septic by cecal ligation and perforation (CLP). Animals were randomized to CLP or sham study groups and studied 6 h, 24 h, or 48 h later. In postcapillary venules of the extensor digitorum longus muscle, we found that: (1) over the course of the study, leukocyte adhesion and extravasation increased in both experimental groups (analysis of variance [ANOVA], significant time effect: adhesion, p < 0.001; extravasation, p < 0.05); (2) leukocyte adhesion was decreased by CLP treatment (ANOVA, sepsis effect, p = 0.05), particularly after 24 to 48 h of sepsis (ANOVA, sepsis x time interaction, p < 0.05); and (3) the reduction in leukocyte adhesion in CLP animals was associated with a decrease in leukocyte extravasation (ANOVA, sepsis effect, p < 0.01). After correction for the reduction in systemic leukocyte count associated with CLP, the effect of sepsis on leukocyte adhesion and extravasation no longer reached statistical significance. These findings suggest that chronic (6 to 48 h) bacterial sepsis does not upregulate leukocyte adhesion in a manner similar to that seen in models of acute endotoxemia. These data suggest that the increased microcirculatory flow heterogeneity seen in this and other models of bacterial sepsis may not be explained by leukocyte entrapment in postcapillary venules.

Women's beliefs and decisions about hormone replacement therapy

To examine preventive health practices in older women, we conducted computer-assisted telephone interviews with 1082 women aged 50-80 who were enrollees of Group Health Cooperative of Puget Sound (June-November 1995; 80.3% response rate). We sought to describe the women's reasons for initiating, discontinuing, or not initiating hormone replacement therapy (HRT). HRT use was categorized as current (42.5%), past (20.9%), or never (36.6%) based on the interviews. The reasons most frequently cited by current users for initiating HRT were menopausal symptoms (47.3%), osteoporosis prevention (32.4%), and physician advice (30.3%). The most frequently cited reasons for quitting HRT were side effects (26.6%), physician's advice (22.9%), fear of cancer (15.4%), and not wanting menstrual periods or bleeding (15.2%). Of past users, 53.8% reported stopping HRT on their own, and 46.2% did so at their physician's advice. The reasons most commonly cited by never users for not initiating HRT were that hormones were not needed (49.9%) and that menopause is a natural event (17.9%). Among never users, 33.1% reported considering HRT, only 46.6% discussing it with their provider, and 5.0% being given an HRT prescription they did not fill. Many women made decisions about HRT independent of interactions with health care providers. Better understanding of the beliefs and decisions that influence women's choice to use or not use HRT is needed to develop more effective counseling strategies.

The action of Taiwan cobra venom on methionine enkephalin: a useful assay for oligopeptidase content

The pentapeptide methionine enkephalin is readily hydrolysed by the oligopeptidase activity contained in Taiwan cobra (Naja naja atra) venom. It is a significantly better substrate than the peptides previously used to identify the presence of this enzyme, but it retains many of the sequence characteristics shared by these other peptides. Analysis of the manner of hydrolysis by means of high-performance liquid chromatography and electrospray mass spectrometry revealed the simultaneous actions of at least two types of oligopeptidase on the neuropeptide, producing two routes of initial breakdown. By one route, an endopeptidase cleaved the Gly-Phe bond of enkephalin first to release Tyr-Gly-Gly and Phe-Met. By the other route, an aminopeptidase was able to release Tyr and Gly-Gly-Phe-Met by cleaving the Tyr-Gly bond first. From amongst the various peptide fragments produced, Tyr-Gly-Gly was subject to immediate aminopeptidase action to release Tyr and Gly-Gly. The free Tyr produced in these reactions was in turn quickly transformed by the L-amino acid oxidase in the venom. The kinetic qualities of the enkephalin hydrolysis, and the conversions of the fragments Tyr-Gly-Gly and Tyr, were measured. Methionine enkephalin has potential as a routine assay for venom oligopeptidases, either in testing the venoms from other species or in attempts to purify these enzymes. Moreover, the ease of hydrolysis of this bioactive peptide, coupled with the revelation of the other enzymic steps involving the fragments generated, may provide important clues as to the possible role of the oligopeptidases (and L-amino acid oxidase) in the venom.

Characterisation of the molybdenum-responsive ModE regulatory protein and its binding to the promoter region of the modABCD (molybdenum transport) operon of Escherichia coli

Molybdenum-dependent repression of transcription of the Escherichia coli modABCD operon, which encodes the high-affinity molybdate transporter, is mediated by the ModE protein. This regulatory protein was purified as an N-terminal His6-tagged derivative and characterised both with and without the N-terminal oligohistidine extension. Equilibrium centrifugation showed that ModE is at least a 57-kDa homodimer. Circular dichroism spectroscopy indicated that when molybdate or tungstate bind to ModE there is little change in its alpha-helical content, but a major change in the environment of tryptophan and tyrosine residues occurs. Addition of molybdate or tungstate to the protein results in almost 50% quenching of the fluorescence attributed to tryptophan. Titration of fluorescence quenching showed that two molecules of molybdenum bind to each dimer of ModE with a Kd of 0.8 microM. DNA mobility-shift assays showed that ModE requires molybdenum, or tungstate, to bind with high affinity (approximate Kd of 30 nM ModE) to the modABCD promoter region. In accord with ModE's role as a molybdenum-dependent transcriptional repressor, DNase I footprinting experiments showed that the ModE-molybdenum complex binds to a single 31-bp region around the transcription start of the modABCD promoter. This region contains a 6-base palindromic sequence CGTTAT-N12-ATAACG.