Total quality management in the delivery of public health services: a focus on North Carolina WIC programs

Principles of quality improvement have been successfully implemented in the for-profit sector of the United States economy. The purpose of this study is to test the use of quality improvement strategies including development of leadership skills, a focus on internal quality, ongoing training and staff development, and efficient use of resources in the delivery of services in the public sector. The emphasis of this study is strategies for improving the delivery of nutrition education and supplemental foods to high-risk women, infants, and children through a federally funded program called WIC.

Genetically modified ruminal bacteria protect sheep from fluoroacetate poisoning

Four strains of Butyrivibrio fibrisolvens, transformed with a gene encoding fluoroacetate dehalogenase, maintained a combined population of 10(6) to 10(7) cells ml-1 in the rumens of test sheep. Five inoculated sheep showed markedly reduced toxicological symptoms after fluoroacetate poisoning when behavioral, physiological, and histological effects were compared with those of five uninoculated control sheep.

A framework for practice with women survivors of childhood sexual abuse

Women who are victims of prolonged childhood sexual abuse involving penetration, and physical and emotional abuse are more likely to develop major psychiatric distress. These survivors may use defence mechanisms to block out the past, and their distress may only come to the attention of health professionals at times of crisis. However, health practitioners do not routinely assess for a history of sexual abuse. This state of affairs is compounded by limited research on survivors of childhood sexual abuse and a readiness to label them with adult psychopathology. Such labels result from a failure to listen and from a willingness to blame, processes replicated from the dominant culture.

Aqueous solubilization of transmembrane peptide sequences with retention of membrane insertion and function

We recently reported that the peptide C-K4-M2GlyR mimics the action of chloride channels when incorporated into the apical membrane of cultured renal epithelial monolayers. C-K4-M2GlyR is one of a series of peptides that were prepared by the addition of lysine residues to the N- or C-terminus of the M2 transmembrane sequence of the brain glycine receptor. This study addresses how such modifications affect physical properties such as aqueous solubility, aggregation, and secondary structure, as well as the ability of the modified peptides to form channels in epithelial monolayers. A graded improvement in solubility with a concomitant decrease in aggregation in aqueous media was observed for the M2GlyR transmembrane sequences. Increases in short-circuit current (I(SC)) of epithelial monolayers were observed after treatment with some but not all of the peptides. The bioactivity was higher for the more soluble, less aggregated M2GlyR peptides. As described in our previous communication, sensitivity of channel activity to diphenylamine-2-carboxylate, a chloride channel blocker, and bumetanide, an inhibitor of the Na/K/2Cl cotransporter, was used to assess changes in chloride selectivity for the different assembled channel-forming peptides. The unmodified M2GlyR sequence and the modified peptides with less positive charge are more sensitive to these agents than are the more highly charged forms. This study shows that relatively insoluble transmembrane sequences can be modified such that they are easier to purify and deliver in the absence of organic solvents with retention of membrane association, insertion, and assembly.

From the Journals

INNOVATIVE TREATMENT FOR DIABETIC FOOT ULCERATION A MULTIDISCIPLINARY WOUND ASSESSMENT TOOL LOW-DOSE CYCLOSPORIN IN THE TREATMENT OF PYODERMA GANGRENOSUM INTERPRETING REPORTS OF COMMERCIAL DRUG TRIALS.

A synthetic peptide derived from glycine-gated Cl- channel induces transepithelial Cl- and fluid secretion

M2GlyR is a synthetic 23-amino acid peptide that mimics the second membrane-spanning region of the alpha-subunit of the postsynaptic glycine receptor. This peptide has been shown to form an anion-selective channel in phospholipid bilayers. We have investigated the possibility that the peptide may incorporate into the apical membrane of secretory epithelia and induce the secretion of Cl- and water. We improved the solubility of this peptide by adding four lysine residues to the carboxy terminus, C-K4-M2GlyR, and assayed its channel-forming activity using a subculture of Madin-Darby canine kidney (MDCK) cells. The addition of 100 microM C-K4-M2GlyR to the apical surface of MDCK monolayers significantly increased short-circuit current (Ise), hyperpolarized transepithelial potential difference, and induced fluid secretion. The increase in Ise was inhibited by 100 microM bumetanide and by Cl- channel inhibitors. The effectiveness of the channel blockers followed the sequence niflumic acid > or = 5-nitro-2-(3-phenylpropylamino)benzoate > diphenylamine-2-carboxylate (DPC) > glibenclamide. The effect of the peptide was not inhibited by 4.4'-diisothiocyanostilbene-2-2'-disulfonic acid. Removing Cl from the bathing solutions also inhibited the effect of the peptide. The Cl- efflux pathway induced by C-K4-M2GlyR differs from the native pathway activated by the adenosine 3',5'-cyclic monophosphate (cAMP) agonist, forskolin. First, intracellular cAMP levels were unaffected. Second, the concentration of DPC required to inhibit the effect of the peptide was much lower than that needed to block the forskolin response (100 microM vs. 3 mM). These results support the hypothesis that the synthetic peptide C-K4-M2GlyR can from Cl -selective channels in the apical membrane of secretory epithelial cells and can induce sustained transepithelial secretion of Cl- and fluid.

Multilineage differentiation of cloned HRA-19 cells in serum-free medium: a model of human colorectal epithelial differentiation

Colorectal epithelium is composed of polarised absorptive enterocytes, mucus-producing goblet cells and enteroendocrine cells. All these cell lineages are thought to arise from multipotential stem cells located near the base of the crypt, but the mechanisms which control differentiation and commitment of cells to a particular lineage are poorly understood. We have used the human rectal adenocarcinoma cell line, HRA-19, to investigate the regulation of expression of lineage-specific markers. HRA-19 cells have multipotential characteristics, forming absorptive, mucous and endocrine cells when grown as xenografts. However, HRA-19 cells grown in vitro in culture medium containing 10% foetal calf serum show negligible expression of the differentiated phenotypes observed in vivo. These findings initially suggested that the absence of positive stimuli from extracellular matrix, stromal cells and/or soluble factors present in vivo resulted in the lack of differentiation in vitro. The subsequent demonstration of a marked inhibitory effect of foetal calf serum on differentiation provided an alternative explanation for the differences between in vivo and in vitro differentiation. In addition, the inhibition of differentiation differed widely between batches of foetal calf serum and limited the usefulness of the system for studying the regulation of differentiation. This manuscript describes the development of chemically defined culture conditions (Dulbecco's Eagles medium supplemented with insulin, transferrin and ascorbic acid) which reproducibly induced the multilineage differentiation of HRA-19 cells into absorptive, mucous and endocrine cells. Morphological characteristics and the expression of lineage-specific markers, as determined by immunocytochemistry, identified absorptive, goblet and endocrine cells in HRA-19 monolayers grown in this serum-free medium. Differentiation of cloned HRA-19 cells in to the three cell lineages proceeds in the absence of stromal cells and without exogenous extracellular matrix, although these factors may subsequently be shown to modulate the rate of cell differentiation. These chemically defined culture conditions will facilitate the study of differentiation in the HRA-19 cell line in the absence of the complex mixture of growth factors, hormones and differentiation inhibitory factor(s) present in foetal calf serum.

Morphological analysis of gastro-esophageal diseases by molecular cell techniques

The molecular cell sciences have had a great impact in the analysis of the genetic and epigenetic events of esophageal and gastric tumorigenesis. In other regions of the alimentary tract such as the colon, the serial identification of the molecular events in the corresponding morphological lesions is perhaps most advanced. This is, in part, due to the relative ease of the histological characterisation of the premalignant lesions. In this regard the analysis of morphological and molecular adaptation in the alimentary tract is inextricable. This review aims, therefore, to judiciously assess the relative applications of contemporary techniques in investigative histopathology.

Organisation and gel contraction by human colonic carcinoma (HCA-7) sublines grown in 3-dimensional collagen gel

The role of cell-matrix interactions in controlling phenotypic heterogeneity in human colonic carcinoma sublines has been investigated. Four cell lines (colony 1, colony 3, colony 6 and colony 30) previously isolated from a single human colonic carcinoma cell line, HCA-7, were grown in 3-dimensional collagen gels. In collagen, the growth of the 4 sublines ranged from well-organised glandular structures (colony 30) to elongated branching structures (colony 3). The capability of cells to organise into glandular structures in collagen correlated with the degree of differentiation observed in their xenografts. Certain sublines, most notably colony 3, were able to contract the collagen gel. Gel contraction could be partially inhibited by a function-blocking antibody directed to the alpha 2 integrin chain but not by an antibody directed to the alpha 3 integrin chain demonstrating a role for alpha 2 integrin in the contraction process. In addition, colony 3 cultures treated with the function-blocking alpha 2 antibody formed more compact structures with limited outgrowth, suggesting a role for alpha 2 integrin in cell migration. Gel contraction and cell migration in collagen gel was largely restricted to 1 subline, colony 3. The subsequent demonstration that alpha 2 integrin is involved in both of these processes suggests that integrin expression and function has a role in generating the phenotypic heterogeneity exhibited by these cell lines.

Dietary calcium intake in 18-year-old women: comparison with recommended daily intake and dietary energy intake

Average dietary calcium intake and energy intake of 113 18-year-old university students in Western Australia was examined. Four-day, weighted diet records, including 1 weekend day, were completed by the subjects. A large proportion of the students (68%) had an average daily calcium consumption below the 800 mg recommended by the National Health and Medical Research Council of Australia. A strong positive association was also found between dietary calcium and dietary energy intakes. Many young women on self-imposed energy reduction diets are at risk of a dietary calcium intake deficit at a time when it should be enhanced. These findings are significant for nursing practice as they indicate the need for further health education concerning the importance of dietary calcium in young women.

Endocrine and mucous differentiation by a cloned human rectal adenocarcinoma cell line (HRA-19) in vitro: inhibition by TGF-beta 1

Colorectal epithelium is composed of absorptive, mucous and endocrine cells, all of which are considered to arise from a common stem cell located in the crypt base. However, the factors controlling the commitment to differentiate are poorly understood. This is partly due to the lack of in vitro model systems for the study of differentiation in colorectal epithelium. The HRA-19 cell line, established from a human rectal adenocarcinoma, has been shown to have multipotential characteristics with cloned HRA-19 cells able to differentiate into absorptive, mucous and endocrine cells when grown as xenografts. The lack of such differentiated cells in HRA-19 monolayers in vitro suggests that differentiation is controlled by extracellular matrix, stromal cells and/or soluble factors. Such observations show that differentiation in HRA-19 cells can be controlled by extrinsic factors and therefore provide a model system for studying control of differentiation in colorectal epithelium. Unfortunately, the restriction of differentiation to xenografts of the cell line limits the degree to which this differentiation can be manipulated. In this study, the possibility that HRA-19 cells could be induced to differentiate in vitro under appropriate conditions has been investigated. Endocrine and mucous cells were identified by immunocytochemistry with differentiation-related antibodies and histology of monolayers. Preconfluent HRA-19 cells grown in 10% foetal calf serum formed a well polarised monolayer with apical tight junctions and sparse microvilli, but cells with mucous or endocrine phenotypes were only very occasionally observed. However, endocrine and mucous cells could reproducibly be demonstrated in postconfluent monolayers grown in 1% foetal calf serum.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous caudal anesthesia for inguinal hernia repair in former preterm infants

STUDY OBJECTIVE

To determine the feasibility of continuous caudal anesthesia with 2-chloroprocaine in conscious former preterm infants undergoing inguinal hernia repair.

DESIGN

Prospective study.

SETTING

University-affiliated children's hospital.

PATIENTS

Ten former preterm infants, ASA physical status II and III, who were 35 to 49.5 weeks postconceptional age at the time of surgery.

INTERVENTIONS

Caudal anesthesia was administered via an indwelling catheter using a loading dose of 1 ml/kg (30 mg/kg) of 3% 2-chloroprocaine, followed by incremental doses of 0.3 ml/kg (9 mg/kg) to achieve a level of T4 to T2. The block was maintained by a minimum infusion rate of 30 mg/kg/hr (1 ml/kg/hr) of the same local anesthetic solution.

MEASUREMENTS AND MAIN RESULTS

The mean cumulative dose of 2-chloroprocaine was 2.8 +/- 1.0 ml/kg/hr (84 +/- 30 mg/kg/hr) infused over a mean duration of 95 +/- 35 minutes. Serum cholinesterase concentration and plasma 2-chloroprocaine concentration were measured in five infants.

CONCLUSIONS

Three percent 2-chloroprocaine can be used effectively for continuous caudal anesthesia in conscious, former preterm infants for inguinal hernia and penoscrotal surgical procedures lasting 85 to 170 minutes.

Bupivacaine versus bupivacaine plus fentanyl for epidural analgesia: effect on maternal satisfaction

OBJECTIVE

To compare a combination of epidural fentanyl and bupivacaine with bupivacaine alone for epidural analgesia in labour and to evaluate factors in addition to analgesia that may influence maternal satisfaction.

DESIGN

A prospective randomised pilot study.

SETTING

Birmingham Maternity Hospital.

SUBJECTS

85 primiparous women who requested epidural analgesia in labour and their babies.

INTERVENTIONS

Group 1 mothers were treated with bupivacaine conventionally, group 2 mothers with bupivacaine and fentanyl in a more complex way designed to provide satisfactory analgesia but with less troublesome side effects.

MAIN OUTCOME MEASURES

Overall maternal satisfaction, maternal perception of epidural analgesia and its side effects, and aspects of mothers' psychological states during labour, quantified using 100 mm visual linear analogue scales; the frequency of normal and operative deliveries; and measurements of neonatal wellbeing.

RESULTS

Satisfaction was higher in group 2 mothers (median group difference +3 mm, 95% confidence interval +1 to +5, p = 0.012): this was associated with more normal deliveries (difference between proportions 0.23, 95% confidence interval +0.03 to +0.42); greater self control (median group difference -7 mm, -17 to -2, p = 0.003); and reduced unpleasantness of motor blockade (-10 mm, -19 to -5, p less than 0.001), sensory blockade (-5 mm, -11 to -2, p = 0.002) and shivering (-5 mm, -18 to 0, p = 0.046) at the expense of mild itching (0 mm, 0 to 0, p less than 0.001). Group 1 mothers found restricted movements more unpleasant (-1 mm, -11 to 0, p = 0.006) and were more sleepy (-4 mm, -20 to 0, p = 0.032). The addition of fentanyl to bupivacaine reduced the requirement for local anaesthetic (-33 mg, -55 to -15, p less than 0.001) without compromising analgesia. No adverse effects in neonates were attributed to the use of fentanyl.

CONCLUSIONS

The already high maternal satisfaction from conventional epidural analgesia can be improved; epidural fentanyl may be combined with bupivacaine to reduce operative deliveries and confer other advantages that may increase maternal satisfaction. Further investigations should be performed to determine the exact mechanisms of these findings and, in particular, to develop a safe method of delivering such analgesia to women.

Upper-limb and lower-limb exercise training in patients with chronic airflow obstruction

We designed a randomized controlled study to evaluate the benefit of upper-limb exercise training, alone and in combination with walking training, in patients with severe CAO. In an outpatient department supervised by a physiotherapist, we evaluated 28 patients with severe stable CAO (FEV1, 32 percent of predicted). Patients were randomly allocated to either a control (eight), upper-limb (six), lower-limb (seven), or combined (seven) exercise group. The upper-limb group trained with a circuit of upper-limb exercises, the lower-limb group by walking, and the combined group with both. Exercise was for one hour three times per week for eight weeks. Assessment before and after training included pulmonary function, mouth pressures, respiratory muscle endurance, maximal bicycle exercise test, maximal and submaximal arm ergometer, six-minute walking distance, and a scale of well-being (Bandura scale). Twenty-six patients completed the program. There was a significant improvement (Wilcoxon rank sum test) in the following: six-minute walking distance in the lower-limb (p less than 0.005) and combined (p less than 0.003) groups; arm ergometer in the upper-limb (p less than 0.005) and combined (p less than 0.04) groups; and the scale of well-being in the combined (p less than 0.005) group. There was no significant change in any other parameter measured. We conclude that exercise training improves exercise performance in severe CAO, that the training is specific for the muscle group trained, and that upper-limb exercises should be included in training programs for these patients.

Effects of social isolation on brain catecholamines and forced swimming in rats: prevention by antidepressant treatment

Post-weaning rats were housed alone or in groups for a period of 4 or 8 weeks. A portion of the animals received tricyclic antidepressant treatment, desipramine 20 mg/kg/day, during this period. Animals were then tested behaviorally by forced swimming. Isolation was associated with significantly longer durations of immobility during forced swimming. This was blocked by desipramine treatment. Desipramine treatment did not have a significant effect on the swimming durations of group-housed rats. Hindbrain and midbrain levels of catecholamines were subsequently measured and turnover rates estimated by administration of alpha-methyl-p-tyrosine or saline. Isolated rats had increased levels and decreased turnover of catecholamines. The increase in norepinephrine but not dopamine levels was blocked by desipramine, while antidepressant effects on turnover could not be tested with this method. Reduced social stimulation thus appears to be associated with reduced catecholamine release which may result in the accumulation of these transmitters in the central nervous system. Treatment with desipramine appeared essentially to compensate for reduced social stimulation, blocking isolation-induced noradrenergic neurochemical changes, while having few significant effects on control animals. This study may be helpful in furthering our understanding of how the interaction of organisms with their environment influence catecholamine systems and how antidepressants may act to restore function.

Alterations in blood pressure of normotensive and hypertensive rats following intrathecal injections of neuropeptide Y

The effect of the intrathecal administration of neuropeptide Y (NPY) on blood pressure and heart rate of anesthetized normotensive and hypertensive rats was studied. Neuropeptide Y was observed to produce a decrease in the blood pressure of Sprague-Dawley, Wistar Kyoto (WKY), DOCA-salt, and DOCA-sham control rats. The maximum percent decrease in blood pressure of Sprague-Dawley rats was 12.8 and 15.2% in response to 0.1 and 1.0 nmol NPY, respectively. Similar changes in heart rate were observed. The depressor effect of intrathecal NPY was attenuated by prior treatment with yohimbine and propranolol but not prazosin. The depressor effect of intrathecal NPY observed in normotensive and DOCA-salt hypertensive rats was not seen in the spontaneously hypertensive rat (SHR). The studies extend to the spinal cord the list of regions and tissues where NPY can produce physiological effects. It is concluded that the effects of NPY are closely associated with sympathetic preganglionic neurons in the spinal cord that the depressor effect of NPY involves alpha 2 and beta adrenoceptors, and that a loss of the depressor effect of NPY may contribute to the development or maintenance of hypertension in the SHR.