Practice Perspectives on Care Coordination in Rural Settings

PURPOSE

Social needs and nonmedical health determinants are increasingly incorporated into care coordination models. However, little is known about the practice of operationalizing enhanced care coordination, particularly in rural settings. The objective of this study was to determine care coordination practices in rural settings that integrate social services with health care.

PRIMARY PRACTICE SETTINGS

Staff and administrators in rural Missouri health and health care settings were interviewed about their organization's implementation of enhanced care coordination practices.

METHODOLOGY AND SAMPLE

This is a mixed-methods study; 16 key informant structured interviews were conducted across 14 organizations.

RESULTS

Organizations reported a median care coordination population of 800 (range: 50-21,500) across a median of 11 case managers (range: 3-375). The percentage of organizations reporting social determinants of health services included the following: 100% transportation, 86% mental health, 79% food, 71% housing, and 50% dental. Implementation of the essential indicators of care coordination quality ranged from 41.7% to 100%. We report organizations' innovative solutions to care coordination barriers.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

This study contributes to a very limited literature on the practice of rural care coordination by assessing the quality of care provided compared with a recommended standard. This study also contributes an in-depth reporting on the variety of service models being implemented. Finally, this study uniquely contributes innovative interprofessional examples of enhanced care coordination initiatives. These examples may provide inspiration for rural health care organizations. As the care coordination landscape evolves to include social determinants of health, there remain important fundamental barriers to ensuring quality of care.

The use of a mobile app to motivate evidence-based oral hygiene behaviour

INTRODUCTION

Mobile apps are software programmes that run on smartphones and other mobile devices. Mobile health apps can help people manage their own health and wellness, promote healthy living and gain access to useful information when and where they need it. The Brush DJ oral health app was developed to use the opportunity mobile apps offer to motivate an evidence-based oral hygiene routine. A literature review has found no research investigating the use of a mobile app to motivate evidence-based oral hygiene behaviour.

OBJECTIVE

The objective of this preliminary investigation was to assess user perception of an oral health app to give a basis for future research and development of app technology in relation to oral health.

METHOD

A cross-sectional qualitative user perception questionnaire.RESULTS :One hundred and eighty-nine people responded to the questionnaire. Seventy percent (n = 113) of respondents reported that their teeth felt cleaner since using the app. Eighty-eight percent (n = 133) reported the app motivated them to brush their teeth for longer and 92.3% (n = 144) would recommend the app to their friends and family. Four broad themes relating to how the app helped toothbrushing were reported. These themes were motivation, education, compliance and perceived benefits.

CONCLUSION

A mobile app is a promising tool to motivate an evidence-based oral hygiene routine.

Tobacco, alcohol and drug use among dental undergraduates at one English university in 1998 and 2008

OBJECTIVE

To estimate the prevalence of tobacco, alcohol and drug use among dental undergraduates at one English university in 2008, and compare these with prevalence in 1998.

DESIGN

Cross-sectional survey using an anonymous self-report questionnaire.

SUBJECTS AND METHODS

In 2008 all 384 dental undergraduates at one English university were sent a questionnaire in order to obtain data on the frequency and amount of tobacco, alcohol, cannabis and other illicit drugs used before and during their time as a dental undergraduate. The same survey had been conducted on dental undergraduates at the university 10 years earlier.

RESULTS

Tobacco smoking was reported by 27% of males and 13.5% of females, a reduction from 1998 (42% of males and 32% of females) being significant among females. 63% of males and 69.5% of females reported drinking alcohol: significantly fewer than in 1998 (82% males and 90% females). Binge drinking was reported by 69.5% of males compared to 56% in 1998. In females 66% binged compared to 58.5% in 1998. The increase in males was significant. 62% of males and 68% of females had never used cannabis compared to 38% in males and 50.5% of females in 1998, a significant reduction. A significant reduction in amphetamine use was reported among both male and female undergraduates in 2008 compared to 1998 and a significant increase in amyl nitrate use was reported by females. Reported illicit drug use was associated with alcohol drinking, and particularly with tobacco use.

CONCLUSION

Dental undergraduates at one English university in 2008 when compared to those in 1998 are reported to be significantly less likely to drink alcohol, use cannabis and amphetamines. If female, they are significantly less likely to smoke tobacco and overestimate the number of units of alcohol they can safely consume in a week, but more likely to use amyl nitrate. If male, those who drink alcohol are significantly less likely to drink at a level of increased risk, but more likely to binge drink.

Alcohol and drug use among vocational dental practitioners

OBJECTIVE

This study was designed to investigate the prevalence of alcohol and drug use in vocational dental practitioners (VDPs).

DESIGN

Anonymous self-report questionnaire.

SUBJECTS AND METHODS

All UK vocational dental practitioners (n = 719) who started practice in the summer of 1999 were questioned on their use of alcohol, tobacco, cannabis and other illicit drugs whilst a VDP and before graduation.

RESULTS

Eighty-nine per cent of males and 88% of females reported alcohol use. Of these, 35% of males and 36% of females drank above sensible levels (up to 21 units per week for males, 14 units for females), with 48% of males and 52% of females "binge drinking". Thirty-three per cent of respondents reported cannabis use whilst a VDP. Regular drug use (use at least once a month) other than cannabis whilst a VDP was found to be highest among males, with regular ecstasy use reported by 4% and regular cocaine use reported by 2%. Regular tobacco use (ten or more cigarettes per day) was reported by 9% of VDPs. Regular tobacco users were found to be six times more likely to use cannabis on a regular basis, three times more likely to use ecstasy on a regular basis and four times more likely to use cocaine on a regular basis than those VDPs who reported non regular tobacco use.

CONCLUSION

VDPs are drinking above sensible limits, binge drinking, using tobacco and indulging in illicit drug use to a degree that will cause health problems. However, use of all substances had reduced since qualification.

A survey of alcohol and drug use among UK based dental undergraduates

OBJECTIVE

This study was designed to investigate the prevalence of alcohol and drug use.

DESIGN

Anonymous self-report questionnaire.

SETTING

A UK dental school in May 1998.

SUBJECTS AND METHODS

1st-5th year dental undergraduates (n = 264) were questioned on their use of alcohol and tobacco, cannabis and other illicit drugs whilst at dental school, and before entry.

RESULTS

Eighty two per cent of male and 90% of female undergraduates reported drinking alcohol. Of those drinking, 63% of males and 42% of females drank in excess of sensible weekly limits (14 units for females, 21 units for males), with 56% of males and 58.5% of females 'binge drinking'. Regular tobacco smoking (10 or more cigarettes a day) was found to have a statistically significant association with year of study, 4th-5th year undergraduates being eight times more likely to regularly smoke than their junior colleagues. Fifty five per cent of undergraduates reported cannabis use at least once or twice since starting dental school, with 8% of males and 6% of females reporting current regular use at least once a week.

CONCLUSION

Dental undergraduates are drinking above sensible weekly limits of alcohol, binge drinking and indulging in illicit drug use. Dental Schools should designate a teacher responsible for education of undergraduates regarding alcohol and substance abuse.

Effects of antiprogestins on the rate of proliferation of breast cancer cells

We have examined the influence of progestins (progesterone, R5020) and antiprogestins (RU486, ZK98299, Org 31710 and Org 31806) on the rate of proliferation of wild type T47D cells cultured in whole fetal bovine serum (FBS) or in single charcoal stripped fetal bovine serum (SSFBS). All of the progesterone antagonists RU486, ZK98299 and two novel antiprogestins Org 31710 and Org 31806 inhibited cell proliferation when cells were cultured in FBS. In contrast, all of the antiprogestins with the exception of ZK98299 enhanced cell growth when cells were cultured in SSFBS. This stimulatory effect of RU486 was observed only at a high concentration of the ligand (1 microM). The effect of R5020, however, was concentration independent. The number of cells in the presence of RU486 was approximately 600% followed by R5020 approximately 400% above control values after a 28 day culturing period. In contrast, when the cells were grown in the presence of medium containing non-stripped whole serum, RU486 inhibited the extent of cell proliferation by 45%. Estradiol (E2) stimulated the rate of proliferation in cells cultured in SSFBS. Similar to when cells were cultured in whole serum, the antiprogestins inhibited cell growth in E2-supplemented SSFBS. Detection of the growth enhancement effects of progesterone receptor (PR) ligands such as RU486 and R5020 on the cells grown in charcoal-stripped medium appear to require the removal of E2 by charcoal stripping of the serum.

Characterization of ligand binding, DNA binding and phosphorylation of progesterone receptor by two novel progesterone receptor antagonist ligands

In order to gain a better understanding of the distinctive mechanisms of the various types of antiprogestins, we have characterized in vitro ligand binding, specific DNA binding and phosphorylation of progesterone receptor (PR) from T47D cells after treatment of cells with progestins (progesterone, R5020) and antiprogestins (RU486, ZK98299, Org 31806 and Org 31710). Treatment of the cells with R5020 or PR antagonists, with the exception of ZK98299, resulted in a quantitative upshift of PR-A and PR-B indicative of ligand/DNA-induced phosphorylation of PR. Treatment of cells with RU486, Org 31710 or Org 31806, but not R5020 or ZK98299 resulted in detectable PR-progesterone response element complexes (PR-PREc) as assessed by gel mobility shift assay. Although treatment of cells with ZK98299, a type I PR antagonist, did not induce phosphorylation, the antiprogestins, Org 31806 and Org 31710, in a manner identical to RU486, did. Our data suggest that Org 31806 and Org 31710 affect properties of PR from T47D cells that are similar to RU486.

Biochemical factors in the lens opacities. Case-control study. The Lens Opacities Case-Control Study Group

OBJECTIVE

To evaluate associations with biochemical indicators of nutritional and other risk factors in the Lens Opacities Case-Control Study.

DESIGN

Case-control study.

SETTING AND PARTICIPANTS

The Lens Opacities Case-Control Study determined risk factors for cortical, nuclear, and posterior subcapsular opacities among 1380 participants aged 40 to 79 years.

DATA COLLECTION

Vitamin E, selenium, and biochemistry profile determinations were performed on all patients; red blood cell enzymes and amino acids were measured in systematic samples of about 25% of the Lens Opacities Case-Control Study population.

OUTCOME

Laboratory test values in cases and controls were compared and expressed as odds ratios and 95% confidence intervals.

RESULTS

In polychotomous logistic regression analyses controlling for age and sex, the risk of opacities was reduced to less than one half in persons with higher levels of vitamin E (odds ratio, 0.44 for nuclear opacities), albumin-globulin ratio (odds ratio, 0.41 for mixed opacities), or iron (odds ratio, 0.43 for cortical opacities); higher uric acid levels increased risk (odds ratio, 1.74 for mixed opacities). Persons with opacities were twice as likely to have high glutathione reductase activity (with flavin adenine dinucleotide), which suggests low riboflavin status (odds ratio, 2.13). Most odds ratios for amino acids were under unity and were significantly decreased for glycine (0.36) and aspartic acid (0.31).

CONCLUSIONS

Lens opacities were associated with lower levels of riboflavin, vitamin E, iron, and protein nutritional status. Higher levels of uric acid increased risk of mixed opacities. The findings for riboflavin, vitamin E, iron, and uric acid are compatible with the dietary intake and medical history results of the Lens Opacities Case-Control Study.

Lack of effect of tacrine administration on the anticoagulant activity of warfarin

The effect of tacrine administration on prothrombin time was studied in 13 patients receiving prolonged warfarin therapy. After a 3-week baseline period and 5 days of placebo administration, patients received 20 mg tacrine four times daily for 5 days. Prothrombin times were determined during baseline, daily before the morning doses of placebo and tacrine, and 14 days after the last tacrine dose (closeout). Mean (+/- SD) prothrombin times were 16.2 +/- 2.8 seconds at baseline, 15.1 +/- 2.6 seconds during the placebo phase, 15.8 +/- 3.6 seconds during the tacrine phase, and 15.3 +/- 3.6 seconds at closeout, indicating that tacrine has no effect on the anticoagulant activity of warfarin. Alteration of warfarin dosage should not be required in patients receiving concurrent tacrine therapy.

Learning style theory and patient education

This article argues for the use of learning style theory in patient education. Although nurses need to have a repertoire of teaching strategies as well as possess flexibility in teaching clients, research has demonstrated that nurses do not understand teaching and learning principles. This article discusses the theoretical tenets of Kolb's learning style theory and applies this theory to patient education.

Absorption of vitamin A by children with diarrhoea during treatment with oral rehydration salt solution

The results of a study of absorption by children of vitamin A indicate that absorption is lower in children with acute diarrhoea compared with normal children. The glucose or electrolytes present in solutions of oral rehydration salts had no effect on the absorption. Despite malabsorption, 70% of the administered dose of 100 000 IU of vitamin A in 500 ml of fluid was absorbed and retained.

Comparison of messenger RNAs induced in cells infected with each member of the morbillivirus group

Virus-specific mRNAs radiolabelled with [32P]orthophosphate in the presence of actinomycin D were extracted from the cytoplasm of Vero cells infected with each of the known morbilliviruses: measles virus, canine distemper virus, rinderpest virus, and peste des petits ruminants virus. When analysed on denaturing agarose-formaldehyde gels the major RNA species from all viruses in the group were identical, except for canine distemper virus where one of the virus-specific mRNAs (mRNA 5), which probably codes for the virus haemagglutinin (S.E.H. Russell, D. K. Clarke, E. M. Hoey, B. K. Rima, S. J. Martin, J. Gen. Virol. 66, 433-441 (1985], was significantly smaller than the corresponding mRNA induced by the other viruses. Plasmid DNA containing a virus-specific insert, representing greater than 98% of the gene derived from the P-protein mRNA of canine distemper virus, showed significant cross-hybridisation with all the other members of the morbillivirus group.

Comparative metabolism of the cis and trans isomers of N-nitroso-2,6-dimethylmorpholine in rats, hamsters and guinea pigs

The in vivo metabolism of the cis and trans isomers of N-[3,5-3H]nitroso-2,6-dimethylmorpholine (NDMM) was studied in female Fischer rats, Syrian golden hamsters and guinea pigs by analysis of urinary metabolites using high pressure liquid chromatography (HPLC). Animals were treated by gavage with 12 mg/kg body wt. of NDMM, composed of both isomers and 12 microCi/kg body wt. of either of the separated radioactive isomers (cis or trans). Control animals received 12 mg, 12 microCi/kg body wt. NDMM with both isomers labeled in their natural proportion. There was a substantial increase in the excretion of a particular metabolite, 2-(2-hydroxyl-methyl)ethoxy propanoic acid, in the urine of rats, hamsters and guinea pigs 24 h after received the trans isomer (24, 22 and 13% of the total dose excreted, respectively). A minor metabolite was determined to be 2,6-dimethylmorpholine-3-one, another product of alpha-oxidation. The metabolite 1-amino-2-hydroxypropanol was identified, indicating that NDMM was metabolized by both alpha- and beta-oxidation. In all three species, animals administered the cis isomer excreted larger amounts of N-nitroso(2-hydroxypropyl)(2-oxopropyl)amine (HPOP) and N-nitroso-bis(2-hydroxypropyl)amine (BHP) products of beta oxidation, than those treated with the trans isomer. Hamsters and guinea pigs treated with the more carcinogenic cis isomer in these species, also excreted twice as much of two other metabolites than was found in the urine of animals given the trans isomer. The trans isomer of NDMM appeared to be preferentially metabolized by alpha-oxidation and from earlier studies this metabolic pathway seemed to be important in carcinogenesis by NDMM in the rat. The cis isomer might be in a conformation more favorable for beta-oxidation and this pathway may be of primary importance in carcinogenesis by NDMM in hamsters and guinea pigs.

Comparative metabolism of 2,6-dimethylnitrosomorpholine in rats, hamsters, and guinea pigs

The metabolism of N-[3,5-3H]nitroso-2,6-dimethylmorpholine (NDMM) was studied in female Sprague-Dawley rats. Syrian golden hamsters, and guinea pigs. NDMM induces tumors in the esophagus in rats, pancreatic cancer in hamsters, and hemangioendothelial tumors of the liver in guinea pigs. An intragastric dose of NDMM (2 mg, 2 muCi/animal) was rapidly distributed throughout the tissues of both the rat and hamster, with no apparent accumulation of radioactivity in any one tissue. At low dose levels, NDMM was metabolized rapidly by both species. The hamster appeared to metabolize the compound faster than did the rat or guinea pig. At appreciable amount of radioactivity was excreted in the urine in all three species after 8 hr: approximately 54% in the hamster, 39% in the rat; and 30% in the guinea pig. During the first 24 hr, only a small percentage of the radioactivity excreted by the hamster, rat, and guinea pig was NDMM (0.8, 2, and 0.5%, respectively). High-pressure liquid chromatography analysis of urine collected 24 hr after administration revealed 12 metabolites. Although the urinary metabolites appeared to be similar in all three species, one large difference was the presence of a major urinary metabolite in hamster urine, which was absent or present in only small quantities in the rat and guinea pig. The guinea pig urine also had relatively more radioactivity present in one major fraction than did the hamster or rat.

Treating sexual dysfunction in general practice

A method of training general practitioners in the treatment of sexual dysfunction is described, using fortnightly seminars at which the doctors discussed the continuing care of their patients.Doctors took on patients presenting in their practices and treated couples together, where possible, using a mixture of insight-directed and behavioural techniques similar to those used by Masters and Johnson (1970). Interviews were reported back to the group which gave advice and support. The doctors, all beginners in this type of work, were able to help substantially 72 per cent of 47 couples treated.