The TELEhealth Shared decision-making Coaching and Navigation in Primary carE (TELESCOPE) intervention: a study protocol for delivering shared decision-making for lung cancer screening by patient navigators

Background

Lung cancer screening (LCS) can reduce lung cancer mortality but has potential harms for patients. A shared decision-making (SDM) conversation about LCS is required by the Centers for Medicare & Medicaid Services (CMS) for LCS reimbursement. To overcome barriers to SDM in primary care, this protocol describes a telehealth decision coaching intervention for LCS in primary care clinics delivered by patient navigators. The objective of the study is to evaluate the effectiveness of the intervention and its implementation potential, compared with an enhanced usual care (EUC) arm.

Methods

Patients (n = 420) of primary care clinicians (n = 120) are being recruited to a cluster randomized controlled trial. Clinicians are randomly assigned to 1) TELESCOPE intervention: prior to an upcoming non-acute clinic visit, patients participate in a telehealth decision coaching session about LCS delivered by trained patient navigators and nurse navigators place a low-dose CT scan (LDCT) order for each TELESCOPE patient wanting LCS, or 2) EUC: patients receive enhanced usual care from a clinician. Usual care is enhanced by providing clinicians in both arms with access to a Continuing Medical Education (CME) webinar about LCS and an LCS discussion guide. Patients complete surveys at baseline and 1-week after the scheduled clinic visit to assess quality of the SDM process. Re-navigation is attempted with TELESCOPE patients who have not completed the LDCT within 3 months. One month before being due for an annual screening, TELESCOPE patients whose initial LCS showed low-risk findings are randomly assigned to receive a telehealth decision coaching booster session with a navigator or no booster. Electronic health records are abstracted at 6, 12 and 18 months after the initial decision coaching session (TELESCOPE) or clinic visit (EUC) to assess initial and annual LCS uptake, imaging results, follow-up testing for abnormal findings, cancer diagnoses, treatment, and tobacco treatment referrals. This study will evaluate factors that facilitate or interfere with program implementation using mixed methods.

Discussion

We will assess whether a decision coaching and patient navigation intervention can feasibly support high-quality SDM for LCS and guideline-concordant LCS uptake for patients in busy primary care practices serving diverse patient populations.

Trial Registration

This study was registered at ClinicalTrials.gov (NCT05491213) on August 4, 2022.

Rectal varices due to chronic inferior mesenteric vein thrombosis caused by external compression in a large hiatus hernia containing the pancreas

A 79-year-old woman presented with a large fresh rectal bleed. Computed tomography revealed that she had a large type IV hiatus hernia, which contained the stomach and pancreas. Compression of the inferior mesenteric vein and splenic vein had led to thrombosis within these vessels and retrograde flow within the inferior mesenteric vein. This had led to the formation of portosystemic rectal varices. Ectopic varices occasionally form in the rectum, often in the context of liver cirrhosis. At the time of writing, ours is the first reported case of portosystemic rectal varices formulated in response to obstruction of vessels within a hiatus hernia.

Decision-making processes of patients who use the emergency department for primary care needs

Emergency department (ED) use for non-urgent needs is widely viewed as a contributor to various health care system flaws and inefficiencies. There are few qualitative studies designed to explore the complexity of patients' decision-making process to use the ED vs. primary care alternatives. In this study, semi-structured interviews were conducted with 30 patients who were discharged from the low acuity area of a university hospital ED. A grounded theory approach including cycles of immersion/crystallization was used to identify themes and reportable interpretations. Patients reported multiple decision-making considerations that hinged on whether or not they knew about primary care options. A model is developed depicting the complexity and variation in patients' decision-making to use the ED. Optimizing health system navigation and use requires improving objective factors such as access and costs as well as subjective perceptions of patients' health care, which are also a prominent part of their decision-making process.

The Use of Knowledge Management in Healthcare: The Implementation of Shared Care Plans in Electronic Medical Record Systems at One Primary Care Practice

A transformation in the way in which primary care is delivered is underway in the US. Across the country primary care practices are grappling with how to change from the traditional physician-directed model to a more patient-centred collaborative style as part of the effort to curb the rise of chronic disease. To date, few tools or techniques exist to help the individual primary care provider make this difficult and complex transformation. One such tool that has arisen is the shared care plan (SCP). As defined in the Taking Action for Learning and Knowledge Management to improve Diabetes Mellitus (TALK/DM) study (a NIDDK funded pilot project to implement SCPs in primary care), the SCP of primary care becomes the product of collaboration between the practice and the patients. The SCP is created by combining knowledge management (KM) techniques and motivational interviewing (MI) health counselling methods to form a new knowledge object. This paper focuses on this aspect of the TALK/DM study and takes a case study approach to explore how one primary care practice is implementing the SCP as knowledge object (both a paper document and an electronic record in the EMR system) in its organisation. This study adds nuance and insight into how knowledge objects such as the SCP can serve as a tool for collaboration in primary care.

A typology of electronic health record workarounds in small-to-medium size primary care practices

OBJECTIVE

Electronic health record (EHR) use in ambulatory care can improve safety and quality; however, problems with design, implementation, and poor interface with other systems lead users to develop 'workarounds', or behaviors users adopt to overcome perceived limitations in a technical system. We documented workarounds used in independent, community-based primary care practices, and developed a typology of their key features.

MATERIALS AND METHODS

Comparative case study of EHR use in seven independent primary care practices. Field researchers spent approximately 1 month in each practice to observe EHR use, conduct patient pathways, and interview clinicians and staff.

RESULTS

We observed workarounds addressing a wide range of EHR-related problems, including: user interface issues (eg, insufficient data fields, limited templates), barriers to electronic health information exchange with external organizations, and struggles incorporating new technologies into existing office space. We analyzed the observed workarounds inductively to develop a typology that cuts across specific clinical or administrative processes to highlight the following key formal features of workarounds in general: temporary/routinized, which captures whether the workaround is taken for granted as part of daily workflow or is understood as a short-term solution; avoidable/unavoidable, referring to the extent to which the workaround is within the practice's power to eliminate; and deliberately chosen/unplanned, which differentiates strategically chosen adaptations from less thoughtful workarounds.

CONCLUSIONS

This workaround typology provides a framework for EHR users to identify and address workarounds in their own practices, and for researchers to examine the effect of different types of EHR workarounds on patient safety, care quality, and efficiency.

Electronic health record impact on work burden in small, unaffiliated, community-based primary care practices

BACKGROUND

The use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices.

OBJECTIVE

To study the impact of EHR use on clinician and staff work burden in small, community-based primary care practices.

DESIGN

We conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9-14 days over a 4-8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach.

PARTICIPANTS

All practice members and selected patients in seven community-based primary care practices in the Northeastern US.

KEY RESULTS

The impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHR-related work burden for clinicians, as well as facilitate population-based care.

CONCLUSIONS

The complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.

Typical electronic health record use in primary care practices and the quality of diabetes care

PURPOSE

Recent efforts to encourage meaningful use of electronic health records (EHRs) assume that widespread adoption will improve the quality of ambulatory care, especially for complex clinical conditions such as diabetes. Cross-sectional studies of typical uses of commercially available ambulatory EHRs provide conflicting evidence for an association between EHR use and improved care, and effects of longer-term EHR use in community-based primary care settings on the quality of care are not well understood.

METHODS

We analyzed data from 16 EHR-using and 26 non-EHR-using practices in 2 northeastern states participating in a group-randomized quality improvement trial. Measures of care were assessed for 798 patients with diabetes. We used hierarchical linear models to examine the relationship between EHR use and adherence to evidence-based diabetes care guidelines, and hierarchical logistic models to compare rates of improvement over 3 years.

RESULTS

EHR use was not associated with better adherence to care guidelines or a more rapid improvement in adherence. In fact, patients in practices that did not use an EHR were more likely than those in practices that used an EHR to meet all of 3 intermediate outcomes targets for hemoglobin A(1c), low-density lipoprotein cholesterol, and blood pressure at the 2-year follow-up (odds ratio = 1.67; 95% CI, 1.12-2.51). Although the quality of care improved across all practices, rates of improvement did not differ between the 2 groups.

CONCLUSIONS

Consistent use of an EHR over 3 years does not ensure successful use for improving the quality of diabetes care. Ongoing efforts to encourage adoption and meaningful use of EHRs in primary care should focus on ensuring that use succeeds in improving care. These efforts will need to include provision of assistance to longer-term EHR users.

Identifying teachable moments for health behavior counseling in primary care

OBJECTIVE

Situations with potential to motivate positive change in unhealthy behavior have been called 'teachable moments'. Little is known about how they occur in the primary care setting.

METHODS

Cross-sectional observational design. Audio-recordings collected during 811 physician-patient interactions for 28 physicians and their adult patients were analyzed using conversation analysis.

RESULTS

Teachable moments were observed in 9.8% of the cases, and share three features: (1) the presence of a concern that is salient to the patient that is either obviously relevant to an unhealthy behavior, or through conversation comes to be seen as relevant; (2) a link that is made between the patient's salient concern and a health behavior that attempts to motivate the patient toward change; and (3) a patient response indicating a willingness to discuss and commit to behavior change. Additionally, we describe phenomena related to, but not teachable moments, including teachable moment attempts, missed opportunities, and health behavior advice.

CONCLUSIONS

Success of the teachable moment rests on the physician's ability to identify and explore the salience of patient concerns and recognize opportunities to link them with unhealthy behaviors.

PRACTICE IMPLICATIONS

The skills necessary for accomplishing teachable moments are well within the grasp of primary care physicians.

Coordination of health behavior counseling in primary care

PURPOSE

We wanted to examine how coordinated care is implemented in primary care practices to address patients' health behavior change needs.

METHODS

Site visit notes, documents, interviews, and online implementation diaries were collected from July 2005 to September 2007 from practice-based research networks (PBRNs) participating in Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks (P4H). An iterative group process was used to conduct a cross-case comparative analysis of 9 interventions. Published patient outcomes reports from P4H interventions were referenced to provide information on intervention effectiveness.

RESULTS

In-practice health risk assessment (HRA) and brief counseling, coupled with referral and outreach to a valued and known counseling resource, emerged as the best way to consistently coordinate and encourage follow-through for health behavior counseling. Findings from published P4H outcomes suggest that this approach led to improvement in health behaviors. Automated prompts and decision support tools for HRA, brief counseling and referral, training in brief counseling strategies, and co-location of referral with outreach facilitated implementation. Interventions that attempted to minimize practice or clinician burden through telephone and Web-based counseling systems or by expanding the medical assistant role in coordination of health behavior counseling experienced difficulties in implementation and require more study to determine how to optimize integration in practices.

CONCLUSIONS

Easy-to-use system-level solutions that have point-of-delivery reminders and decision support facilitate coordination of health behavior counseling for primary care patients. Infrastructure is needed if broader integration of health behavior counseling is to be achieved in primary care.

Electrical control of the exciton-biexciton splitting in self-assembled InGaAs quantum dots

The authors demonstrate how lateral electric fields can be used to precisely control the exciton-biexciton splitting in InGaAs quantum dots. By defining split-gate electrodes on the sample surface, optical studies show how the exciton transition can be tuned into resonance with the biexciton by exploiting the characteristically dissimilar DC Stark shifts. The results are compared to model calculations of the relative energies of the exciton and biexciton, demonstrating that the tuning can be traced to a dominance of hole-hole repulsion in the presence of a lateral field. Cascaded decay of the exciton-biexciton system enables the generation of entangled photon pairs without the need to suppress the fine structure splitting of the exciton. Our results demonstrate how the exciton-biexciton system can be electrically controlled.

Electronic medical records are not associated with improved documentation in community primary care practices

The adoption of electronic medical records (EMRs) in ambulatory settings has been widely recommended. It is hoped that EMRs will improve care; however, little is known about the effect of EMR use on care quality in this setting. This study compares EMR versus paper medical record documentation of basic health history and preventive service indicators in 47 community-based practices. Differences in practice-level documentation rates between practices that did and did not use an EMR were examined using the Kruskal-Wallis nonparametric test and robust regression, adjusting for practice-level covariates. Frequency of documentation of health history and preventive service indicator items were similar in the 2 groups of practices. Although EMRs provide the capacity for more robust record keeping, the community-based practices here do not use EMRs to their full capacity. EMR usage does not guarantee more systematic record keeping and thus may not lead to improved quality in the community practice setting.

An atomically resolved study of InGaAs quantum dot layers grown with an indium flush step

In this cross-sectional scanning tunnelling microscopy study we investigate the indium flush method as a means to control the height of self-assembled InGaAs quantum dots and wetting layers. The results show that application of an indium flush step during growth results in flattened dots and a reduced wetting layer of which the height can be precisely controlled by varying the height of the first capping layer.

Fidelity versus flexibility: translating evidence-based research into practice

BACKGROUND

Understanding the process by which research is translated into practice is limited. This study sought to examine how interventions change during implementation.

METHODS

Data were collected from July 2005 to September 2007. A real-time and cross-case comparison was conducted, examining ten interventions designed to improve health promotion in primary care practices in practice-based research networks. An iterative group process was used to analyze qualitative data (survey data, interviews, site visits, and project diary entries made by grantees approximately every 2 weeks) and to identify intervention adaptations reported during implementation.

RESULTS

All interventions required changes as they were integrated into practice. Modifications differed by project and by practice, and were often unanticipated. Three broad categories of changes were identified and include modifications undertaken to accommodate practices' and patients' circumstances as well as personnel costs. In addition, research teams played a crucial role in fostering intervention uptake through their use of personal influence and by providing motivation, retraining, and instrumental assistance to practices. These efforts by the research teams, although rarely considered an essential component of the intervention, were an active ingredient in successful implementation and translation.

CONCLUSIONS

Changes are common when interventions are implemented into practice settings. The translation of evidence into practice will be improved when research design and reporting standards are modified to help quality-improvement teams understand both these adaptations and the effort required to implement interventions in practice.

Diagnosis of ear pain

Many patients in primary care present with ear pain (otalgia). When the ear is the source of the pain (primary otalgia), the ear examination is usually abnormal. When the ear is not the source of the pain (secondary otalgia), the ear examination is typically normal. The cause of primary otalgia is usually apparent on examination; the most common causes are otitis media and otitis externa. The cause of secondary otalgia is often difficult to determine because the innervation of the ear is complex and there are many potential sources of referred pain. The most common causes are temporomandibular joint syndrome, pharyngitis, dental disease, and cervical spine arthritis. If the diagnosis is not clear from the history and physical examination, options include a trial of symptomatic treatment without a clear diagnosis; imaging studies; and consultation with an otolaryngologist. Patients who smoke, drink alcohol, are older than 50 years, or have diabetes are at higher risk of a cause of ear pain that needs further evaluation. Patients whose history or physical examination increases suspicion for a serious occult cause of ear pain or whose symptoms persist after symptomatic treatment should be considered for further evaluation, such as magnetic resonance imaging, fiberoptic nasolaryngoscopy, or an erythrocyte sedimentation rate measurement.

Abnormal uterine bleeding: a management algorithm

Abnormal uterine bleeding is a common problem, and its management can be complex. Because of this complexity, concise guidelines have been difficult to develop. We constructed a concise but comprehensive algorithm for the management of abnormal uterine bleeding between menarche and menopause that was based on a systematic review of the literature as well as the actual management of patients seen in a gynecology clinic. We started by drafting an algorithm that was based on a MEDLINE search for relevant reviews and original research. We compared this algorithm to the actual care provided to a random sample of 100 women with abnormal bleeding who were seen in a university gynecology clinic. Discrepancies between the algorithm and actual care were discussed during audiotaped meetings among the 4 investigators (2 family physicians and 2 gynecologists). The audiotapes were used to revise the algorithm. After 3 iterations of this process (total of 300 patients), we agreed on a final algorithm that generally followed the practices we observed, while maintaining consistency with the evidence. In clinic, the gynecologists categorized the patient's bleeding pattern into 1 of 4 types: irregular bleeding, heavy but regular bleeding (menorrhagia), severe acute bleeding, and abnormal bleeding associated with a contraceptive method. Subsequent management involved both diagnostic and treatment interventions, which often occurred simultaneously. The algorithm in this article is designed to help primary care physicians manage abnormal uterine bleeding using strategies that are consistent with the evidence as well as the actual practice of gynecologists.

Optically probing spin and charge interactions in a tunable artificial molecule

We optically probe and electrically control a single artificial molecule containing a well defined number of electrons. Charge and spin dependent interdot quantum couplings are probed optically by adding a single electron-hole pair and detecting the emission from negatively charged exciton states. Coulomb- and Pauli-blockade effects are directly observed, and tunnel coupling and electrostatic charging energies are independently measured. The interdot quantum coupling is shown to be mediated by electron tunneling. Our results are in excellent accord with calculations that provide a complete picture of negative excitons and few-electron states in quantum dot molecules.

Hepatitis C identification and management by family physicians

BACKGROUND AND OBJECTIVES

Many people with hepatitis C receive all or most of their care from primary care physicians, yet little information exists about the practice patterns, knowledge, and beliefs and attitudes of family physicians related to hepatitis C.

METHODS

We mailed a written survey to a random sample of active members of the American Academy of Family Physicians.

RESULTS

Nearly all respondents (94%) reported at least one patient with hepatitis C in their practice, and 66% had diagnosed at least one new case of hepatitis C in the past year. While most respondents (85%) correctly identified common hepatitis C risk factors, only 63% reported routinely asking patients about those risk factors. Respondents (74%) preferred to involve specialists in the care of hepatitis C patients, but half (50%) reported barriers to referral. A small number (5%) of respondents have prescribed antiviral medication within the past year. Most respondents think family physicians should screen (94%), diagnose (98%), and provide general care (69%) for hepatitis C patients.

CONCLUSIONS

Family physicians know how to identify high-risk people and test for hepatitis C. Most prefer to refer patients with hepatitis C to specialists for workup and treatment but report frequent barriers to those referrals.

Direct observation of controlled coupling in an individual quantum dot molecule

We report the direct observation of quantum coupling in individual quantum dot molecules and its manipulation using static electric fields. A pronounced anticrossing of different excitonic transitions is observed as the electric field is tuned. A comparison of our experimental results with theory shows that the observed anticrossing occurs between excitons with predominant spatially direct and indirect character and reveals a field driven transition of the nature of the molecular ground state exciton wave function. Finally, the interdot quantum coupling strength is deduced optically and its dependence on the interdot separation is calculated.

Factors influencing cessation of pregnancy care in Oregon

BACKGROUND AND OBJECTIVES

Anecdotal evidence suggests that many providers who previously delivered babies are no longer doing so, both in Oregon and nationally. This study determined the proportion of pregnancy care providers who have stopped or are planning to stop providing this care in Oregon and identified the important factors influencing such practice changes.

METHODS

We mailed a survey in October and November 2002 to all obstetrician-gynecologists, family physicians, general practitioners, and certified nurse midwives practicing in Oregon. The survey inquired about whether they currently perform deliveries. If they did not do so, or if they did so but planned to stop, further questions were asked about reasons for not providing this care.

RESULTS

A total of 2,158 surveys were mailed; 1,232 were returned (58% adjusted response rate), and 1,069 had sufficient information to be included in our analysis. Of respondents, 511 (47.8%) currently perform deliveries. Of these, 157 (30.7%) indicated that they planned to stop doing so in 1 to 5 years, with cost of professional liability insurance (59%) and fear of lawsuits (43%) most frequently cited as major reasons. A total of 367 (34%) respondents had previously stopped performing deliveries. Providers who stopped providing this care since 1999 were significantly more likely to cite cost of medical liability insurance and low reimbursement as major reasons, compared to providers who stopped earlier.

CONCLUSIONS

Our study suggests that as many as half of clinicians who previously performed or currently perform deliveries in Oregon are planning to stop or have already stopped providing this service, raising concern about access to pregnancy care services for women in the state.

Screening for hepatitis C virus infection: a review of the evidence for the U.S. Preventive Services Task Force

BACKGROUND

Hepatitis C virus (HCV) is the most common bloodborne pathogen in the United States and is an important cause of patient morbidity and mortality, but it is unclear whether screening to identify asymptomatic infected persons is appropriate.

PURPOSE

To synthesize the evidence on risks and benefits of screening for HCV infection.

DATA SOURCES

MEDLINE (through February 2003), Cochrane Clinical Trials Registry (2002, Issue 2), reference lists, and experts.

STUDY SELECTION

Controlled studies of screening and antiviral therapy and observational studies on other interventions, risk factors, accuracy of antibody testing, work-up, harms of biopsy, and long-term outcomes.

DATA EXTRACTION

Using preset criteria, the authors assessed the quality of included studies and abstracted information about settings, patients, interventions, and outcomes.

DATA SYNTHESIS

There are no published trials of screening for HCV infection. Approximately 2% of U.S. adults have HCV antibodies, with the majority having chronic infection. Risk factor assessment could identify adults at substantially higher risk. Antiviral treatment can result in a sustained virologic response rate of 54% to 56%, but no trials have been done specifically in asymptomatic patients likely to be identified by screening. Data are insufficient to determine whether treatment improves long-term outcomes. There are no data to estimate the benefit from counseling or immunizations. Although risks of biopsy and treatment appear minimal or self-limited, data on other adverse effects of screening, such as labeling or anxiety, are sparse.

CONCLUSIONS

Antiviral treatment can successfully eradicate HCV, but data on long-term outcomes in populations likely to be identified by screening are lacking. Although the yield from targeted screening, particularly in intravenous drug users, would be substantially higher than in the general population, data are inadequate to accurately weigh the overall benefits and risks of screening in otherwise healthy asymptomatic adults.

Glutamine deprivation facilitates tumour necrosis factor induced bacterial translocation in Caco-2 cells by depletion of enterocyte fuel substrate

BACKGROUND AND AIMS

Factors that induce luminal bacteria to cross the intestinal epithelium following injury remain poorly defined. The aim of this study was to investigate the interaction between glutamine metabolism, energy supply, and inflammatory mediators in determining the translocation of non-pathogenic bacteria across cultured enterocytes.

METHODS

The effect of tumour necrosis factor alpha (TNF-alpha) on translocation of Escherichia coli C25 across Caco-2 epithelial monolayers was studied in the presence of products and inhibitors of glutamine metabolism. Simultaneous measurements of transepithelial electrical resistance (TEER) and flux of lucifer yellow were used to assess effects on the paracellular pathway. Lactate dehydrogenase release was used to monitor enterocyte integrity. Imaging of monolayers in these experimental conditions was undertaken with transmission electron microscopy.

RESULTS

Exposure to basolateral TNF-alpha (20 ng/ml) for six hours induced translocation of E coli across Caco-2 but only if accompanied by simultaneous glutamine depletion (p<0.01). Translocation was inhibited by addition of glutamine for two hours (p<0.01) but not by an isonitrogenous mixture of non-glutamine containing amino acids. Inhibition of glutamine conversion to alpha-ketoglutarate, but not blockade of glutathione or polyamine synthesis, also induced translocation in the presence of TNF-alpha. Manipulations that induced bacterial translocation were associated with a marked reduction in enterocyte ATP levels. No effect of these treatments on paracellular permeability or lactate dehydrogenase release was observed. Conditions in which translocation occurred were associated with the presence of bacteria within enterocyte vacuoles but not the paracellular space.

CONCLUSIONS

In inflammatory conditions, the availability of glutamine as an enterocyte fuel substrate is essential for the preservation of a functional barrier to microorganisms. In conditions of acute glutamine depletion, cytokine mediated bacterial translocation appears to be primarily a transcellular process.

Brain mediation of Anolis social dominance displays. II. Differential forebrain serotonin turnover, and effects of specific 5-HT receptor agonists

Serotonin (5-HT) functions are associated with social dominance status in diverse species, but to date the brain regions wherein 5-HT exerts such effects are uncertain. Here, we indexed 5-HT turnover in male Anolis carolinensis as the ratio of 5-HT to its metabolite, 5-hydroxy-indol-acetic acid, and also as the accumulation of the in vivo tracer 14C-alpha-methyl-tryptophan (14C-AMT). After patching one eye, displaying dominant animals increased both measures of 5-HT turnover in the forebrain hemisphere receiving display-evocative visual stimuli, compared to control, contralateral brain, whereas both 5-HT turnover indices were decreased when animals displayed submissively. In contrast, various non-displaying controls showed forebrain symmetry on both measures. Drugs that stimulate 5-HT(2C) receptors in mammals, and have 5-HT(2C)-like binding in A. carolinensis, evoked some elements of dominant display behaviors in non-dominant anole males and also activated dorsolateral basal ganglia as seen in non-medicated dominants when they display [Baxter et al., 2001]. Thus, acute changes in forebrain 5-HT output from baseline equilibrium, acting at 5-HT(2C)-like receptors, might effect some elements of the dominant vs. submissive male anoles' territorial displays. A mechanistic model of how this might occur is offered. Given similarities in 5-HT systems, forebrain functions, and territorial display routines, similar mechanisms might have similar functions in other amniotes, including primates.

Brain mediation of Anolis social dominance displays. I. Differential basal ganglia activation

Ritualistic displays of aggressive intent are important social signals, often obviating physically dangerous engagement. To date, however, brain regions mediating such behaviors are not established. Here we used male Anolis carolinensis together with an in vivo 14C-2-deoxyglucose method to determine patterns of brain activation during elicitation of this animal's dominance displays vs. other behaviors. By patching one eye regional brain activation in the hemisphere receiving display-evocative visual stimuli ('seeing' side) was compared to activity in the contralateral brain that did not see specific stimuli ('patched' side); this was quantitated as the ratio of seeing/patched activity for brain regions of interest. Lone males displaying dominantly to mirrors activated dorsolateral basal ganglia (BG) in the seeing, compared to the patched hemisphere; this was not seen in various non-displaying controls. Degree of dorsolateral BG activation also correlated with a measure of dominant display activity, but not with locomotion. In socially stable pairs, displaying dominants showed similar activation of dorsolateral BG, but deactivated ventromedial BG; non-dominant cagemates displaying submissively had the opposite pattern. When cohabiting peacefully without displaying, paired dominants' and subordinates' brain activity patterns were similar to each other. Thus, different BG subsystems seem involved in dominant vs. submissive display behaviors. Given similarities in both social displays and BG organization, homologous brain systems might have similar functions in members of other amniote classes, including primates.

Mammal-like striatal functions in Anolis. I. Distribution of serotonin receptor subtypes, and absence of striosome and matrix organization

Serotonin (5-HT) 5-HT(2A) and 5-HT(2C) receptors are thought to play important roles in the mammalian striatum. As basal ganglia functions in general are thought highly conserved among amniotes, we decided to use in situ autoradiographic methods to determine the occurrence and distribution of pharmacologically mammal-like 5-HT(2A) and 5-HT(2C) receptors in the lizard, Anolis carolinensis, with particular attention to the striatum. We also determined the distributions of 5-HT(1A), 5-HT(1B/D), 5 HT(3), and 5-HT(uptake) receptors for comparison. All 5-HT receptors examined showed pharmacological binding specificity, and forebrain binding density distributions that resembled those reported for mammals. Anolis 5 HT(2A/C) and 5-HT(1A) site distributions were similar in both in vivo and ex vivo binding experiments. 5-HT(2A & C) receptors occur in both high and low affinity states, the former having preferential affinity for (125)I-(+/-)-2,5-dimethoxy-4-iodo-amphetamine hydrochloride ((125)I-DOI). In mammals (125)I-DOI binding shows a patchy density distribution in the striatum, being more dense in striosomes than in surrounding matrix. There was no evidence of any such patchy density of (125)I-DOI binding in the anole striatum, however. As a further indication that anoles do not possess a striosome and matrix striatal organization, neither (3)H-naloxone binding nor histochemical staining for acetylcholinesterase activity (AChE) were patchy. AChE did show a band-like striatal distribution, however, similar to that seen in birds.

Mammal-like striatal functions in Anolis. II. Distribution of dopamine D(1) and D(2) receptors, and a laminar pattern of basal ganglia sub-systems

We used in situ autoradiographic ligand binding methods to determine the occurrence and distribution of dopamine D(1) and D(2) receptor sub-types in the anole lizard, Anolis carolinensis. Both were present and exhibited pharmacological specificity characteristics similar to those described for mammals. However, unlike in mammals where in the neostriatum [outside the nucleus accumbens/olfactory tubercle complex (NA/OT)] these receptors exhibit only slight dorsolateral (D(2) high, D(1) low) to ventromedial (D(1 )high, D(2) low) gradients that co mingle extensively, in the anole striatum outside the NA/OT there was a striking laminar pattern, with little if any overlap between D(2) (high in a dorsal band) and D(1) (high ventral to the D(2) band) distributions. As D(1) receptors are related to the direct and D(2) to the indirect basal ganglia (BG) subsystems in mammals, we also determined anole striatal distributions of pre-proenkephalin mRNA, a marker for striatal efferents to the indirect BG subsystem in mammals. Here, too, there was a striking laminar pattern, with pre-proenkephalin mRNA in a band similar to that seen for D(2) receptors. The crisp neuroanatomical separation between these classic BG subsystem markers in Anolis striatum make this species attractive for the study of such systems' functions during behavior.

Pathogenesis of cerebral edema after treatment of diabetic ketoacidosis

We studied the roles of acidosis, plasma osmolality, and organic osmolytes in the pathogenesis of cerebral edema in an animal model of diabetes mellitus. Normonatremic rats with streptozotocin-induced non-ketotic (NKD) and ketotic (DKA) diabetes were sacrificed before or after treatment with hypotonic saline and insulin. Brains were analyzed for water, electrolyte, and organic osmolyte content. Brain water decreased by 2% in untreated DKA and NKD despite a 12% increase in plasma osmolality due to hyperglycemia. After treatment of both NKD and DKA, brain water increased equivalently by 8%. The cerebral edema that occurred after treatment was associated with decreased brain sodium content and no change in total major brain organic osmolytes in both NKD and DKA. However, brain content of the individual osmolytes glutamine and taurine increased after treatment of DKA. In a separate study, brain water and solute content of rats with DKA were compared after treatment with either hypotonic or isotonic fluid. Animals treated with isotonic fluid had significantly less cerebral edema and higher brain sodium content than those treated with hypotonic fluid. In our studies, brain swelling after treatment of DKA and NKD was primarily due to a rapid reduction of plasma glucose and osmolality, and was not caused by sodium movement into the brain. Acidosis did not appear to play a major role in the pathogenesis of cerebral edema after treatment of DKA.

Depletion of glutathione from brain cells in hyponatremia

In response to hyponatremia, brain cells extrude electrolytes and organic osmolytes, thereby minimizing brain edema. We demonstrate that rat brain is depleted of the antioxidant glutathione in response to hyponatremia and that osmotically-induced loss of glutathione makes neuronal cells more susceptible to oxidative injury. Total glutathione content of brain tissue decreased from 6.80 +/- 0.14 mumol/g dry wt in normonatremic controls to 5.00 +/- 0.31 mumol/g dry wt after 72 hours of hyponatremia. Following slow correction of hyponatremia, brain glutathione content returned to control values (6.77 +/- 0.34 mumol/g dry wt). Brain content of taurine, a beta-amino acid with antioxidant properties, similarly decreased in hyponatremia (29.6 +/- 0.9 to 17.1 +/- 1.2 mumol/g dry wt), then increased with slow correction (24.8 +/- 1.3 mumol/g dry wt). Although taurine served as an osmolyte in rat heart, liver and brain, osmotically-induced changes in glutathione content were found only in brain. We also studied osmotically-induced changes in glutathione and taurine content in C6 glioma and SK-N-SH neuroblastoma cells. In both cell lines, adaptive decreases in glutathione and taurine content were found in response to lowering medium sodium concentration from 140 mM to 100 mM. The cell content of these solutes increased after returning to media containing 140 mM sodium. Following exposure of both cell lines to hypoosmolar media, there was no increase in media content of glutathione. This suggest that osmotic depletion of glutathione is not due to cellular efflux of intact glutathione. We questioned if osmotic depletion of glutathione and taurine renders brain cells more susceptible to oxidative stress. Incubation of SK-N-SH cells with 1.0 mM H2O2 for four hours induced greater cytolytic injury in cells adapted to hypoosmolar media than in isoosmolar controls. Hypoosmolar C6 glioma cells were not significantly more sensitive to cytolytic injury from H2O2 than were cells grown in isosmolar media. We conclude that hypoosmolality induces glutathione depletion in rat brain in vivo and in cultured brain cells in vitro. Osmotic depletion of this antioxidant renders SK-N-SH neuronal cells more susceptible to oxidative injury.

Continuous ambulatory peritoneal dialysis complicated by Aureobasidium pullulans peritonitis

We describe a case of peritonitis caused by Aureobasidium pullulans in a patient on continuous ambulatory peritoneal dialysis (CAPD). This dematiaceous fungus rarely causes infection in humans and to date has not been reported as an etiology of CAPD-associated peritonitis. The patient was managed successfully with peritoneal catheter removal and a prolonged course of intravenous amphotericin B, allowing resumption of CAPD. In vitro susceptibility testing confirmed sensitivity of this organism to amphotericin B.

Hyperosmolality impairs ammonia-mediated inflammation: implications for the renal medulla

Although ammonia modifies the third component of complement (C3) and activates the alternative pathway, inflammation is not seen in the renal medulla where ammonia concentrations are normally elevated. We examined the effect of the unique hyperosmolar milieu of the renal medulla on the interaction of ammonia with C3 and the capacity of ammonia-modified C3 (NH3.C3) to induce cytolytic injury and stimulate neutrophils (PMN). Incubation of purified human C3 with ammonia in concentrations found in urine results in significant disruption of the C3 thiolester bond compared with ammonia-free controls. Coincubation with urinary osmolytes and hyperosmolar NaCl and urea does not impair thiolester disruption over a range of ammonia concentrations. However, hyperosmolar NaCl and urea virtually abolish cytolytic injury mediated by the alternative pathway. Coincubation with the organic osmolytes betaine, sorbitol, and inositol fails to reverse this inhibitory effect of hyperosmolar NaCl and urea. Hyperosmolar NaCl and urea also suppress lytic injury mediated by ammonia and complement in MDCK, a cell line derived from canine distal tubular epithelium. Both PMN degranulation and respiratory burst responses to NH3.C3 are significantly blunted in the presence of hyperosmolar NaCl and urea. Hyperosmolality also impairs PMN responses to the formyl peptide N-formyl-Met-Leu-Phe and phorbol 12-myristate 13-acetate (PMA). Therefore, in an in vitro setting of hyperosmolar NaCl and urea, amidation of C3 occurs, but subsequent membrane-directed and receptor-mediated functions of NH3.C3 are markedly impaired.(ABSTRACT TRUNCATED AT 250 WORDS)

Hydrogen peroxide-induced renal injury. A protective role for pyruvate in vitro and in vivo

Hydrogen peroxide (H2O2) contributes to renal cellular injury. alpha-Keto acids nonenzymatically reduce H2O2 to water while undergoing decarboxylation at the 1-carbon (1-C) position. We examined, in vitro and in vivo, the protective role of sodium pyruvate in H2O2-induced renal injury. Pyruvate effectively scavenged H2O2 in vitro, and suppressed H2O2-induced renal lipid peroxidation. Injury to LLC-PK1 cells induced by hydrogen peroxide was attenuated by pyruvate to an extent comparable to that seen with catalase. Studies utilizing [1-14C]pyruvate further demonstrated 1-C decarboxylation concurrent with cytoprotection by pyruvate from H2O2-induced injury. Pyruvate was also protective in vivo. Infusion of pyruvate before and during the intrarenal infusion of H2O2 attenuated H2O2-induced proteinuria. Systemic administration of pyruvate was also protective in the glycerol model of acute renal failure, a model also characterized by increased generation of H2O2. These findings indicate that pyruvate, a ubiquitous alpha-keto acid, scavenges H2O2 and protects renal tissue in vitro and in vivo from H2O2-mediated injury. These data suggest a potential therapeutic role for pyruvate in diseases in which increased generation of H2O2 is incriminated in renal damage.

Prevalence of coronary heart disease in Scotland: Scottish Heart Health Study

Data from 10,359 men and women aged 40-59 years from 22 districts in the Scottish Heart Health Study were used to describe the prevalence rates of coronary heart disease in Scotland in 1984-1986 and their relation to the geographical variation in mortality in these districts. Prevalence was measured by previous history, Rose chest pain questionnaire, and the Minnesota code of a 12 lead resting electrocardiogram. The prevalence of coronary heart disease in Scotland was high compared with studies from other countries that used the same standardised methods. A history of angina was more common in men (5.5%) than in women (3.9%), though in response to the Rose questionnaire 8.5% of women and 6.3% of men reported chest pain. A history of myocardial infarction was three times more common in men than women, as was a Q/QS pattern on the electrocardiogram. There were significant correlations between the different measures of coronary prevalence. District measures of angina correlated well with mortality from coronary heart disease, and these correlations tended to be stronger in women than in men. There was no significant correlation between mortality from coronary heart disease and measures of myocardial infarction. The study provides data on the prevalence of coronary heart disease in men and women that are valuable for the planning of cardiological services.

Evaluation of two formulations of dihydrocodeine using patient-controlled analgesia

A randomised, double-blind study of 90 patients after cardiac bypass surgery was undertaken to assess the relative analgesic efficacies of normal- and controlled-release oral dihydrocodeine. Patients received either placebo, normal-release dihydrocodeine, or controlled-release dihydrocodeine at regular intervals on the first to third days after operation. This was supplemented in all groups by intravenous morphine administered on demand by a patient-controlled analgesia system. Morphine requirements in the control group were significantly greater during this 48-hour period than in either of the active groups (p less than 0.01), but there was no statistically significant difference between the two active preparations.

Evaluation of a portable measure of expired-air carbon monoxide

There are a variety of independent methods of estimating smoking status; measurement of expired air carbon monoxide has proven to be reliable and convenient. This article describes a new, inexpensive, portable analyzer for measuring expired-air carbon monoxide --the Bedfont EC50. We have compared this analyzer with the standard instrument for measuring expired-air carbon monoxide in 138 normal subjects and found good correlation and agreement. The Bedfont was demonstrated to be better at identifying smoking status, and the relevance of this finding for classification of smokers and nonsmokers by fixed-threshold carbon monoxide levels is discussed. The features of the Bedfont EC50 are particularly appealing for field and clinical use.

Intraoperative hemodialysis during cardiopulmonary bypass in chronic renal failure

This report describes the features and the course of a patient on maintenance hemodialysis in whom infective endocarditis of the aortic valve ensued. The subsequent development of intractable congestive heart failure necessitated aortic valve replacement. Use of intraoperative hemodialysis, facilitating the intraoperative and postoperative management of the patient, is described. Following valve replacement the patient did well with no evidence of congestive heart failure.

Unreliable drug histories, analgesics, and changes in renal function

One hundred and nine outpatients were questioned on their use of analgesics and asked to provide urine and blood samples. Forty-one per cent said they used analgesics daily and 54% said they had ingested analgesics during the 3 days before questioning. The analgesics used were mainly aspirin or paracetamol, alone or in combination. Five (42%) of the patients who denied the use of analgesics, and 10 (29%) of those who denied intake during the preceding week, had detectable amounts of paracetamol or aspirin in their urine. Mean serum urea, although still within the normal range, increased with increasing use of analgesics. The mean serum urea of patients who used aspirin and paracetamol in combination was significantly higher than that of those who used either of the drugs alone. The findings suggest that one should not rely heavily on the history of analgesic use, and that by replacing phenacetin with paracetamol one might not have achieved much as far as renal function is concerned.

The on-off effect in Parkinson's disease treated with levodopa with remarks concerning the effect of sleep

The "On-Off Effect" in levodopa treated Parkinson's disease began in a few patients during the first year of treatment. The number of patients suffering from this phenomenon increased rapidly the first three or four years with some continuing increase throughout the six years of the study. Even those whose disease had worsened would become even more incapacitated during parts of each day. One group of patients experienced their initial "On" effect upon arising at their usual hour of awakening. This would last for 1 to 3 hours and was their best time of day.

Human cadaver kidney preservation using hypothermic hyperosmolar, intracellular washout solution

The utilization of a hypothermic, hyperosmolar, intracellular washout solution for human kidney preservation was shown to be successful in 18 kidneys obtained from 9 heart beating cadavers. The ischemic interval ranged from 2 hrs and 57 mins to 39 hrs and 48 mins. All 18 kidneys functioned within 3 hrs of revascularization. Acute tubular necrosis with oliguria was noted in 4 of 6 patients with ischemic intervals longer than 20 hrs but not in the 12 patients obtaining kidneys preserved for 19 hrs or less. All patients with acute tubular necrosis required hemodialysis for one to 16 days post-transplantation with eventual recovery.

GLC determination of phendimetrazine in serum

A sensitive, specific, and quantitative GLC method for the determination of phendimetrazine in serum is described. The procedure involves the addition of an internal standard to serum samples, followed by extraction at pH 13 into toluene. The extracted bases are back-extracted into 1 ml of 4 M hydrochloric acid and again into 100 mu1 of chloroform after making the 4 M hydrochloric acid extract basic with 1.5 ml of 4 M sodium hydroxide. The sensitivity of the method is such that 25 ng of material can be detected in 5 ml of serum.