CD200 Expression in Neuroendocrine Neoplasms

Objectives

CD200 expression has been well studied in hematopoietic malignancies; however, CD200 expression has not been well-characterized in neuroendocrine neoplasms. We examined CD200 expression in 391 neuroendocrine neoplasms from various anatomic sites.

Methods

Tissue blocks containing pulmonary small cell carcinoma, pulmonary carcinoid, large cell neuroendocrine carcinoma, pancreatic neuroendocrine tumor, gastrointestinal carcinoid, and Merkel cell carcinoma were evaluated for CD200 expression by immunohistochemistry. A set of nonneuroendocrine carcinomas was stained for comparison.

Results

CD200 was expressed in 87% of the neuroendocrine neoplasms studied, including 60 of 72 (83%) pulmonary small cell carcinomas, 15 of 22 (68%) pulmonary carcinoids, three of four (75%) pulmonary large cell neuroendocrine carcinomas, 125 of 146 (86%) Merkel cell carcinomas, 79 of 83 (95%) gastrointestinal luminal carcinoids, and 56 of 60 (93%) pancreatic neuroendocrine tumors. Thirty-two of 157 (20%) nonneuroendocrine carcinomas expressed CD200. In gastrointestinal carcinoid and pancreatic neuroendocrine neoplasms, CD200 negativity correlated with higher grade.

Conclusions

CD200 is a relatively sensitive marker of neuroendocrine neoplasms and represents a potential therapeutic target in these difficult-to-treat malignancies.

Pancreatic cancer: Update on immunotherapies and algenpantucel-L

Pancreatic adenocarcinoma is notoriously lethal, and despite improvements in systemic chemotherapy approaches bringing survival rates for metastatic disease to almost 1 year, by 2030 it is expected to become the second leading cause of cancer death. Pancreatic cancer (PC) prognosis has been associated with both the presence of intratumoral helper and cytotoxic T lymphocytes, as well as humoral immune responses to tumor associated antigens like mesothelin. It is well described that the PC microenvironment is characterized by a fibroinflammatory and immunosuppressive stroma. On these premises several immune-targeted strategies have been developed to harness the adaptable immune system with a goal of improving survival with little toxicity. Cancer vaccines involve the administration of tumor-associated antigens with the goal of inducing an endogenous anti-tumor response. Among several strategies discussed, we will focus on the algenpantucel-L (HyperAcute™ Pancreas) immunotherapy. Algenpantucel-L is a whole cell immunotherapy consisting of irradiated allogeneic PC cells genetically engineered to express the murine enzyme α(1,3)-galactosyltransferase (αGT), which ultimately leads to hyperacute rejection with complement- and antibody-dependent cytotoxicity. While phase III data in the adjuvant treatment of pancreatic cancer are pending, phase II results have been encouraging, particularly for patients who demonstrated humoral immunologic responses. Novel strategies using immune checkpoint inhibitors, costimulatory antibodies, and combinations with cancer vaccines may overcome immunotolerance and improve treatment success.

How primary care providers talk to patients about alcohol: a qualitative study

BACKGROUND

Alcohol misuse is a common and well-documented source of morbidity and mortality. Brief primary care alcohol counseling has been shown to benefit patients with alcohol misuse.

OBJECTIVE

To describe alcohol-related discussions between primary care providers and patients who screened positive for alcohol misuse.

DESIGN

An exploratory, qualitative analysis of audiotaped primary care visits containing discussions of alcohol use.

PARTICIPANTS

Participants were 29 male outpatients at a Veterans Affairs (VA) General Internal Medicine Clinic who screened positive for alcohol misuse and their 14 primary care providers, all of whom were participating in a larger quality improvement trial.

MEASUREMENTS

Audiotaped visits with any alcohol-related discussion were transcribed and coded using grounded theory and conversation analysis, both qualitative research techniques.

RESULTS

Three themes were identified: (1) patients disclosed information regarding their alcohol use, but providers often did not explore these disclosures; (2) advice about alcohol use was typically vague and/or tentative in contrast to smoking-related advice, which was more common and usually more clear and firm; and (3) discomfort on the part of the provider was evident during alcohol-related discussions.

LIMITATIONS

Generalizability of findings from this single-site VA study is unknown.

CONCLUSION

Findings from this single site study suggest that provider discomfort and avoidance are important barriers to evidence-based brief alcohol counseling. Further investigation into current alcohol counseling practices is needed to determine whether these patterns extend to other primary care settings, and to inform future educational efforts.

Readiness to change in primary care patients who screened positive for alcohol misuse

PURPOSE

Readiness to change drinking may influence the content or effectiveness of brief alcohol counseling. This study was designed to assess readiness to change and its relationship to alcohol misuse severity among primary care patients whose screening questionnaire was positive for alcohol misuse.

METHODS

This study was a cross-sectional analysis of data collected from 2 consecutive mailed questionnaires. Male outpatients at 7 Veterans Affairs (VA) general medicine clinics were eligible if they returned both questionnaires, screened positive for alcohol misuse (augmented CAGE Questionnaire > or =1 point), responded to 3 readiness-to-change questions, and completed the Alcohol Use Disorders Identification Test (AUDIT). A validated algorithm based on 3 standardized questions categorized participants into 3 readiness groups (precontemplation, contemplation, action). Measures of alcohol misuse severity included AUDIT, CAGE, and the 3 consumption questions from the AUDIT (AUDIT-C). Analyses were descriptive; linear-by-linear associations between alcohol misuse severity and readiness were tested with chi2 statistics.

RESULTS

Response rates to the first and second surveys were 59% and 55%, respectively. Of the 6,419 eligible outpatients who screened positive for alcohol misuse, 4,797 (75%) reported any readiness to change (contemplation 24%, action 51%). Among patients with AUDIT scores >8, more than 90% indicated that they drank more than they should and/or had contemplated drinking less. Greater readiness was significantly associated with greater alcohol misuse severity (P <.001 for all measures).

CONCLUSIONS

Most primary care patients who screen positive for alcohol misuse indicate some readiness to change. Contrary to stereotypes of denial, those with greater alcohol misuse severity are more likely to report readiness to change.

Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients

BACKGROUND

Primary care providers need practical methods for managing patients who screen positive for at-risk drinking. We evaluated whether scores on brief alcohol screening questionnaires and patient reports of prior alcohol treatment reflect the severity of recent problems due to drinking.

METHODS

Veterans Affairs general medicine outpatients who screened positive for at-risk drinking were mailed questionnaires that included the Alcohol Use Disorders Identification Test (AUDIT) and a question about prior alcohol treatment or participation in Alcoholics Anonymous ("previously treated"). AUDIT questions 4 through 10 were used to measure past-year problems due to drinking (PYPD). Cross-sectional analyses compared the prevalence of PYPD and mean Past-Year AUDIT Symptom Scores (0-28 points) among at-risk drinkers with varying scores on the CAGE (0-4) and AUDIT-C (0-12) and varying treatment histories.

RESULTS

Of 7861 male at-risk drinkers who completed questionnaires, 33.9% reported PYPD. AUDIT-C scores were more strongly associated with Past-Year AUDIT Symptom Scores than the CAGE (p < 0.0005). The prevalence of PYPD increased from 33% to 46% over the range of positive CAGE scores but from 29% to 77% over the range of positive AUDIT-C scores. Among subgroups of at-risk drinkers with the same screening scores, patients who reported prior treatment were more likely than never-treated at-risk drinkers to report PYPD and had higher mean Past-Year AUDIT Symptom Scores (p < 0.0005). We propose a simple method of risk-stratifying patients using AUDIT-C scores and alcohol treatment histories.

CONCLUSIONS

AUDIT-C scores combined with one question about prior alcohol treatment can help estimate the severity of PYPD among male Veterans Affairs outpatients.

Long term cryostorage of UC blood units: ability of the integral segment to confirm both identity and hematopoietic potential

BACKGROUND

With the maturation of UC blood banking, cord blood (CB) units stored for years prior to use in transplantation present a new set of issues in clinical transplantation, including interval improvements in immune typing and confirmation of product identity and viability. A preliminary analysis of the transplants supported by the St Louis Cord Blood Bank, looking for an impact of length of CB storage time and transplant outcome was performed. We evaluated the utility of an integral segment containing an aliquot of cryopreserved product that has been exposed to the same post-processing storage conditions as the unit as a quality control tool for CB banking.

METHODS

Engraftment and survival following unrelated donor UC blood transplant were evaluated based on length of CB product storage at the St Louis Cord Blood Bank. A strategy of routine testing of the contiguous segment for high-resolution HLA typing (also confirming identity) and CFU analysis was tested in 283 consecutive CB searches. Comparison between CB unit and contiguous segment viability and hematopoietic potential was performed on 30 research CB units that had been stored up to 5 years.

RESULTS

There was no statistical difference in engraftment or survival following unrelated donor cord blood transplant employing units banked < 1 year or > 3 years. Confirmatory HLA typing, CFU and viability testing was successfully performed from the same segment as part of a strategy for product release evaluation. When comparing the segment with its corresponding CB unit, the total colony-forming units (CFU) measured in the two was similar (P = 0.51, paired t-test). Three research units purposely sabotaged by an overnight thaw and refreeze had no CFU growth, but viability as measured by Trypan was still 68-98%.

DISCUSSION

No deterioration of hematopoietic potential has been detected with storage up to 5 years. The contiguous segment CFU is representative of the product, and thus is a useful tool for quality control and confirmation of product viability. Viability, as measured by Trypan blue dye exclusion may be falsely reassuring.

Integrating outcomes into computerized information systems. It's time to get guidelines off the shelf

The tools used to measure outcomes in the 21st century probably will look nothing like the tools used to measure outcomes during the past century. These guideposts (guidelines, information systems, and vocabulary) are only three of the many new tools that will be available to us through technology. The three guideposts described in this column are necessary ingredients for success in managing outcomes and demonstrating accountability. They look like the lampposts to a bright future.

A sodium channel signaling complex: modulation by associated receptor protein tyrosine phosphatase beta

Voltage-gated sodium channels in brain neurons were found to associate with receptor protein tyrosine phosphatase beta (RPTPbeta) and its catalytically inactive, secreted isoform phosphacan, and this interaction was regulated during development. Both the extracellular domain and the intracellular catalytic domain of RPTPbeta interacted with sodium channels. Sodium channels were tyrosine phosphorylated and were modulated by the associated catalytic domains of RPTPbeta. Dephosphorylation slowed sodium channel inactivation, positively shifted its voltage dependence, and increased whole-cell sodium current. Our results define a sodium channel signaling complex containing RPTPbeta, which acts to regulate sodium channel modulation by tyrosine phosphorylation.

The extracellular domain of the beta1 subunit is both necessary and sufficient for beta1-like modulation of sodium channel gating

The type IIA voltage-gated sodium Na(+) channel from rat brain is composed of a large, pore-forming alpha subunit and the auxiliary subunits beta1 and beta2. When expressed in Xenopus oocytes, the beta1 subunit modulates the gating properties of the type IIA alpha subunit, resulting in acceleration of both inactivation and recovery from inactivation and in a negative shift in the voltage dependence of fast inactivation. The beta1 subunit is composed of an extracellular domain with a single immunoglobulin-like fold, a single transmembrane segment, and a small intracellular domain. A series of chimeras with exchanges of domains between the Na(+) channel beta1 and beta2 subunits and between beta1 and the structurally related protein myelin P0 were constructed and analyzed by two-microelectrode voltage clamp in Xenopus oocytes. Only chimeras containing the beta1 extracellular domain were capable of beta1-like modulation of Na(+) channel gating. Neither the transmembrane segment nor the intracellular domain was required for modulation, although mutation of Glu(158) within the transmembrane domain altered the voltage dependence of steady-state inactivation. A truncated beta1 subunit was engineered in which the beta1 extracellular domain was fused to a recognition sequence for attachment of a glycosylphosphatidylinositol membrane anchor. The beta1(ec)-glycosylphosphatidylinositol protein fully reproduced modulation of Na(+) channel inactivation and recovery from inactivation by wild-type beta1. Our findings demonstrate that extracellular domain of the beta1 subunit is both necessary and sufficient for the modulation of Na(+) channel gating.

Functional roles of the extracellular segments of the sodium channel alpha subunit in voltage-dependent gating and modulation by beta1 subunits

Voltage-gated sodium channels consist of a pore-forming alpha subunit associated with beta1 subunits and, for brain sodium channels, beta2 subunits. Although much is known about the structure and function of the alpha subunit, there is little information on the functional role of the 16 extracellular loops. To search for potential functional activities of these extracellular segments, chimeras were studied in which an individual extracellular loop of the rat heart (rH1) alpha subunit was substituted for the corresponding segment of the rat brain type IIA (rIIA) alpha subunit. In comparison with rH1, wild-type rIIA alpha subunits are characterized by more positive voltage-dependent activation and inactivation, a more prominent slow gating mode, and a more substantial shift to the fast gating mode upon coexpression of beta1 subunits in Xenopus oocytes. When alpha subunits were expressed alone, chimeras with substitutions from rH1 in five extracellular loops (IIS5-SS1, IISS2-S6, IIIS1-S2, IIISS2-S6, and IVS3-S4) had negatively shifted activation, and chimeras with substitutions in three of these (IISS2-S6, IIIS1-S2, and IVS3-S4) also had negatively shifted steady-state inactivation. rIIA alpha subunit chimeras with substitutions from rH1 in five extracellular loops (IS5-SS1, ISS2-S6, IISS2-S6, IIIS1-S2, and IVS3-S4) favored the fast gating mode. Like wild-type rIIA alpha subunits, all of the chimeric rIIA alpha subunits except chimera IVSS2-S6 were shifted almost entirely to the fast gating mode when coexpressed with beta1 subunits. In contrast, substitution of extracellular loop IVSS2-S6 substantially reduced the effectiveness of beta1 subunits in shifting rIIA alpha subunits to the fast gating mode. Our results show that multiple extracellular loops influence voltage-dependent activation and inactivation and gating mode of sodium channels, whereas segment IVSS2-S6 plays a dominant role in modulation of gating by beta1 subunits. Evidently, several extracellular loops are important determinants of sodium channel gating and modulation.

Urinary incontinence: a program that works

Using a simple and inexpensive intervention, improvement in dryness was apparent by the first week of the study. More importantly, results were achieved by changing staff behavior, rather than residents' behavior.

New tools--new models to integrate outcomes into quality measurement

Nurse managers are faced with a changing health care system that values measurement of outcomes and performance. Today's nurse managers are confronted with the need for information to make decisions that translate information into knowledge about health care outcomes, effectiveness, efficiency, and quality. These same nurse managers are being held accountable for the efforts of nurses to enhance the health of the public. New models of evidence and outcomes integrated into the models of nursing process are required to measure quality in this new environment. Yet the measurement of outcomes and the measurement of quality should be united in this new paradigm. The author describes new tools available from the Agency for Health Care Policy and Research that could assist nurse managers in delivering and developing computerized patient record systems that capture the evidence, the clinical indicators, and the performance measures to assist in describing the outcomes of care.

Molecular determinants of Na+ channel function in the extracellular domain of the beta1 subunit

The rat brain voltage-gated Na+ channel is composed of three glycoprotein subunits: the pore-forming alpha subunit and two auxiliary subunits, beta1 and beta2, which contain immunoglobulin (Ig)-like folds in their extracellular domains. When expressed in Xenopus oocytes, beta1 modulates the gating properties of the channel-forming type IIA alpha subunit, resulting in an acceleration of inactivation. We have used a combination of deletion, alanine-scanning, site-directed, and chimeric mutagenesis strategies to examine the importance of different structural features of the beta1 subunit in the modulation of alphaIIA function, with an emphasis on the extracellular domain. Deletion analysis revealed that the extracellular domain is required for function, but the intracellular domain is not. The mutation of four putative sites of N-linked glycosylation showed that they are not required for beta1 function. Mutations of hydrophobic residues in the core beta sheets of the Ig fold disrupted beta1 function, whereas substitution of amino acid residues in connecting segments had no effect. Mutations of acidic residues in the A/A' strand of the Ig fold reduced the effectiveness of the beta1 subunit in modulating the rate of inactivation but did not significantly affect the association of the mutant beta1 subunit with the alphaIIA subunit or its effect on recovery from inactivation. Our data suggest that the Ig fold of the beta1 extracellular domain serves as a scaffold that presents the charged residues of the A/A' strands for interaction with the pore-forming alpha subunit.

Formation of the b subunit dimer is necessary for interaction with F1-ATPase

In earlier work, we [McCormick, K. A., et al. (1993) J. Biol. Chem. 268, 24683-24691] observed that mutations at Ala-79 of the b subunit affect assembly of F1F0 ATP synthase. Polypeptides modeled on the soluble portion of the b subunit (bsol) with substitutions at the position corresponding to Ala-79 have been used to investigate secondary structure and dimerization of the b subunit. Circular dichroism spectra and chymotrypsin digestion experiments suggested that the recombinant polypeptides with Ala-79 substitutions assumed conformations similar to the bsol polypeptide. However, cross-linking studies of the Ala-79 substitution bsol polypeptides revealed defects in dimerization. The efficiency of dimer formation appeared to be related to the capacity of the altered bsol polypeptides for competing with F1-ATPase for binding to F1-depleted membrane vesicles. Ala-79 substitution polypeptides displaying limited dimerization, such as bsol Ala-79-->Leu, were shown to elute with F1-ATPase during size exclusion chromatography, suggesting a specific interaction. Sedimentation equilibrium studies indicated that 8% of the bsol Ala-79-->Leu polypeptide was in the form of a 30.6 kDa dimer and 92% a 15.3 kDa monomer. When the dimer concentration of bsol Ala-79-->Leu was normalized to the concentration of bsol, both had virtually identical capacities for competing with F1-depleted membrane vesicles for binding F1-ATPase. The result indicated that the amount of dimer formed is directly proportional to its ability to bind F1-ATPase. This suggests that formation of the b subunit dimer may be a necessary step preceding F1-ATPase binding in the assembly of the enzyme complex.

The role of the Agency for Health Care Policy and Research (AHCPR) in improving outcomes of care

This article describes the various outcomes programs supported by the Agency for Health Care Policy and Research (AHCPR). The mission of the agency is to generate and disseminate information that improves the delivery and quality of health care. The agency is charged with helping consumers, providers, purchasers, health plans, and policy makers meet the challenge of improving the quality of health care services while reducing spending. AHCPR has been recognized as funding the development of "gold standard" clinical practice guidelines and the source of unbiased, science-based information on what works and does not work in health care.

Improving nursing documentation to include outcomes of care in computerized information systems

Often times when models of information systems are developed, outcomes are either left out or described as an end product of treatment alone. However, in research demonstrating outcomes, evaluating whether outcomes are achieved can best be accomplished when the outcomes are integrated into the entire care process. This paper describes a model for nursing to consider when integrating outcomes during several components of nursing care delivery, and several nursing domains for achieving outcome of care.

Including oncology outcomes of care in the computer-based patient record

Changes in the health care system have caused a shift in research to outcomes of care, effectiveness, efficiencies, clinical practice guidelines, and costs. The greater use of computer systems, including decision support systems, quality assurance systems, effectiveness systems, cost containment systems, and networks, will be required to integrate administrative and patient care data for use in determining outcomes and resource management. This article describes developments to look forward to in the decade ahead, including the integration of outcomes data and clinical practice guidelines as content into computer-based patient records; the development of review criteria from clinical practice guidelines to be used in translating guidelines into critical paths; and feedback systems to monitor performance measures and benchmarks of care, and ultimately cost out cancer care.

Modulation of cardiac Na+ channel expression in Xenopus oocytes by beta 1 subunits

Voltage-gated Na+ channels consist of a large alpha subunit of 260 kDa associated with beta 1 and/or beta 2 subunits of 36 and 33 kDa, respectively. alpha subunits of rat cardiac Na+ channels (rH1) are functional when expressed alone in Xenopus oocytes or mammalian cells. beta 1 subunits are present in the heart, and localization of beta 1 subunit mRNA by in situ hybridization shows expression in the perinuclear cytoplasm of cardiac myocytes. Coexpression of beta 1 subunits with rH1 alpha subunits in Xenopus oocytes increases Na+ currents up to 6-fold in a concentration-dependent manner. However, no effects of beta 1 subunit coexpression on the kinetics or voltage dependence of the rH1 Na+ current were detected. Increased expression of Na+ currents is not observed when an equivalent mRNA encoding a nonfunctional mutant beta 1 subunit is coexpressed. Our results show that beta 1 subunits are expressed in cardiac muscle cells and that they interact with alpha subunits to increase the expression of cardiac Na+ channels in Xenopus oocytes, suggesting that beta 1 subunits are important determinants of the level of excitability of cardiac myocytes in vivo.

Toward a uniform language for nursing in the US: work of the American Nurses Association Steering Committee on databases to support clinical practice

This paper reports on the work of the American Nurses Association Steering Committee on Databases to Support Clinical Practice, in existence since 1989. Responding to its broad charges, the Steering Committee has laid down the foundations for its work in declaring the nursing process as the framework for nursing data in database systems, and in endorsing the Nursing Minimum Data Set as the set of minimum elements for any system designed to carry health-related data that reflects nursing care. In addition, the Steering Committee has begun initiatives to: 1) promote the inclusion of nursing-related data in large health-related databases, and 2) develop a Uniform Language for nursing through a phased approach. The Steering Committee also works directly with the International Council of Nurses to promote the inclusion of nursing data in internationally used classification systems and to develop an international language that describes nursing care.

The effects of changing prompted voiding schedules in the treatment of incontinence in nursing home residents

OBJECTIVE

To determine the effects of different prompted voiding schedules on urinary incontinence on a continence unit (CU) and the maintenance of benefits on normal nursing units.

DESIGN

Multiphase study with both intra- and inter-subject comparisons.

PARTICIPANTS

Subjects were 41 consenting incontinent nursing home residents. Based on clinical criteria, subjects were assigned to one of four treatment groups that varied as to the schedule of prompted voiding received.

MEASUREMENT

The study used chart review, Katz ADL, and MMSE. Urologic status, self-initiated toileting, urine volumes voided, and incontinence assessed by pad/pants checks were measured by research nurses. Baseline pad check data were collected on residents' normal nursing units. Residents were transferred to the CU where baseline measurement was repeated, and the effects of different prompted voiding schedules were then assessed. Indigenous staff were trained to use prompted voiding, and nurse supervisors were instructed in special procedures for enhancing maintenance of the intervention. Residents were returned to their normal units and the maintenance of improvements in continence status was assessed at 2 weeks and 3 months post-CU discharge.

RESULTS

One of the four groups showed significant improvement on the CU in response to the 2-hour schedule; two groups improved on the less intensive 3-hour schedule (P < 0.05). Two groups maintained this improvement on their normal nursing units (P < 0.05); one group showed a non-significant trend toward improvement. Self-initiated toileting decreased (P < 0.05) and volume voids in an appropriate receptacle increased (P < 0.05) during training.

CONCLUSIONS

Prompted voiding is an effective treatment for urinary incontinence, and a less intensive 3-hour schedule may be superior to the standard 2-hour schedule for some residents. These improvements in dryness can be maintained by normal nursing home staff if formal staff management procedures are utilized by nurse supervisors.

Toward standard classification schemes for nursing language: recommendations of the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice

The American Nurses Association (ANA) Cabinet on Nursing Practice mandated the formation of the Steering Committee on Databases to Support Clinical Nursing Practice. The Committee has established the process and the criteria by which to review and recommend nursing classification schemes based on the ANA Nursing Process Standards and elements contained in the Nursing Minimum Data Set (NMDS) for inclusion of nursing data elements in national databases. Four classification schemes have been recognized by the Committee for use in national databases. These classification schemes have been forwarded to the National Library of Medicine (NLM) for inclusion in the Unified Medical Language System (UMLS) and to the International Council of Nurses for the development of a proposed International Classification of Nursing Practice.

Characterization of mutations in the b subunit of F1F0 ATP synthase in Escherichia coli

Site-directed mutagenesis was used to investigate the restrictions on Ala-79 of the b subunit in F1F0 adenosine triphosphate synthase. This amino acid had been previously identified as particularly sensitive to mutation (McCormick, K. A., and Cain, B. D. (1991) J. Bacteriol. 173, 7240-7248). Mutant uncF (b) genes were placed under control of the lac promoter and monitored for F1F0 ATP synthase function in an uncF(b) deletion strain. Three deleterious bAla-79 mutations were moved to the unc operon in the chromosome by homologous recombination. Decreases in enzymatic activity in the uncF (b) mutant strains resulted from reduced amounts of enzyme. With the exception of the bAla-79-->Pro mutation, high expression of mutant uncF (b) genes resulted in increases in F1F0 ATP synthase activity which were sufficient to overcome the defects. In addition to the decrease in the amount of enzyme, the bAla-79-->Lys mutation affected ATP synthesis to a much greater extent than ATP-driven proton translocation. The evidence supports our earlier hypothesis, in which bAla-79 was proposed to play an important, but not essential, structural role in F1F0 ATP synthase assembly or stability.

Behavioral management strategies for urinary incontinence

Behavioral interventions are recommended by Agency for Health Care Policy and Research Clinical Guideline as the first line of treatment for most types of urinary incontinence. This article defines and briefly describes the six behavioral treatment techniques and discusses the research base for the efficacy of each type of intervention. Caveats and needed research are also presented.

Clinical practice guidelines. The Agency for Health Care Policy and Research fosters the development of evidence-based guidelines

As medical technology increases rapidly and becomes more complex, clinical practice guidelines can help healthcare providers assess current practices and integrate technological advances. Through the Agency for Health Care Policy and Research (AHCPR), the federal government has begun to facilitate the development of clinical practice guidelines. Expert or contract panels, authorized by the AHCPR, develop guidelines on specific clinical conditions. The AHCPR guideline methodology is designed to produce evidence-based guidelines that are valid, clinically applicable, and clinically flexible. Each panel spends a year or more developing the guideline, beginning with an extensive literature search and review. The panel prepares evidence tables, statistically analyzes aggregate data (where appropriate), conducts harm and benefit analyses, and prepares health policy analyses (or cost-impact studies). During this process, the panel holds an open forum to solicit comments on the guideline topic. After this public discussion, the panel prepares a final draft of the guideline. Several hundred individuals review the guideline. Some policymakers believe clinical practice guidelines can lead to better healthcare outcomes. Guidelines can provide information in a useful format for clinicians to use at the bedside or the point of decision making in patient care. Guidelines also provide information that can be used in continuing education and professional education programs.

Urinary incontinence: an augmented prompted void approach

Continence improves from 44.7% dryness at baseline to 54.7% at the end of treatment, an improvement of 22%, or about one incontinent episode per day. Urinary incontinence is improved in cognitively impaired residents by augmenting the prompted voiding procedure with a bellpad. Bladder behavior changes with behavioral treatment strategies, because the volume voided into an appropriate receptacle increased an average of 26 mL per 2 hours. Reimbursement policies should not exclude treatment of the severely cognitively impaired nor the immobile in nursing homes.

Assessing toileting skills and habits in an adult day care center

In a structured assessment of mobility and toileting skills, all the continent clients but only 46.2% of incontinent clients were able to toilet themselves, even with verbal and physical guidance. Unobtrusive observation of toileting habits indicated that incontinent clients used the toilet less often than continent clients and used more staff assistance to do so. On mental status examination, incontinent clients scored significantly lower than continent clients. Incontinence in this population is a multidimensional disorder in which physical disability is a predominant factor.

Targeted mutagenesis of the b subunit of F1F0 ATP synthase in Escherichia coli: Glu-77 through Gln-85

Subunit b of Escherichia coli F1F0 ATP synthase contains a large hydrophilic region thought to be involved in the interaction between F1 and F0. Oligonucleotide-directed mutagenesis was used to evaluate the functional importance of a segment of this region from Glu-77 through Gln-85. The mutagenesis procedure employed a phagemid DNA template and a doped oligonucleotide primer designed to generate a predetermined collection of missense mutations in the target segment. Sixty-one mutant phagemids were identified and shown to contain nucleotide substitutions encoding 37 novel missense mutations. Mutations were isolated singly or in combinations of up to four mutations per recombinant phagemid. F1F0 ATP synthase function was studied by mutant phagemid complementation of a novel E. coli strain in which the uncF (b) gene was deleted. Complementation was assessed by observing growth on solid succinate minimal medium. Many phagemid-encoded uncF (b) gene mutations in the targeted segment resulted in growth phenotypes indistinguishable from those of strains expressing the native b subunit, suggesting abundant F1F0 ATP synthase activity. In contrast, several specific mutations were associated with a loss of enzyme function. Phagemids specifying the Ala-79----Pro, Arg-82----Pro, Arg-83----Pro, or Gln-85----Pro mutation failed to complement uncF (b) gene-deficient E. coli. F1F0 ATP synthase displayed the greatest sensitivity to mutations altering a single site in the target segment, Ala-79. The evidence suggests that Ala-79 occupies a restricted position in the enzyme complex.

Effect of postural stress on left ventricular performance using the continuous-wave Doppler technique

To evaluate the effect of postural shifts on continuous-wave Doppler indices of left ventricular performance in normal man, we recorded Doppler signals suprasternally in 69 healthy volunteers, ranging in age from 20 to 86 years, in the supine position and 2 min after assumption of sitting and standing postures. All indices decreased progressively with increasing orthostasis: peak acceleration (PKA): 15.6 +/- 4.5 m/s2 to 14.0 +/- 4.0 m/s2 to 13.6 +/- 4.6 m/s2; peak velocity (PKV): 0.64 +/- 0.18 m/s to 0.58 +/- 0.17 m/s to 0.56 +/- 0.17 m/s; stroke distance (SD): 11.4 +/- 3.7 cm to 9.8 +/- 3.4 cm to 8.0 +/- 2.8 cm; SD x heart rate (VIH): 717 +/- 272 cm to 655 +/- 268 cm to 572 +/- 217 cm, from supine to sitting to standing, respectively (p less than 0.001). In contrast heart rate increased modestly from 62.4 +/- 10.0 bpm supine, to 66.9 +/- 12.4 bpm sitting, to 71.3 +/- 9.9 bpm standing (p less than .001). Similar postural changes in Doppler variables were seen in all three age groups (20 to 44 years; 45 to 64 years; and 65 to 86 years). Thus, orthostasis in normal subjects is accompanied by a reduction in all continuous-wave Doppler indices of left ventricular performance, regardless of age.

Future data needs for quality of care monitoring, DRG considerations, reimbursement and outcome measurement

For nurses and vendors, the challenge to achieve a useful automated record involves becoming participants in the organizations defining the nursing component of the medical record. The development of systems that monitor costs, quality and access are means to better support nurses and other health professionals.

Evaluation of UNIS: Urological Nursing Information Systems

Unis is a nurse expert system prototype specifically designed to assist nurses caring for elderly, incontinent patients residing in nursing homes. Two studies measuring the performance level of UNIS were implemented. In the first study, results of sessions with UNIS on case studies of elderly, incontinent patients were compared to sessions with nurse experts. The relevance of questions, value of recommendations and overall performance were rated by an evaluation panel. In the second study, UNIS was implemented on two nursing units in a nursing home. The number of wet occurrences of patients residing on units where UNIS was consulted by nurses was compared to the number of wet occurrences of patients residing on units where UNIS was not consulted by nurses. The knowledge of urinary incontinence of nurses who consulted UNIS and those who did not consult UNIS were also compared. The results indicate that when judged by an evaluation panel, the relevance of the questions and value of the recommendations generated by UNIS were not rated significantly different than ratings assigned to nurse experts consulting on the same case studies. There was a significant difference between assigned ratings for overall performance; F.01 (4,16) = 10.4. UNIS scored the highest on four out of five case studies. In the second study, the number of wet occurrences of patients residing on units where nurses consulted UNIS decreased significantly; F.01 (2,9) = 34.67. The knowledge of urinary incontinence also improved significantly when nurses' consulted UNIS; F.001 (2,157) = 19.46. The methods and results of these two studies are presented.

Cost-effectiveness of treating incontinence in severely mobility-impaired long term care residents

Severely mobility-impaired residents in long term care facilities are usually incontinent. The incontinence and immobility predispose this group to decubitus ulcers and urinary tract infections that have been described as adding to the "consequence costs of incontinence" of $80 million per year. In this quasi-experimental study of ten subjects, a mechanical lift (Clinilift) was used with a two-hour schedule to improve incontinence. Subjects showed improvement in not only dryness but also volume of urine voided and the frequency of decubitus ulcers and UTIs. Because this incontinence treatment is labor intensive, the costs of treating incontinence increased by $2.90 over the cost of providing incontinent care. When the costs of decubitus ulcers and urinary tract infections are considered, however, the treatment savings were $13.38 per patient per day.

Do nurses consistently document incontinence?

1. Urinary incontinence is inconsistently documented on medical records of nursing home residents. 2. Documentation of urinary incontinence by professional nurses may be improved by changes in organizational factors such as staffing, policy implementation, and staff education. 3. Forms that employ cue words for eliminative status show more documentation of continence status than forms that have an open format. 4. Evaluation of changes in nursing practice in the nursing home setting can benefit from nursing studies that employ an organizational perspective.

Nursing management of urinary incontinence in geriatric inpatients

The management and treatment of incontinence represent two interrelated areas--providing enough providers of care and describing the types of management and treatment options available to the incontinent patient. This article has stressed that adequate staffing underlies any successful program of continence management and treatment. In addition, many options for the management and treatment of incontinence in the elderly have been presented. Of importance are the specific nursing implications that will make many continence protocols successful. These guidelines can provide the basis for planning patient care through the nursing process. This article has also addressed management and treatment strategies for incontinence that not only improve incontinence in patients but may cure it. These include behavioral management strategies which nurses should be encouraged to use in treating incontinent patients in the community. These same behavioral management strategies are being studied in inpatient settings, and the results indicate that nurses in inpatient settings and long-term care facilities should implement behavioral treatment programs for incontinent patients.