Patient and provider barriers to colorectal cancer screening in the primary care safety-net

OBJECTIVES

This study examines patient and provider barriers to screening for colorectal cancer among low-income uninsured African-Americans aged 50 years or older in an urban safety-net primary care clinic, with the goal of informing a future intervention.

METHODS

Four focus groups were conducted among 40 patients from, or living in the immediate neighborhood of, a primary care clinic for uninsured residents of Washington, DC. An additional focus group was conducted among primary care providers from the same clinic. Using semistructured open-ended questions, moderators elicited perceptions of barriers and promoters of colorectal cancer screening and suggestions to improve adherence to screening guidelines. The focus groups were audio-taped and transcribed verbatim. The transcripts were independently coded by two reviewers using established qualitative methodology.

RESULTS

Patient and provider comments from the five focus groups fell into one of eight content areas: primary care characteristics (36% of comments), procedural issues related to screening (16% of comments), knowledge (14% of comments), cost/insurance coverage (13%), ordering of priorities (12%), attitudes (5%), information sources (2%), and perceptions of discrimination (2%). Involving various members of the primary care team in colorectal cancer screening processes, and using reminders with feedback, were identified as promising avenues for future interventions in the safety-net setting. Patients and providers cited the lack of referral sources for colonoscopy for follow-up of abnormal fecal occult blood tests (FOBT), and lack of treatment sources as major barriers to the initiation of colorectal cancer screening in uninsured populations.

CONCLUSIONS

Organizational level interventions, such as a team approach to colorectal cancer screening, are important areas identified for future colorectal cancer screening interventions in the safety-net primary care setting. Larger policy efforts to provide coverage for screening, diagnosis, and treatment among the uninsured are critical to implementing adequate colorectal cancer screening for this population.

Interaction of normal and expanded CAG repeat sizes influences age at onset of Huntington disease

Huntington disease (HD) is a neurodegenerative disorder caused by the abnormal expansion of CAG repeats in the HD gene on chromosome 4p16.3. Past studies have shown that the size of expanded CAG repeat is inversely associated with age at onset (AO) of HD. It is not known whether the normal Huntington allele size influences the relation between the expanded repeat and AO of HD. Data collected from two independent cohorts were used to test the hypothesis that the unexpanded CAG repeat interacts with the expanded CAG repeat to influence AO of HD. In the New England Huntington Disease Center Without Walls (NEHD) cohort of 221 HD affected persons and in the HD-MAPS cohort of 533 HD affected persons, we found evidence supporting an interaction between the expanded and unexpanded CAG repeat sizes which influences AO of HD (P = 0.08 and 0.07, respectively). The association was statistically significant when both cohorts were combined (P = 0.012). The estimated heritability of the AO residual was 0.56 after adjustment for normal and expanded repeats and their interaction. An analysis of tertiles of repeats sizes revealed that the effect of the normal allele is seen among persons with large HD repeat sizes (47-83). These findings suggest that an increase in the size of the normal repeat may mitigate the expression of the disease among HD affected persons with large expanded CAG repeats.

Prevalence of attention-deficit/hyperactivity disorder in a community sample of older adolescents

OBJECTIVE

To study the prevalence and correlates of attention-deficit/hyperactivity disorder (ADHD) in a community sample of older adolescents.

METHOD

From 1986 to 1988, 3,419 seventh, eighth, and ninth graders were screened with the Center for Epidemiologic Studies-Depression Scale. The top decile scorers and a random sample of the remainder were interviewed with the Schedule for Affective Disorders and Schizophrenia for School-Age Children. These data are from the second wave of interviews (N = 490, mean age = 18.65).

RESULTS

The weighted prevalence of DSM-III-R ADHD was 1.51% (males: 2.62%, females: 0.54%). Significant associations (p < .05) were found for gender (male), comorbid affective disorders, baseline undesirable life events, and fewer than two biological parents at baseline. Family cohesion (p = .058) is inversely associated with ADHD. For subjects not meeting the age-at-onset criterion, 1.94% met the eight symptom criteria, and females (3.2%) were more prevalent than males (0.3%).

CONCLUSIONS

ADHD remains a problem in this sample of older adolescents and is often comorbid with affective disorders. A significant number report eight ADHD symptoms but do not meet the age-at-onset criterion. This group deserves research attention.

Sequencing of the cholesteryl ester transfer protein 5' regulatory region using artificial transposons

We have isolated and sequenced genomic clones encompassing more than 5 kb of the 5' flanking region of the cholesteryl ester transfer protein gene. This region contains multiple Alu repeats, a Mermaid repeat, and an extensive GA repeat, which made sequencing exceedingly difficult. To circumvent the problems that these repeats posed to traditional sequencing methodologies, we employed a novel transposon-facilitated technique, which greatly simplified sequencing of regions that had been difficult to accomplish otherwise. We utilized the artificial transposon, AT-2, a Bluescript derivative containing the dhfr gene and unique primer sites at both ends of the insertion DNA. Integration of the transposon occurred efficiently and covered the entire region of interest. Analysis of the sequence indicates a number of potential regulatory factor binding sites upstream of the previously characterized minimal promoter. The 5.7-kb regulatory region confers significant transcriptional activation in a conditionally transformed mouse hepatocyte line as compared to a minimal 137-bp promoter fragment. In addition, a tetranucleotide repeat of variable length that may provide a useful genetic marker has been identified 2 kb upstream of the CETP transcriptional start site.

Detection of HIV-1 DNA in cells and tissue by fluorescent in situ 5'-nuclease assay (FISNA)

The critical aspects of successful in situ amplification include fixation, permeabilization, amplification and detection. We address these aspects and present a novel detection scheme that eliminates hybridization following amplification. We use the 5'-nuclease activity of Taq polymerase to cleave in situ a 5'-reporter dye from an oligonucleotide probe which hybridizes to the target amplicon during amplification. The 5'-reporter dye is disassociated from the 3'-quenching dye and remains localized by charge interactions. In addition, we describe probe design constraints for 5'-nuclease assays both in solution and in situ. Using this technique, we show the sensitive and specific detection of HIV-1 DNA in cells lines and tissue from HIV-1-infected individuals.

Development of an epidural abscess following staphylococcal septicemia in an acutely burned patient: case report

A 57-year-old black female burned in a house fire sustained 22.5% total body surface area burns. On postburn day 45, she developed Staphylococcus aureus septicemia, and vancomycin was begun. On postburn day 50, quadriplegia developed. Magnetic resonance imaging revealed an anterior cervical mass, and cervical drainage of a staphylococcal cervical abscess was conducted. Antibiotics were continued. The patient regained almost complete neurologic function and was discharged doing well.

Effect of peer counselors on breastfeeding initiation, exclusivity, and duration among low-income urban women

This study examined the effect of support from trained peer counselors on breastfeeding initiation, duration, and exclusivity among low-income urban women. Training of counselors, under the supervision of a registered nurse certified in lactation, adapted education techniques from Paulo Freire to provide information about lactation management and other health care issues. The study compared infant feeding practices of women who planned to breastfeed and received support from counselors (counselor group, N = 59) to women who requested counselors but, owing to inadequate numbers of trained counselors, did not have a counselor (No-counselor group, N = 43). Women in the counselor group had significantly greater (p < .05) breastfeeding initiation (93 percent vs. 70 percent), exclusivity (77 percent vs. 40 percent), and duration (mean of 15 weeks vs. mean of 8 weeks) than women in the no-counselor group. The findings suggest that peer counselors, well-trained, and with on-going supervision, can have a positive effect on breastfeeding practices among low-income urban women who intend to breastfeed.

Phenotypic conversions in renal development

The transporting epithelia of the kidney are derived from an embryonic rudiment containing two distinct cell populations: ureteric bud epithelia and mesenchymal cells of the metanephric blastema. The ureteric bud is a caudal outgrowth of the Wolffian Duct and gives rise to the renal collecting system by branching morphogenesis. The metanephric blastema gives rise to diverse cells of the nephron after receiving an inductive stimulus. It has been proposed that mesenchymal progenitors of the metanephric blastema derive directly from intermediate mesoderm, although this hypothesis has never been tested directly. Utilizing direct lineage analysis techniques we demonstrate, in an organ culture system, that mesenchymal nephron progenitors are immediate descendants of ureteric bud epithelia. Ureteric bud epithelia can give rise to mesenchymal nephron progenitors that populate the metanephric blastema by undergoing an epithelial-to-mesenchymal transition followed by delamination. If this process occurs in vivo, renal morphogenesis can be characterized by two phenotypic conversions: an epithelial-to-mesenchymal transition leading to the generation of mesenchymal-nephron progenitors, followed by a mesenchymal-to-epithelial transition leading to the generation of diverse nephron epithelial cell types. We have immortalized an embryonic renal mesenchymal cell line and demonstrate that the clonal cell line, RSTEM-1, undergoes phenotypic conversions in vitro, providing a suitable model to study the regulation of the epithelial phenotype.

Anomalous expression of P-glycoprotein in highly drug-resistant human KB cells

KB-A1 and KB-A10 are 2 multi-drug-resistant cell lines which are 100- and 1,000-fold resistant to Adriamycin, respectively. We have examined the expression of P-glycoprotein at the molecular and cellular levels in these human carcinoma cells. Both MDR cell lines, when compared to the parental KB-3-1, show characteristic increases in mdr 1 gene copy number, an increase in mdr 1 mRNA expression, a corresponding increase in transcription rate and a consequent over-expression of P-glycoprotein. However, the more highly resistant KB-A10 cells have a lower gene copy number, express less mdr 1 mRNA and contain less P-glycoprotein than the A1 cell line. To determine whether higher levels of cellular resistance were attributable to enhanced efficacy of P-glycoprotein or to other cellular regulatory mechanisms, we examined other major cellular properties known to be associated with the mdr phenotype. Both the KB-A1 and KB-A10 lines exhibit similar increases in protein kinase C activity as compared to the drug-sensitive parent. In addition, neither glutathione-S-transferase nor topoisomerase II activities account for enhanced resistance of the KB-A10 cells. The above observations are contrary to the premise that the level of drug resistance is necessarily proportional to expression of P-glycoprotein or to other common factors thought to participate in drug insensitivity; consequently, new mechanisms of resistance must be in operation in these cells.

Expression of c-fos in human and murine multidrug-resistant cells

In both mouse sarcoma 180 and human KB cells selected for the multiple drug resistance (MDR) phenotype, there is an elevation in the steady state mRNA level of c-fos. There is no detectable gene amplification for c-fos, nor is there any significant change in the rate of mRNA transcription or degradation, suggesting that other factors are responsible for the increased expression level in resistance. Cells selected for resistance to methotrexate, a drug not in the MDR group, do not have an increase in c-fos mRNA expression. When drug-sensitive cells are exposed for 30 min to an ED50 concentration of vinblastine, Adriamycin, colchicine, or VP-16, but not to methotrexate or cisplatin, there is a 3-6-fold induction in the level of c-fos message. Because the former drugs are members of the MDR class and the latter are not, the results are consistent with the hypothesis that induction of c-fos by low levels of cytotoxic drugs may be an early event in the acquisition of the MDR phenotype. If this were the case, then c-fos would be expected to act in concert with c-jun to control transcription by binding to a specific DNA regulatory site. Consistent with this explanation is the existence of an AP-1 sequence in the promotor region for the P-glycoprotein gene (mdr1), as well as the fact that c-jun is also overexpressed in MDR cells.

Asthma in the vicinity of power stations: II. Outdoor air quality and symptoms

To assess longitudinally the effect of living in the vicinity of coal-fired power stations on children with asthma, 99 schoolchildren with a history of wheezing in the previous 12 months were studied for 1 year, using daily diaries and measurements of air quality. The children had been identified in a cross-sectional survey of two coastal areas: Lake Munmorah (LM), within 5 km of two power stations, and Nelson Bay (NB), free from major industry. Daily air quality [sulphur dioxide (SO2) and nitrogen oxides (NOx)], respiratory symptoms, and treatment for asthma were recorded throughout the year. Measurements of SO2 and NOx at LM were well within recommended guidelines although they were several times higher than at NB: maximum daily levels in SO2 (micrograms/m3) were 26 at LM, 11 at NB (standard, 365); yearly average SO2 was 2 at LM, 0.3 at NB (standard, 60); yearly average NOx (micrograms/m3) was 2 at LM, 0.4 at NB (standard, 94). Marked weekly fluctuations occurred in the prevalence of cough, wheezing, and breathlessness, without any substantial differences between LM and NB. Overall, the prevalence of symptoms was low (10% for wheezing, 20% for any symptom). Whether the daily SO2 and NOx levels affected the occurrence of respiratory symptoms was investigated in children at LM using a logistic regression (Korn and Whittemore technique). For these children as a group, air quality measurements were not associated with the occurrence of symptoms.

Asthma in the vicinity of power stations: I. A prevalence study

Respiratory symptoms, atopy, and bronchial reactivity were measured in primary school children living in Lake Munmorah (LM), a coastal town near two power stations, and in Nelson Bay (NB), a coastal town free from any possible major sources of outdoor air pollution. A prevalence survey and longitudinal follow-up study were performed 1 year apart. In both studies, the prevalence of ever wheezed, current wheezing, breathlessness, wheezing with exercise, diagnosed asthma, and use of drugs for asthma at LM were all approximately double the prevalence at NB (all P values less than 0.01). The prevalence of bronchial reactivity was significantly greater at LM than NB (P less than 0.01) at the first but not the second survey. By contrast, no significant differences were found between the two areas for skin test atopy or for parental history of allergic disease. Multivariate analysis supported the conclusion from the univariate analysis that there was more wheezing at LM compared to NB at both studies, when adjusted for atopy, smoking in the home, age, and sex. As expected, a positive skin test reaction to house dust mite was the predominant explanatory variable. Asthma was more common in the community near power stations (LM) than in the NB area. The absence of significant differences in skin test atopy and parental history of allergic disease argued against major genetic differences between the two groups. By contrast, the more common reporting of siblings' chest disease and asthma in Lake Munmorah supported an environmental cause.

Comparison of preservative-free and preservative-containing ipratropium bromide

A double-blind crossover study was performed on 33 children with asthma to compare the effectiveness of nebulized solutions of preservative-containing and preservative-free ipratropium bromide. Both solutions produced bronchodilation. No significant differences were found between the two solutions at any time after nebulization in minimum and maximum changes from baseline value or in the areas under the lung function time curves. The presently formulated preservative-containing ipratropium bromide solution was not shown to be inferior to a preservative-free compound.

Early discharge with home follow-up: impacts on low-income mothers and infants

Low-income mothers and infants discharged at 24 to 47 hours after birth were compared to two control groups: early discharge with infant separation and conventional discharge. No differences among the three groups in maternal or infant morbidity at seven to 15 days postdelivery were recorded. Simultaneous early discharge was associated with higher maternal attachment scores, fewer maternal concerns, and greater maternal satisfaction with discharge type than early discharge with infant separation. All three groups had substantial morbidity in the first two weeks of life. A shorter hospital stay and more health monitoring postdischarge may be a better use of health resources than a conventional hospital stay for low-income mothers and their infants.

A case of developmental right hemisphere dysfunction: implications for psychiatric diagnosis and management

The authors present the case of an adult woman who was treated in the mental health system for many years for a syndrome of mixed anxiety and depression unresponsive to psychopharmacologic or psychotherapeutic treatment. A computed tomography scan revealed asymmetrical enlargement of the right temporal horn. This finding, as well as findings of severe difficulties in spatial relations together with mildly abnormal posturing of the left hand when walking (especially when the gait was stressed), suggested that the patient had a developmental disability of the right cerebral hemisphere. The authors conclude that because such patients might appear to have primarily psychiatric rather than neurologic problems, the diagnosis of right hemisphere dysfunction should be considered when the clinical presentation is indicative of atypical anxiety and affective disorders.

Effect of a folate-binding protein on the plasma transport and tissue distribution of folic acid

Folic acid (3H-pteroylglutamic acid or 75Se-selenofolate) administered free or bound to folate-binding protein (FABP) was rapidly cleared from the plasma but the plasma survival when bound to FABP was longer than unbound during the initial 5 min. 75Se-folate bound to FABP is more rapidly taken up by the liver than when administered as free 75-Se-folate. 125I-labeled FABP was rapidly cleared from the plasma (90% in 5 min). The rapid uptake of FABP, a sialoglycoprotein, was inhibited by the preadministration of desialyzed fetuin. Following the hepatic uptake of 75Se-folate/FABP, only free 75Se-folate was found in the bile. The total biliary secretion of 75Se-folate over 240 min was 63% when administered bound to FABP and 33% when administered as free 75Se-folate. The liver retained 33.5% of the 125I activity 5 min following the administration of 125I-FABP, while only 4.46% of the 125I activity was secreted into the bile over 180 min. This data suggests that FABP may play an important role in the enterohepatic circulation of folates by directing nonmethylated folates to the liver.

An evaluation of behavioral techniques reinforced with an anorectic drug in a double-blind weight loss study

Sixty obese outpatients participated in a double-blind comparison of diethylpropion hydrochloride and placebo in conjunction with a behavior modification program for weight reduction. Assessments of efficacy and program acceptance included total weight loss, percent of initial (baseline) weight loss, percent excess weight lost, effectiveness of overall program, and helpfulness of medication. Diethylpropion was significantly better than placebo in all five assessments. An added behavioral technique, a substantial refundable deposit of money, reduced the attrition rate of all study entrants from 50% to 10%; thus patient compliance was greatly enhanced.

A dying patient: the question of euthanasia

Mrs. A. B., a 61-year-old woman who presented with carcinoma of the breast in 1964, was readmitted to the hospital in 1974 in respiratory distress ensuing from chronic lung disease and metastatic illness. An active member of Alcoholics Anonymous for the past sixteen years, she had a living pattern in which she felt in control of herself, and from which she derived an important sense of self-esteem. Although in the hospital she requested that no extraordinary measures be taken to prolong her life, when she went into respiratory failure the house staff on duty intubated her and placed her in the Intensive Care Unit. Even though her physical condition rapidly improved, the patient told her own physician that she wanted to be extubated and off Intensive Care, despite her knowledge of a probable short survival. When her request was agreed to, contrary to expectations, she continued to improve. A lawyer, interested in problems of dying and euthanasia, interviewed her, and subsequently Psychosocial Rounds were held. The general conclusions at the Rounds were that she would die an appropriate death, and that euthanasia would not be possible under current circumstances. The staff at the Conference decided to accept at face value her request that she be allowed to die without heroic measures and with dignity.

Living dangerously--the effect of chronic pulmonary and renal failure on self-image

Patients with severe chronic obstructive lung disease (COLD) are difficult to interview because of their inability to verbalize freely. The draw-a-person (DAP) and the draw-a-house (DAH) tests were given to COLD patients (n = 14), and to patients on chronic renal dialysis (n = 14). The COLD patients showed significantly more disorganization in the drawings (p less than 0.05 for DAP and p less than 0.001 for DAH) than the renal patients. There were certain other findings specific to the circumstances of each disorder. The DAP and DAH may be clinically useful in rapidly identifying the patients in need of greater psychosocial support.

Ego-supportive care in open-heart surgery

Open heart surgery has been shown to have a rate of occurrence of postoperative psychopathological phenomena (9 percent-57 percent) many times greater than that of general surgery (1/1500). These phenomena result from an interplay of organic, environmental, psychological, and social factors which act on the integrative and coping capacity of the ego.

Treatment is accomplished through support of the ego by: 1) establishment of a relationship, 2) reassurance, 3) environmental support, 4) consultative relationships with staff, 5) ventilation of feelings, 6) medical measures in support of somatic function, and 7) anti-anxiety drugs. Such supportive measures are usually effective in bringing about a rapid remission of these psychopathological phenomena.