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Sevick MA, Levine DW, Burkart JM, Rocco MV, Keith J, Cohen SJ. Measurement of Continuous Ambulatory Peritoneal Dialysis Prescription Adherence Using a Novel Approach. Perit Dial Int 2020. [DOI: 10.1177/089686089901900105] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective The purpose of the study was to test a novel approach to monitoring the adherence of continuous ambulatory peritoneal dialysis (CAPD) patients to their dialysis prescription. Design A descriptive observational study was done in which exchange behaviors were monitored over a 2-week period of time. Setting Patients were recruited from an outpatient dialysis center. Participants A convenience sample of patients undergoing CAPD at Piedmont Dialysis Center in Winston–Salem, North Carolina was recruited for the study. Of 31 CAPD patients, 20 (64.5%) agreed to participate. Measures Adherence of CAPD patients to their dialysis prescription was monitored using daily logs and an electronic monitoring device (the Medication Event Monitoring System, or MEMS; APREX, Menlo Park, California, U.S.A.). Patients recorded in their logs their exchange activities during the 2-week observation period. Concurrently, patients were instructed to deposit the pull tab from their dialysate bag into a MEMS bottle immediately after performing each exchange. The MEMS bottle was closed with a cap containing a computer chip that recorded the date and time each time the bottle was opened. Results One individual's MEMS device malfunctioned and thus the data presented in this report are based upon the remaining 19 patients. A significant discrepancy was found between log data and MEMS data, with MEMS data indicating a greater number and percentage of missed exchanges. MEMS data indicated that some patients concentrated their exchange activities during the day, with shortened dwell times between exchanges. Three indices were developed for this study: a measure of the average time spent in noncompliance, and indices of consistency in the timing of exchanges within and between days. Patients who were defined as consistent had lower scores on the noncompliance index compared to patients defined as inconsistent ( p = 0.015). Conclusions This study describes a methodology that may be useful in assessing adherence to the peritoneal dialysis regimen. Of particular significance is the ability to assess the timing of exchanges over the course of a day. Clinical implications are limited due to issues of data reliability and validity, the short-term nature of the study, the small sample, and the fact that clinical outcomes were not considered in this methodology study. Additional research is needed to further develop this data-collection approach.
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Affiliation(s)
- Mary Ann Sevick
- Departments of Public Health Sciences and Internal Medicine/Nephrology, Wake Forest University School of Medicine, Winston–Salem, North Carolina, U.S.A
| | - Douglas W. Levine
- Departments of Public Health Sciences and Internal Medicine/Nephrology, Wake Forest University School of Medicine, Winston–Salem, North Carolina, U.S.A
| | - John M. Burkart
- Departments of Public Health Sciences and Internal Medicine/Nephrology, Wake Forest University School of Medicine, Winston–Salem, North Carolina, U.S.A
| | - Michael V. Rocco
- Departments of Public Health Sciences and Internal Medicine/Nephrology, Wake Forest University School of Medicine, Winston–Salem, North Carolina, U.S.A
| | - Jennifer Keith
- Departments of Public Health Sciences and Internal Medicine/Nephrology, Wake Forest University School of Medicine, Winston–Salem, North Carolina, U.S.A
| | - Stuart J. Cohen
- Departments of Public Health Sciences and Internal Medicine/Nephrology, Wake Forest University School of Medicine, Winston–Salem, North Carolina, U.S.A
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Cohen SJ, Meister JS, deZapien JG. Special Action Groups for Policy Change and Infrastructure Support to Foster Healthier Communities on the Arizona-Mexico Border. Public Health Rep 2016; 119:40-7. [PMID: 15147648 PMCID: PMC1502256 DOI: 10.1177/003335490411900110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
As part of efforts to help stem the rising tide of diabetes among Hispanic Americans living in Arizona-Mexico border communities, the Border Health Strategic Initiative was launched to foster community-based approaches to diabetes prevention and control. A major thrust of the initiative was establishment of special community action groups (SAGs) to help stimulate policy change and sustain interventions designed to reduce the risk of diabetes and its complications. The SAGs met regularly for more than two years, focusing primarily on policies that encourage development of an infrastructure to support physical activity and healthier nutrition. Through involvement with planning commissions, parks and recreation, and private companies, two community development block grants were obtained to support new walking trails. The SAGs also encouraged elementary schools to improve physical education and change vending machine products, and grocery store owners and managers to allow the demonstration and promotion of healthier foods. These groups, focused on policy and infrastructure change within their communities, may be the glue needed to hold comprehensive community health promotion efforts together.
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Affiliation(s)
- Stuart J Cohen
- Mel and Enid Zuckerman Arizona College of Public Health, Tucson, AZ 85724-5163, USA.
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O'Neil BH, Scott AJ, Ma WW, Cohen SJ, Aisner DL, Menter AR, Tejani MA, Cho JK, Granfortuna J, Coveler AL, Olowokure OO, Baranda JC, Cusnir M, Phillip P, Boles J, Nazemzadeh R, Rarick M, Cohen DJ, Radford J, Fehrenbacher L, Bajaj R, Bathini V, Fanta P, Berlin J, McRee AJ, Maguire R, Wilhelm F, Maniar M, Jimeno A, Gomes CL, Messersmith WA. A phase II/III randomized study to compare the efficacy and safety of rigosertib plus gemcitabine versus gemcitabine alone in patients with previously untreated metastatic pancreatic cancer. Ann Oncol 2016; 27:1180. [PMID: 26945010 DOI: 10.1093/annonc/mdw095] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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O'Neil BH, Scott AJ, Ma WW, Cohen SJ, Leichman L, Aisner DL, Menter AR, Tejani MA, Cho JK, Granfortuna J, Coveler L, Olowokure OO, Baranda JC, Cusnir M, Phillip P, Boles J, Nazemzadeh R, Rarick M, Cohen DJ, Radford J, Fehrenbacher L, Bajaj R, Bathini V, Fanta P, Berlin J, McRee AJ, Maguire R, Wilhelm F, Maniar M, Jimeno A, Gomes CL, Messersmith WA. A phase II/III randomized study to compare the efficacy and safety of rigosertib plus gemcitabine versus gemcitabine alone in patients with previously untreated metastatic pancreatic cancer. Ann Oncol 2015; 26:2505. [PMID: 26489442 DOI: 10.1093/annonc/mdv477] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- B H O'Neil
- Simon Cancer Center, Indiana University School of Medicine, Indianapolis
| | - A J Scott
- University of Colorado, Denver, Aurora
| | - W W Ma
- Roswell Park Cancer Institute, Buffalo
| | - S J Cohen
- Fox Chase Cancer Center, Philadelphia
| | | | | | | | - M A Tejani
- University of Rochester Medical Center, Rochester
| | | | | | | | - O O Olowokure
- University of Cincinnati Cancer Institute, Cincinnati
| | - J C Baranda
- University of Kansas Medical Center, Westwood
| | - M Cusnir
- Mount Sinai Medical Center, Miami Beach
| | | | - J Boles
- Rex Cancer Center UNC Healthcare, Raleigh
| | | | - M Rarick
- Kaiser Permanante Northwest, Portland
| | - D J Cohen
- NYU Clinical Cancer Center, New York
| | - J Radford
- Hendersonville Hematology and Oncology at Pardee, Hendersonville
| | | | - R Bajaj
- McLeod Regional Medical Center, Florence
| | - V Bathini
- University of Massachusetts Memorial, Worcester
| | - P Fanta
- UCSD Moores Cancer Center, La Jolla
| | - J Berlin
- Vanderbilt-Ingram Cancer Center, Nashville
| | - A J McRee
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill
| | | | | | - M Maniar
- Onconova Therapeutics Inc., Newtown
| | - A Jimeno
- University of Colorado, Denver, Aurora
| | - C L Gomes
- Oncology Consortia of Criterium Inc., Saratoga Springs, USA
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O'Neil BH, Scott AJ, Ma WW, Cohen SJ, Aisner DL, Menter AR, Tejani MA, Cho JK, Granfortuna J, Coveler L, Olowokure OO, Baranda JC, Cusnir M, Phillip P, Boles J, Nazemzadeh R, Rarick M, Cohen DJ, Radford J, Fehrenbacher L, Bajaj R, Bathini V, Fanta P, Berlin J, McRee AJ, Maguire R, Wilhelm F, Maniar M, Jimeno A, Gomes CL, Messersmith WA. A phase II/III randomized study to compare the efficacy and safety of rigosertib plus gemcitabine versus gemcitabine alone in patients with previously untreated metastatic pancreatic cancer. Ann Oncol 2015; 26:1923-1929. [PMID: 26091808 PMCID: PMC4551155 DOI: 10.1093/annonc/mdv264] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 05/13/2015] [Accepted: 05/26/2015] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Rigosertib (ON 01910.Na), a first-in-class Ras mimetic and small-molecule inhibitor of multiple signaling pathways including polo-like kinase 1 (PLK1) and phosphoinositide 3-kinase (PI3K), has shown efficacy in preclinical pancreatic cancer models. In this study, rigosertib was assessed in combination with gemcitabine in patients with treatment-naïve metastatic pancreatic adenocarcinoma. MATERIALS AND METHODS Patients with metastatic pancreatic adenocarcinoma were randomized in a 2:1 fashion to gemcitabine 1000 mg/m(2) weekly for 3 weeks of a 4-week cycle plus rigosertib 1800 mg/m(2) via 2-h continuous IV infusions given twice weekly for 3 weeks of a 4-week cycle (RIG + GEM) versus gemcitabine 1000 mg/m(2) weekly for 3 weeks in a 4-week cycle (GEM). RESULTS A total of 160 patients were enrolled globally and randomly assigned to RIG + GEM (106 patients) or GEM (54). The most common grade 3 or higher adverse events were neutropenia (8% in the RIG + GEM group versus 6% in the GEM group), hyponatremia (17% versus 4%), and anemia (8% versus 4%). The median overall survival was 6.1 months for RIG + GEM versus 6.4 months for GEM [hazard ratio (HR), 1.24; 95% confidence interval (CI) 0.85-1.81]. The median progression-free survival was 3.4 months for both groups (HR = 0.96; 95% CI 0.68-1.36). The partial response rate was 19% versus 13% for RIG + GEM versus GEM, respectively. Of 64 tumor samples sent for molecular analysis, 47 were adequate for multiplex genetic testing and 41 were positive for mutations. The majority of cases had KRAS gene mutations (40 cases). Other mutations detected included TP53 (13 cases) and PIK3CA (1 case). No correlation between mutational status and efficacy was detected. CONCLUSIONS The combination of RIG + GEM failed to demonstrate an improvement in survival or response compared with GEM in patients with metastatic pancreatic adenocarcinoma. Rigosertib showed a similar safety profile to that seen in previous trials using the IV formulation.
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Affiliation(s)
- B H O'Neil
- Simon Cancer Center, Indiana University School of Medicine, Indianapolis
| | - A J Scott
- University of Colorado, Denver, Aurora
| | - W W Ma
- Roswell Park Cancer Institute, Buffalo
| | - S J Cohen
- Fox Chase Cancer Center, Philadelphia
| | | | | | - M A Tejani
- University of Rochester Medical Center, Rochester
| | | | | | | | - O O Olowokure
- University of Cincinnati Cancer Institute, Cincinnati
| | - J C Baranda
- University of Kansas Medical Center, Westwood
| | - M Cusnir
- Mount Sinai Medical Center, Miami Beach
| | | | - J Boles
- Rex Cancer Center UNC Healthcare, Raleigh
| | | | - M Rarick
- Kaiser Permanante Northwest, Portland
| | - D J Cohen
- NYU Clinical Cancer Center, New York
| | - J Radford
- Hendersonville Hematology and Oncology at Pardee, Hendersonville
| | | | - R Bajaj
- McLeod Regional Medical Center, Florence
| | - V Bathini
- University of Massachusetts Memorial, Worcester
| | - P Fanta
- UCSD Moores Cancer Center, La Jolla
| | - J Berlin
- Vanderbilt-Ingram Cancer Center, Nashville
| | - A J McRee
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill
| | | | | | - M Maniar
- Onconova Therapeutics Inc., Newtown
| | - A Jimeno
- University of Colorado, Denver, Aurora
| | - C L Gomes
- Oncology Consortia of Criterium Inc., Saratoga Springs, USA
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Wujanto R, Testa HJ, Shields RA, Prescott MC, Lawson RS, Cohen SJ. Assessment of renal function and scarring: is a DMSA scan always necessary? Contrib Nephrol 2015; 56:250-5. [PMID: 3038465 DOI: 10.1159/000413814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Cohen SJ, Konski AA, Putnam S, Ball DS, Meyer JE, Yu JQ, Astsaturov I, Marlow C, Dickens A, Cade DN, Meropol NJ. Phase I study of capecitabine combined with radioembolization using yttrium-90 resin microspheres (SIR-Spheres) in patients with advanced cancer. Br J Cancer 2014; 111:265-71. [PMID: 24983373 PMCID: PMC4102951 DOI: 10.1038/bjc.2014.344] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 05/16/2014] [Accepted: 05/27/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This was a prospective single-centre, phase I study to document the maximum tolerated dose (MTD), dose-limiting toxicity (DLT), and the recommended phase II dose for future study of capecitabine in combination with radioembolization. METHODS Patients with advanced unresectable liver-dominant cancer were enrolled in a 3+3 design with escalating doses of capecitabine (375-1000 mg/m(2) b.i.d.) for 14 days every 21 days. Radioembolization with (90)Y-resin microspheres was administered using a sequential lobar approach with two cycles of capecitabine. RESULTS Twenty-four patients (17 colorectal) were enrolled. The MTD was not reached. Haematologic events were generally mild. Common grade 1/2 non-haematologic toxicities included transient transaminitis/alkaline phosphatase elevation (9 (37.5%) patients), nausea (9 (37.5%)), abdominal pain (7 (29.0%)), fatigue (7 (29.0%)), and hand-foot syndrome or rash/desquamation (7 (29.0%)). One patient experienced a partial gastric antral perforation with a capecitabine dose of 750 mg/m(2). The best response was partial response in four (16.7%) patients, stable disease in 17 (70.8%) and progression in three (12.5%). Median time to progression and overall survival of the metastatic colorectal cancer cohort was 6.4 and 8.1 months, respectively. CONCLUSIONS This combined modality treatment was generally well tolerated with encouraging clinical activity. Capecitabine 1000 mg/m(2) b.i.d. is recommended for phase II study with sequential lobar radioembolization.
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Affiliation(s)
- S J Cohen
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - A A Konski
- Department of Radiation Oncology, Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - S Putnam
- Department of Radiology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - D S Ball
- Department of Radiology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - J E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - J Q Yu
- Department of Radiology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - I Astsaturov
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - C Marlow
- Clinical Trials Office, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - A Dickens
- Clinical Trials Office, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - D N Cade
- Sirtex Medical Ltd, Sydney, New South Wales, Australia
| | - N J Meropol
- Division of Hematology and Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
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Aggarwal C, Meropol NJ, Punt CJ, Iannotti N, Saidman BH, Sabbath KD, Gabrail NY, Picus J, Morse MA, Mitchell E, Miller MC, Cohen SJ. Relationship among circulating tumor cells, CEA and overall survival in patients with metastatic colorectal cancer. Ann Oncol 2013; 24:420-428. [PMID: 23028040 DOI: 10.1093/annonc/mds336] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND We previously reported results of a prospective trial evaluating the significance of circulating tumor cells (CTCs) in patients with metastatic colorectal cancer (mCRC). This secondary analysis assessed the relationship of the CTC number with carcinoembryonic antigen (CEA) and overall survival. PATIENTS AND METHODS Patients with mCRC had CTCs measured at baseline and specific time points after the initiation of new therapy. Patients with a baseline CEA value ≥ 10 ng/ml and CEA measurements within ± 30 days of the CTC collection were included. RESULTS We included 217 patients with mCRC who had a CEA value of ≥ 10 ng/ml. Increased baseline CEA was associated with shorter survival (15.8 versus 20.7 months, P = 0.012). Among all patients with a baseline CEA value of ≥ 25 ng/ml, patients with low baseline CTCs (<3, n = 99) had longer survival than those with high CTCs (≥ 3, n = 58; 20.8 versus 11.7 months, P = 0.001). CTCs added prognostic information at the 3-5- and 6-12-week time points regardless of CEA. In a multivariate analysis, CTCs at baseline but not CEA independently predicted survival and both CTCs and CEA independently predicted survival at 6-12 weeks. CONCLUSIONS This study demonstrates that both CEA and CTCs contribute prognostic information for patients with mCRC.
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Affiliation(s)
- C Aggarwal
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia.
| | - N J Meropol
- Department of Medicine, Division of Hematology-Oncology, Case Western Reserve University, Cleveland, USA
| | - C J Punt
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - N Iannotti
- Hematology Oncology Associates, Port Saint Lucie
| | | | - K D Sabbath
- Medical Oncology and Hematology, PC, New Haven
| | | | - J Picus
- Department of Medical Oncology, Washington University, St Louis
| | - M A Morse
- Department of Medical Oncology, Duke University Medical Center, Durham
| | - E Mitchell
- Department of Medicine, Division of Hematology-Oncology, Thomas Jefferson University, Philadelphia
| | | | - S J Cohen
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, USA
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Mackinnon AJ, Kline JL, Dixit SN, Glenzer SH, Edwards MJ, Callahan DA, Meezan NB, Haan SW, Kilkenny JD, Döppner T, Farley DR, Moody JD, Ralph JE, MacGowan BJ, Landen OL, Robey HF, Boehly TR, Celliers PM, Eggert JH, Krauter K, Frieders G, Ross GF, Hicks DG, Olson RE, Weber SV, Spears BK, Salmonsen JD, Michel P, Divol L, Hammel B, Thomas CA, Clark DS, Jones OS, Springer PT, Cerjan CJ, Collins GW, Glebov VY, Knauer JP, Sangster C, Stoeckl C, McKenty P, McNaney JM, Leeper RJ, Ruiz CL, Cooper GW, Nelson AG, Chandler GGA, Hahn KD, Moran MJ, Schneider MB, Palmer NE, Bionta RM, Hartouni EP, LePape S, Patel PK, Izumi N, Tommasini R, Bond EJ, Caggiano JA, Hatarik R, Grim GP, Merrill FE, Fittinghoff DN, Guler N, Drury O, Wilson DC, Herrmann HW, Stoeffl W, Casey DT, Johnson MG, Frenje JA, Petrasso RD, Zylestra A, Rinderknecht H, Kalantar DH, Dzenitis JM, Di Nicola P, Eder DC, Courdin WH, Gururangan G, Burkhart SC, Friedrich S, Blueuel DL, Bernstein LA, Eckart MJ, Munro DH, Hatchett SP, Macphee AG, Edgell DH, Bradley DK, Bell PM, Glenn SM, Simanovskaia N, Barrios MA, Benedetti R, Kyrala GA, Town RPJ, Dewald EL, Milovich JL, Widmann K, Moore AS, LaCaille G, Regan SP, Suter LJ, Felker B, Ashabranner RC, Jackson MC, Prasad R, Richardson MJ, Kohut TR, Datte PS, Krauter GW, Klingman JJ, Burr RF, Land TA, Hermann MR, Latray DA, Saunders RL, Weaver S, Cohen SJ, Berzins L, Brass SG, Palma ES, Lowe-Webb RR, McHalle GN, Arnold PA, Lagin LJ, Marshall CD, Brunton GK, Mathisen DG, Wood RD, Cox JR, Ehrlich RB, Knittel KM, Bowers MW, Zacharias RA, Young BK, Holder JP, Kimbrough JR, Ma T, La Fortune KN, Widmayer CC, Shaw MJ, Erbert GV, Jancaitis KS, DiNicola JM, Orth C, Heestand G, Kirkwood R, Haynam C, Wegner PJ, Whitman PK, Hamza A, Dzenitis EG, Wallace RJ, Bhandarkar SD, Parham TG, Dylla-Spears R, Mapoles ER, Kozioziemski BJ, Sater JD, Walters CF, Haid BJ, Fair J, Nikroo A, Giraldez E, Moreno K, Vanwonterghem B, Kauffman RL, Batha S, Larson DW, Fortner RJ, Schneider DH, Lindl JD, Patterson RW, Atherton LJ, Moses EI. Assembly of high-areal-density deuterium-tritium fuel from indirectly driven cryogenic implosions. Phys Rev Lett 2012; 108:215005. [PMID: 23003274 DOI: 10.1103/physrevlett.108.215005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Indexed: 06/01/2023]
Abstract
The National Ignition Facility has been used to compress deuterium-tritium to an average areal density of ~1.0±0.1 g cm(-2), which is 67% of the ignition requirement. These conditions were obtained using 192 laser beams with total energy of 1-1.6 MJ and peak power up to 420 TW to create a hohlraum drive with a shaped power profile, peaking at a soft x-ray radiation temperature of 275-300 eV. This pulse delivered a series of shocks that compressed a capsule containing cryogenic deuterium-tritium to a radius of 25-35 μm. Neutron images of the implosion were used to estimate a fuel density of 500-800 g cm(-3).
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Affiliation(s)
- A J Mackinnon
- Lawrence Livermore National Laboratory, Livermore, California 94551, USA
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Glenzer SH, MacGowan BJ, Meezan NB, Adams PA, Alfonso JB, Alger ET, Alherz Z, Alvarez LF, Alvarez SS, Amick PV, Andersson KS, Andrews SD, Antonini GJ, Arnold PA, Atkinson DP, Auyang L, Azevedo SG, Balaoing BNM, Baltz JA, Barbosa F, Bardsley GW, Barker DA, Barnes AI, Baron A, Beeler RG, Beeman BV, Belk LR, Bell JC, Bell PM, Berger RL, Bergonia MA, Bernardez LJ, Berzins LV, Bettenhausen RC, Bezerides L, Bhandarkar SD, Bishop CL, Bond EJ, Bopp DR, Borgman JA, Bower JR, Bowers GA, Bowers MW, Boyle DT, Bradley DK, Bragg JL, Braucht J, Brinkerhoff DL, Browning DF, Brunton GK, Burkhart SC, Burns SR, Burns KE, Burr B, Burrows LM, Butlin RK, Cahayag NJ, Callahan DA, Cardinale PS, Carey RW, Carlson JW, Casey AD, Castro C, Celeste JR, Chakicherla AY, Chambers FW, Chan C, Chandrasekaran H, Chang C, Chapman RF, Charron K, Chen Y, Christensen MJ, Churby AJ, Clancy TJ, Cline BD, Clowdus LC, Cocherell DG, Coffield FE, Cohen SJ, Costa RL, Cox JR, Curnow GM, Dailey MJ, Danforth PM, Darbee R, Datte PS, Davis JA, Deis GA, Demaret RD, Dewald EL, Di Nicola P, Di Nicola JM, Divol L, Dixit S, Dobson DB, Doppner T, Driscoll JD, Dugorepec J, Duncan JJ, Dupuy PC, Dzenitis EG, Eckart MJ, Edson SL, Edwards GJ, Edwards MJ, Edwards OD, Edwards PW, Ellefson JC, Ellerbee CH, Erbert GV, Estes CM, Fabyan WJ, Fallejo RN, Fedorov M, Felker B, Fink JT, Finney MD, Finnie LF, Fischer MJ, Fisher JM, Fishler BT, Florio JW, Forsman A, Foxworthy CB, Franks RM, Frazier T, Frieder G, Fung T, Gawinski GN, Gibson CR, Giraldez E, Glenn SM, Golick BP, Gonzales H, Gonzales SA, Gonzalez MJ, Griffin KL, Grippen J, Gross SM, Gschweng PH, Gururangan G, Gu K, Haan SW, Hahn SR, Haid BJ, Hamblen JE, Hammel BA, Hamza AV, Hardy DL, Hart DR, Hartley RG, Haynam CA, Heestand GM, Hermann MR, Hermes GL, Hey DS, Hibbard RL, Hicks DG, Hinkel DE, Hipple DL, Hitchcock JD, Hodtwalker DL, Holder JP, Hollis JD, Holtmeier GM, Huber SR, Huey AW, Hulsey DN, Hunter SL, Huppler TR, Hutton MS, Izumi N, Jackson JL, Jackson MA, Jancaitis KS, Jedlovec DR, Johnson B, Johnson MC, Johnson T, Johnston MP, Jones OS, Kalantar DH, Kamperschroer JH, Kauffman RL, Keating GA, Kegelmeyer LM, Kenitzer SL, Kimbrough JR, King K, Kirkwood RK, Klingmann JL, Knittel KM, Kohut TR, Koka KG, Kramer SW, Krammen JE, Krauter KG, Krauter GW, Krieger EK, Kroll JJ, La Fortune KN, Lagin LJ, Lakamsani VK, Landen OL, Lane SW, Langdon AB, Langer SH, Lao N, Larson DW, Latray D, Lau GT, Le Pape S, Lechleiter BL, Lee Y, Lee TL, Li J, Liebman JA, Lindl JD, Locke SF, Loey HK, London RA, Lopez FJ, Lord DM, Lowe-Webb RR, Lown JG, Ludwigsen AP, Lum NW, Lyons RR, Ma T, MacKinnon AJ, Magat MD, Maloy DT, Malsbury TN, Markham G, Marquez RM, Marsh AA, Marshall CD, Marshall SR, Maslennikov IL, Mathisen DG, Mauger GJ, Mauvais MY, McBride JA, McCarville T, McCloud JB, McGrew A, McHale B, MacPhee AG, Meeker JF, Merill JS, Mertens EP, Michel PA, Miller MG, Mills T, Milovich JL, Miramontes R, Montesanti RC, Montoya MM, Moody J, Moody JD, Moreno KA, Morris J, Morriston KM, Nelson JR, Neto M, Neumann JD, Ng E, Ngo QM, Olejniczak BL, Olson RE, Orsi NL, Owens MW, Padilla EH, Pannell TM, Parham TG, Patterson RW, Pavel G, Prasad RR, Pendlton D, Penko FA, Pepmeier BL, Petersen DE, Phillips TW, Pigg D, Piston KW, Pletcher KD, Powell CL, Radousky HB, Raimondi BS, Ralph JE, Rampke RL, Reed RK, Reid WA, Rekow VV, Reynolds JL, Rhodes JJ, Richardson MJ, Rinnert RJ, Riordan BP, Rivenes AS, Rivera AT, Roberts CJ, Robinson JA, Robinson RB, Robison SR, Rodriguez OR, Rogers SP, Rosen MD, Ross GF, Runkel M, Runtal AS, Sacks RA, Sailors SF, Salmon JT, Salmonson JD, Saunders RL, Schaffer JR, Schindler TM, Schmitt MJ, Schneider MB, Segraves KS, Shaw MJ, Sheldrick ME, Shelton RT, Shiflett MK, Shiromizu SJ, Shor M, Silva LL, Silva SA, Skulina KM, Smauley DA, Smith BE, Smith LK, Solomon AL, Sommer S, Soto JG, Spafford NI, Speck DE, Springer PT, Stadermann M, Stanley F, Stone TG, Stout EA, Stratton PL, Strausser RJ, Suter LJ, Sweet W, Swisher MF, Tappero JD, Tassano JB, Taylor JS, Tekle EA, Thai C, Thomas CA, Thomas A, Throop AL, Tietbohl GL, Tillman JM, Town RPJ, Townsend SL, Tribbey KL, Trummer D, Truong J, Vaher J, Valadez M, Van Arsdall P, Van Prooyen AJ, Vergel de Dios EO, Vergino MD, Vernon SP, Vickers JL, Villanueva GT, Vitalich MA, Vonhof SA, Wade FE, Wallace RJ, Warren CT, Warrick AL, Watkins J, Weaver S, Wegner PJ, Weingart MA, Wen J, White KS, Whitman PK, Widmann K, Widmayer CC, Wilhelmsen K, Williams EA, Williams WH, Willis L, Wilson EF, Wilson BA, Witte MC, Work K, Yang PS, Young BK, Youngblood KP, Zacharias RA, Zaleski T, Zapata PG, Zhang H, Zielinski JS, Kline JL, Kyrala GA, Niemann C, Kilkenny JD, Nikroo A, Van Wonterghem BM, Atherton LJ, Moses EI. Demonstration of ignition radiation temperatures in indirect-drive inertial confinement fusion hohlraums. Phys Rev Lett 2011; 106:085004. [PMID: 21405580 DOI: 10.1103/physrevlett.106.085004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Indexed: 05/30/2023]
Abstract
We demonstrate the hohlraum radiation temperature and symmetry required for ignition-scale inertial confinement fusion capsule implosions. Cryogenic gas-filled hohlraums with 2.2 mm-diameter capsules are heated with unprecedented laser energies of 1.2 MJ delivered by 192 ultraviolet laser beams on the National Ignition Facility. Laser backscatter measurements show that these hohlraums absorb 87% to 91% of the incident laser power resulting in peak radiation temperatures of T(RAD)=300 eV and a symmetric implosion to a 100 μm diameter hot core.
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Affiliation(s)
- S H Glenzer
- Lawrence Livermore National Laboratory, Livermore, California 94550, USA
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Griffith CH, Wilson JF, Haist SA, Albritton TA, Bognar BA, Cohen SJ, Hoesley CJ, Fagan MJ, Ferenchick GS, Pryor OW, Friedman E, Harrell HE, Hemmer PA, Houghton BL, Kovach R, Lambert DR, Loftus TH, Painter TD, Udden MM, Watkins RS, Wong RY. Internal medicine clerkship characteristics associated with enhanced student examination performance. Acad Med 2009; 84:895-901. [PMID: 19550183 DOI: 10.1097/acm.0b013e3181a82013] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE To determine which internal medicine (IM) clerkship characteristics are associated with better student examination performance. METHOD The authors collected data from 17 U.S. medical schools (1,817 students) regarding characteristics of their IM clerkships, including structural characteristics, pedagogical approaches, patient contact, and clinical teacher characteristics. Outcomes of interest were postclerkship National Board of Medical Examiners (NBME) subject examination score, United States Medical Licensing Examination (USMLE) 2 score, and change in score from USMLE 1 to 2. To examine how associations of various clerkship characteristics and examination performance may differ for students of different prior achievement, the authors categorized students into those who scored in the top (1/4) of the cohort on USMLE 1 and the bottom (1/4). The authors conducted analyses at both the school and the individual student levels. RESULTS In school-level analyses (using a reduced four-variable model), independent variables associated with higher NBME subject examination score were more small-group hours/week and use of community-based preceptors. Greater score increase from USMLE 1 to 2 was associated with students caring for more patients/day. Several variables were associated with enhanced student examination performance at the student level. The most consistent finding was that more patients cared for per day was associated with higher examination performance. More structured learning activities were associated with higher examination scores for students with lower baseline USMLE 1 achievement. CONCLUSION Certain clerkship characteristics are associated with better student examination performance, the most salient being caring for more patients per day.
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Cohen SJ, Punt CJA, Iannotti N, Saidman BH, Sabbath KD, Gabrail NY, Picus J, Morse MA, Mitchell E, Miller MC, Doyle GV, Tissing H, Terstappen LWMM, Meropol NJ. Prognostic significance of circulating tumor cells in patients with metastatic colorectal cancer. Ann Oncol 2009; 20:1223-9. [PMID: 19282466 DOI: 10.1093/annonc/mdn786] [Citation(s) in RCA: 378] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We demonstrated that circulating tumor cell (CTC) number at baseline and follow-up is an independent prognostic factor in metastatic colorectal cancer (mCRC). This analysis was undertaken to explore whether patient and treatment characteristics impact the prognostic value of CTCs. PATIENTS AND METHODS CTCs were enumerated with immunomagnetic separation from the blood of 430 patients with mCRC at baseline and on therapy. Patients were stratified into unfavorable and favorable prognostic groups based on CTC levels of > or = 3 or <3 CTCs/7.5 ml, respectively. Subgroups were analyzed by line of treatment, liver involvement, receipt of oxaliplatin, irinotecan, or bevacizumab, age, and Eastern Cooperative Oncology Group performance status (ECOG PS). RESULTS Seventy-one percent of deaths have occurred. Median follow-up for living patients is 25.8 months. For all patients, progression-free survival (PFS) and overall survival (OS) for unfavorable compared with favorable baseline CTCs is shorter (4.4 versus 7.8 m, P = 0.004 for PFS; 9.4 versus 20.6 m, P < 0.0001 for OS). In all patient subgroups, unfavorable baseline CTC was associated with inferior OS (P < 0.001). In patients receiving first- or second-line therapy (P = 0.003), irinotecan (P = 0.0001), having liver involvement (P = 0.002), >/=65 years (P = 0.0007), and ECOG PS of zero (P = 0.04), unfavorable baseline CTC was associated with inferior PFS. CONCLUSION Baseline CTC count is an important prognostic factor within specific subgroups defined by treatment or patient characteristics.
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Affiliation(s)
- S J Cohen
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111-2497, USA.
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Schachter KA, Cohen SJ. From research to practice: challenges to implementing national diabetes guidelines with five community health centers on the U.S.-Mexico border. Prev Chronic Dis 2004; 2:A17. [PMID: 15670470 PMCID: PMC1323320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Given the dramatic increase in type 2 diabetes in the United States, the development of effective strategies to prevent and control this potentially devastating illness is more important than ever. In the Southwest, diabetes is a far too common and rapidly growing problem among Mexican Americans living near the U.S.-Mexico border. A project designed to address this problem enabled faculty from the University of Arizona to work with community health centers to evaluate and improve diabetes care in border communities. CONTEXT This project was a component of the Border Health Strategic Initiative (Border Health iSI!) and Racial and Ethnic Approaches to Community Health 2010 (REACH 2010), both funded by the Centers for Disease Control and Prevention. University of Arizona faculty worked in partnership with five community health centers funded by the Health Resources and Services Administration. The goal of the faculty was to assist the community health centers with 1) development of measures of diabetes care based on national clinical practice guidelines, 2) identification of gaps in care based on those measures, and 3) implementation of strategies for closing those gaps. METHODS All five centers prioritized their top four or five indicators of diabetes care (e.g., annual dilated eye examination). Different community health centers selected different indicators. Baseline medical record audits were performed using the chosen indicators. Individual results were shared confidentially with providers; overall center results were shared and discussed with providers and staff. CONSEQUENCES Each clinic chose its own strategies for closing gaps in care. At one-year follow-up, there was evidence of improvement for the majority of indicators in all community health centers. However, some gaps remained. Of the three community health centers having a second-year evaluation, two maintained or increased the improvements made, but one lost ground. INTERPRETATION Our experience with these five border clinics was that translating guidelines into practice is easier said than done. Factors that favored success included an onsite champion, staff buy-in, a willingness to see systems change, and the availability of additional resources, particularly for chart reviews.
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Affiliation(s)
- Kenneth A Schachter
- Mel and Enid Zuckerman Arizona College of Public Health, Tucson, AZ 85719, USA.
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Cohen SJ, Ingram M. Border health strategic initiative: overview and introduction to a community-based model for diabetes prevention and control. Prev Chronic Dis 2004; 2:A05. [PMID: 15670458 PMCID: PMC1323308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Stuart J Cohen
- Mel and Enid Zuckerman Arizona College of Public Health, 1501 N Campbell Avenue, PO Box 245163, Tucson, AZ 85724-5163, USA.
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Din-Dzietham R, Porterfield DS, Cohen SJ, Reaves J, Burrus B, Lamb BM. Quality care improvement program in a community-based participatory research project: example of Project DIRECT. J Natl Med Assoc 2004; 96:1310-21. [PMID: 15540882 PMCID: PMC2568538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
A continuous quality care improvement program (CQIP) was built into Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) to improve providers' patterns of diabetes care and patients' glycemic control. Project DIRECT consisted of a comprehensive program aimed at reducing the burden of diabetes in the vulnerable high-risk African-American population of southeast Raleigh, NC. Forty-seven providers caring for this target population of adult diabetes patients were included in this quasi-experimental study. At the initial session, providers learned about the CQIP components, completed a planning worksheet, and chose a CQIP coordinator. Educational events included continuing education in practices and through conferences by experts, and guideline distribution. Follow-up was accomplished through phone calls and visits. Effectiveness was measured by a change in prevalence of selected patterns of care abstracted from 1,006 medical charts. Appropriate statistical methods were used to account for the cluster design and repeated measures. At the fourth follow-up year, approximately 40% of providers still participated in the program. Among the providers who stayed in the program for the whole study period, most selected quality care patterns showed significant upward trends. Glycemic control indicators did not change, however, despite an increased number of hemoglobin A1c tests per year. A diabetes CQI program can be effectively implemented in a community setting. Improved performance measures were not associated with improved outcomes. These results suggest that a patient-centered component should reinforce the provider-centered component.
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Affiliation(s)
- Rebecca Din-Dzietham
- Morehouse School of Medicine, Preventive Medicine and Community Health, Atlanta, GA 30310-1495, USA.
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Goff DC, Gu L, Cantley LK, Sheedy DJ, Cohen SJ. Quality of care for secondary prevention for patients with coronary heart disease: results of the Hastening the Effective Application of Research through Technology (HEART) trial. Am Heart J 2004; 146:1045-51. [PMID: 14660997 DOI: 10.1016/s0002-8703(03)00522-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Effective therapies for reducing mortality rates in persons with coronary heart disease (CHD) remain underused. We report the results of an effectiveness trial of a quality improvement effort to increase the use of 3-hydroxy-3methylglutaryl coenzyme A (HMG CoA) reductase inhibitors, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors in patients with CHD in a network-model managed-care setting. METHODS Patients with CHD were identified by searching a claims database. The use of therapies was assessed by linkage with a pharmacy database. An intervention, consisting of a guideline summary, peer comparison performance feedback, and patient specific chart reminders was evaluated in a randomized, practice-based effectiveness trial. RESULTS Data were available for >700 patients per year (1999-2002) in 131 practices. At baseline (1999), 55% of patients were receiving HMG CoA reductase inhibitors, 39% of patients were receiving beta-blockers, and 24% of patients were receiving ACE inhibitors. The use of all 3 types of medications increased steadily with time, with the exception of a decrease in the use of HMG CoA reductase inhibitors in the final year (2002). No difference in medication use was observed between randomized groups. CONCLUSIONS The observed pattern of care supports the contention that the quality of outpatient care for secondary prevention of CHD improved from 1999 to 2002 in this setting. The basis for the inconsistent pattern of use of HMG CoA reductase inhibitors is not certain, but may relate to concerns about toxicity. Centralized mailings of guideline summaries, performance feedback reports, and chart reminders had no observable impact on quality of care in this setting. More intensive intervention may be required to improve the quality of outpatient care for the secondary prevention of CHD.
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Affiliation(s)
- David C Goff
- Public Health Sciences and Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1063, USA.
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Cohen SJ, Meister JS, deZapien JG. Special action groups for policy change and infrastructure support to foster healthier communities on the Arizona-Mexico border. Public Health Rep 2004. [PMID: 15147648 PMCID: PMC1502256 DOI: 10.1016/j.phr.2004.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
As part of efforts to help stem the rising tide of diabetes among Hispanic Americans living in Arizona-Mexico border communities, the Border Health Strategic Initiative was launched to foster community-based approaches to diabetes prevention and control. A major thrust of the initiative was establishment of special community action groups (SAGs) to help stimulate policy change and sustain interventions designed to reduce the risk of diabetes and its complications. The SAGs met regularly for more than two years, focusing primarily on policies that encourage development of an infrastructure to support physical activity and healthier nutrition. Through involvement with planning commissions, parks and recreation, and private companies, two community development block grants were obtained to support new walking trails. The SAGs also encouraged elementary schools to improve physical education and change vending machine products, and grocery store owners and managers to allow the demonstration and promotion of healthier foods. These groups, focused on policy and infrastructure change within their communities, may be the glue needed to hold comprehensive community health promotion efforts together.
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Bland DR, Dugan E, Cohen SJ, Preisser J, Davis CC, McGann PE, Suggs PK, Pearce KF. The effects of implementation of the Agency for Health Care Policy and Research urinary incontinence guidelines in primary care practices. J Am Geriatr Soc 2003; 51:979-84. [PMID: 12834518 DOI: 10.1046/j.1365-2389.2003.51311.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To determine whether a multifaceted intervention based on the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guidelines for Urinary Incontinence would increase primary care physician screening for and management of urinary incontinence (UI). DESIGN Group randomized trial, conducted from 1996 to 1997. SETTING Internal medicine and family medicine community practices. PARTICIPANTS Forty-one primary care practices, including 57 physicians and their staff and 1,145 patients aged 60 and older. INTERVENTION Twenty of the 41 primary care practices in North Carolina were randomized to a composite intervention that included a 3-hour continuing medical education accredited course, training in management of UI, patient educational materials, and on-site physician and office support. The remaining 21 practices served as "usual care" controls. Telephone surveys of UI status and quality of life were obtained from 1,145 patients before the intervention. At 1 year, patients and physicians were contacted by telephone and mail to determine the effect of the educational intervention. MEASUREMENTS Patients completed telephone surveys to assess screening for UI, UI status, treatment interventions, and quality of life. Physicians completed surveys related to UI treatment and practice patterns. RESULTS Baseline and endpoint telephone surveys were completed by 668 of 1,145 (58%) of patients, who were cared for by 45 physicians (10 internists, 35 family medicine). Physician screening rates for UI were 22% for those patients who did not report UI. UI was reported by 39.5% of patients at baseline, of whom 30% reported being asked about UI by their primary care physician during the study. Rates of assessment and management of existing UI were low in both the control and intervention groups. Additional historical questioning indicated that 54.2% reported that they had ever undergone assessment, including history, urinalysis, or testing, or had had management of their UI by any physician. CONCLUSION Attempts at increasing screening and management of UI by primary care physicians using the AHCPR standardized guidelines using a multifaceted system of educational and logistical support were not successful. These guidelines may not be the best approach to treating UI in the primary care setting.
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Affiliation(s)
- Deirdre R Bland
- Blue Ridge Medical Associates, Winston-Salem, North Carolina 27103, USA.
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Goff DC, Gu L, Cantley LK, Parker DG, Cohen SJ. Enhancing the quality of care for patients with coronary heart disease: the design and baseline results of the hastening the effective application of research through technology (HEART) trial. Am J Manag Care 2002; 8:1069-78. [PMID: 12500883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
BACKGROUND Effective therapies exist for reducing mortality in persons with coronary heart disease (CHD), but they remain underused. OBJECTIVE To report the design and baseline results of a quality improvement project designed to increase the use of hydroxymethyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors, beta-adrenergic blocking agents, and angiotensin-converting enzyme (ACE) inhibitors in patients with CHD in a network-model managed care setting. METHODS Patients with CHD were identified by searching a claims database. Use of therapies was assessed by linkage with a pharmacy benefits database. A survey was mailed to primary care physicians to collect information related to attitudes and behavioral intentions regarding aggressive management of CHD. An intervention, consisting of a guideline summary, performance feedback, and medical chart reminders, was evaluated in a randomized, practice-based trial. RESULTS Among 1189 patients with CHD, the median prevalence of receipt of HMG-CoA reductase inhibitors, beta-adrenergic blocking agents, and ACE inhibitors across practices at baseline (the first 3 months of 1999) was 50.0%, 35.0%, and 18.8%, respectively. Reported barriers included a perception that aggressive management of CHD is thought to be unimportant by support staff yet to require significant staff time. Aggressive management of CHD was perceived to incur non-reimbursable costs, to be unimportant in their patient population, to require a great deal of patient education and self-management, and to be limited because many patients do not adhere to therapy. CONCLUSIONS Opportunities exist for enhancing the quality of care provided to patients with CHD. Our experience to date supports the logistical feasibility of implementing network-level quality enhancement efforts in managed care networks.
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Affiliation(s)
- David C Goff
- Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1063, USA.
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Matchar DB, Samsa GP, Cohen SJ, Oddone EZ, Jurgelski AE. Improving the quality of anticoagulation of patients with atrial fibrillation in managed care organizations: results of the managing anticoagulation services trial. Am J Med 2002; 113:42-51. [PMID: 12106622 DOI: 10.1016/s0002-9343(02)01131-2] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Randomized trials have indicated that well-managed anticoagulation with warfarin could prevent more than half of the strokes related to atrial fibrillation. However, many patients with atrial fibrillation who are eligible for this therapy either do not receive it or are not maintained within an optimal prothrombin time-international normalized ratio (INR) range. We sought to determine whether an anticoagulation service within a managed care organization would be a feasible alternative for providing anticoagulation care. We performed a multi-site randomized trial in six large managed care organizations in the United States. Subjects were aged 65 years or older and had nonvalvular atrial fibrillation. At each site, physician practices were divided into two geographically defined practice clusters; each site was randomly assigned to have one intervention and one control cluster. The intervention cluster received an anticoagulation service that satisfied specifications for high-quality anticoagulation care and was coordinated through the managed care organization. Control clusters continued with their usual provider-based care. We measured the proportion of time that warfarin-treated patients in each of the clusters (intervention and control) were in the target range for the INR at baseline, and again during a follow-up period. Five of the six selected sites succeeded at developing an anticoagulation service. Patients in the intervention and control clusters had similar demographic characteristics, contraindications to warfarin, and risk factors for stroke. Among patients (n = 144 in the intervention clusters; n = 118 in the control clusters) for whom data were available during the baseline and follow-up periods, the changes in percentages of time in the target range were similar for those in the intervention clusters (baseline: 47.7%; follow-up: 55.6%) and in the control clusters (baseline: 49.1%; follow-up: 52.3%; intervention effect: 5%; 95% confidence interval: -5% to 14%; P = 0.32). Although it was feasible in a managed care organization to implement anticoagulation services that were tailored to local circumstances, provision of this service did not improve anticoagulation care compared with usual care. The effect of the anticoagulation service was limited by the utilization of the service, the degree to which the referring physician supports strict adherence to recommended target ranges for the INR, and the ability of the anticoagulation service to identify and to respond to out-of-range values promptly.
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Affiliation(s)
- David B Matchar
- Center for Clinical Health Policy Research, Duke University, Durham, NC 27705, USA
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Shelton BJ, Wofford JL, Gosselink CA, McClatchey MW, Brekke K, Conry C, Wolfe P, Cohen SJ. Recruitment and retention of physicians for primary care research. J Community Health 2002; 27:79-89. [PMID: 11936759 DOI: 10.1023/a:1014598332211] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The primary objective of this report is to examine factors associated with recruitment of physicians in community-based primary care research. Reported results are based on an observational study of physician recruitment efforts undertaken in a randomized controlled trial designed to improve primary care physicians' cancer screening and counseling activities. The Partners for Prevention project was a statewide randomized controlled trial of primary care physicians selected from the state of Colorado. Two-hundred and ten eligible internal medicine and family medicine practices in both rural and urban community settings of the state of Colorado were selected into this study and a sentinel physician was chosen to represent each practice. Only 6% (13/210) of recruited practices initially declined to participate in the study, but the total refusal rate had reached 30% (59/210) by the time the intervention was implemented five months later. Study participants (n = 136) were younger (mean age 45.7 vs. 50.0, p = 0.008) and more often located in a rural area (46% vs. 31%, p = 0.04) than decliners (n = 59), but there was no association with gender of the physician (87% for females vs. 95% for males, p = 0.13). Participants were more often family practice physicians by training rather than internists (75% vs. 56%, p = 0.008), whereas there was no difference in participation rates by practice type (solo versus group, 60% vs. 64%, p = 0.52). Differences in demographic, geographic, and training characteristics between trial participants and decliners suggest the potential for better targeting of recruitment efforts. Viable strategies for recruiting community-based primary care practices to research studies are proposed.
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Affiliation(s)
- Brent J Shelton
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL 35294-0022, USA.
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Dugan E, Roberts CP, Cohen SJ, Preisser JS, Davis CC, Bland DR, Albertson E. Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians. J Am Geriatr Soc 2001; 49:462-5. [PMID: 11347792 DOI: 10.1046/j.1532-5415.2001.49094.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study explored reasons why older adults with urinary incontinence (UI) do not initiate discussions with or seek treatment for UI from their primary care provider. DESIGN A randomized, prospective controlled trial involving 41 primary care sites. SETTING Primary care practice sites. PARTICIPANTS 49 older adults age 60 and older not previously screened for UI by their primary care doctor. MEASUREMENTS Demographic data, self-reported bladder-control information using questionnaires, and health status. RESULTS Adults who did not discuss UI were older, had less-frequent leaking accidents and fewer nighttime voids and were less bothered by UI than those who did. The two main reasons why patients did not seek help were the perceptions that UI was not a big problem (45%) and was a normal part of aging (19%). CONCLUSIONS Embarrassment or lack of awareness of treatment options were not significant barriers to discussing UI. Adults with a fairly high frequency of UI (average of 1.7 episodes per day) did not view UI as abnormal or a serious medical condition.
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Affiliation(s)
- E Dugan
- Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
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Goldstein LB, Samsa GP, Bonito AJ, Cohen SJ, Matchar DB. Anticoagulation for Atrial Fibrillation: Physicians’ Readiness to Change Practices. Stroke 2001. [DOI: 10.1161/str.32.suppl_1.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
94
PURPOSE.
Determine physicians’ readiness to change anticoagulation practices for patients with non-valvular atrial fibrillation (NVAF).
BACKGROUND.
Only half of eligible NVAF patients receive warfarin. Interventions to alter physicians’ anticoagulation practices must consider their motivation to change.
METHODS.
As part of a US national survey (1993–94), physicians were asked their current practices for patients over age 65 with NVAF, and whether they were comfortable, considering change, or expecting to change those practices.
RESULTS.
Overall, 67% of eligible physicians fully responded to the survey (n=1006). Seventy-three percent (72% of non-internist primary care physicians [PCPs], 76% of internists, 69% of neurologists and 37% of surgeons) responded that they often or always anticoagulate patients over age 65 with NVAF. The majority (73%) indicated they were comfortable with their practices, with the rates differing by specialty (68% PCPs, 76% internists, 82% neurologists, 87% surgeons; p<0.001). Regardless of specialty, 78% of physicians who seldom or never anticoagulate this type of patient were comfortable with this practice. An identical proportion of physicians indicating they always or often use anticoagulants for patients with NVAF were comfortable with their practices.
CONCLUSION.
Although differing by specialty, these data show that the majority of physicians are not expecting or planning to change their anticoagulation practices for patients over age 65 with NVAF. Although the majority believe they anticoagulate such patients and are comfortable with their practices, their actual treatment patterns may differ as several studies show that high proportions of eligible AF patients do not receive warfarin. Utilization review coupled with the identification of specific practice barriers and tailored educational programs may address this discrepancy. A high proportion of physicians who responded that they seldom or never anticoagulate these patients were also comfortable with their practices. Providing current treatment guidelines reinforced by other educational strategies might motivate them to consider a change in practice.
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Affiliation(s)
- Larry B Goldstein
- Duke Univ Medical Ctr, Durham, NC; Duke Univ, Durham, NC; Research Triangle Institute, RTP, NC; Univ of Arizona, Tucson, AZ; Duke Univ, Durham, NC
| | - Gregory P Samsa
- Duke Univ Medical Ctr, Durham, NC; Duke Univ, Durham, NC; Research Triangle Institute, RTP, NC; Univ of Arizona, Tucson, AZ; Duke Univ, Durham, NC
| | - Arthur J Bonito
- Duke Univ Medical Ctr, Durham, NC; Duke Univ, Durham, NC; Research Triangle Institute, RTP, NC; Univ of Arizona, Tucson, AZ; Duke Univ, Durham, NC
| | - Stuart J Cohen
- Duke Univ Medical Ctr, Durham, NC; Duke Univ, Durham, NC; Research Triangle Institute, RTP, NC; Univ of Arizona, Tucson, AZ; Duke Univ, Durham, NC
| | - David B Matchar
- Duke Univ Medical Ctr, Durham, NC; Duke Univ, Durham, NC; Research Triangle Institute, RTP, NC; Univ of Arizona, Tucson, AZ; Duke Univ, Durham, NC
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Abstract
Optimal therapy for pancreatic adenocarcinoma requires surgical removal with tumor-free margins. Superior outcomes have been reported for high-volume centers incorporating a multidisciplinary approach. Postoperative ("adjuvant") chemotherapy and radiation should be considered in patients with successfully resected primary tumors. Combined modality treatment with chemotherapy and radiation should be considered for locally advanced, unresectable tumors. Gemcitabine can provide symptom relief and a modest improvement in survival for patients with metastatic disease. Strict attention to relief of symptoms such as pain, depression, anorexia/cachexia, and jaundice is essential in all patients with pancreatic cancer. All patients with pancreatic cancer should be encouraged to enter clinical trials of new therapies, given that long-term survival for all stages remains poor.
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Affiliation(s)
- S J Cohen
- Department of Medical Oncology, Fox Chase Cancer Center, 7701 Burholme Avenue, Philadelphia, PA 19111, USA
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Robinson JB, Cohen SJ. Climate-change analysis has been changing too. Nature 2000; 406:13. [PMID: 10894518 DOI: 10.1038/35017742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Matchar DB, Samsa GP, Cohen SJ, Oddone EZ. Community impact of anticoagulation services: rationale and design of the Managing Anticoagulation Services Trial (MAST). J Thromb Thrombolysis 2000; 9 Suppl 1:S7-11. [PMID: 10859579 DOI: 10.1023/a:1018722001817] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We describe the design of the Managing Anti-coagulation Services Trial (MAST), a practice-improvement trial testing whether anticoagulation services are a preferred method of managing anticoagulation for stroke prevention among patients with atrial fibrillation. Most randomized trials within the health care environment are designed as efficacy studies to determine what works under ideal conditions or ideal clinical practice. In contrast, effectiveness trials seek to generalize the results of efficacy studies by determining what works under more typical practice conditions. Practice-improvement trials are effectiveness trials that examine the management of a clinical problem in the context in which care is usually given. Noteworthy features of the MAST include defining the intervention in functional terms and collaboration with managed care organizations.
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Affiliation(s)
- D B Matchar
- Center for Clinical Health Policy Research, Duke University Medical Center, Durham, North Carolina 27705, USA
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Abstract
OBJECTIVES To examine the relationship of urinary incontinence (UI) and depressive symptoms (DS) in older adults. DESIGN A randomized, controlled trial to determine the effects of clinical practice guideline implementation on provider attitudes and behavior, and patients' UI, health status, quality of life, and satisfaction with care. Baseline and endpoint data were collected from patients via computer-assisted telephone interviewing. SETTING Forty-one nonacademic primary care practices (PCP) in North Carolina. PARTICIPANTS A total of 668 community-dwelling adults (age > 60) who had visited the one of the selected PCPs. INTERVENTION PCPs in the intervention group were given instruction in the detection and management of UI, educational materials for providers and patients, office system supports, and academic detailing. MEASUREMENTS The dependent measure was assessed using an eight-item screener for DS. UI (status, frequency, amount), health (physical, mental), and demographic (age, gender, marital status) and self-report information about bladder control served as predictors. RESULTS Wilcoxon rank sum tests showed that UI status was associated with moderate to severe DS (43% vs 30%, P = .05). Multivariate analyses showed that UI status, physical and mental health, and gender were significant predictors of DS. Among UI adults (n = 230), physical and mental health, life satisfaction, and the perception that UI interfered with daily life were significant predictors of DS. CONCLUSIONS This study provides clear evidence that UI is related to DS in older adults.
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Affiliation(s)
- E Dugan
- The Department of Public Health Sciences, The Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1063, USA
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Moran WP, Cohen SJ, Preisser JS, Wofford JL, Shelton BJ, McClatchey MW. Factors influencing use of the prostate-specific antigen screening test in primary care. Am J Manag Care 2000; 6:315-24. [PMID: 10977432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVE To evaluate the use of the prostate-specific antigen (PSA) test and digital rectal examination (DRE) in prostate cancer screening by primary care physicians. STUDY DESIGN Physician survey and retrospective medical record review. METHODS We randomly selected and reviewed the medical records of 3 cross-sectional samples of male patients and surveyed their primary care physicians at 1-year intervals. All the physicians practiced in Colorado. The study spanned 3 years, including late 1992, when the American Cancer Society recommended the use of PSA in a prostate cancer screening guideline. RESULTS We reviewed the medical records of 4772 male patients and surveyed 109 primary care physicians. We found that PSA testing for men aged 50 or older increased significantly from 1992 to 1994, from 24% in 1992 to 35% in 1993 and 40% in 1994 (overall odds ratio, 2.94; P < .05). Over the same time period, the DRE rate remained relatively unchanged (39% in 1992, 41% in 1993, and 36% in 1994). Overall PSA use was positively associated with patient age greater than 59 years, patient non-smoking status, physician "readiness to change cancer screening behavior," private insurance status, and nonsolo practice. Before the release of a prostate cancer screening guideline, participating physicians cited the American Cancer Society as the organization that most influenced their practice with respect to cancer screening. The magnitude of the reported influence of the American Cancer Society was correlated with the subsequent use of PSA in 1994 by primary care physicians after adjustment for change in DRE and baseline PSA rates, although the association did not reach statistical significance in multivariable regression models. CONCLUSIONS Primary care physicians in Colorado significantly increased their use of the PSA test from 1992 to 1994, during which time the American Cancer Society issued a guideline recommending the use of PSA for prostate cancer screening. The reported influence of the American Cancer Society on cancer screening practices correlated with the subsequent increase in PSA testing.
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Affiliation(s)
- W P Moran
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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Cohen SJ, Robinson D, Dugan E, Howard G, Suggs PK, Pearce KF, Carroll DD, McGann P, Preisser J. Communication between older adults and their physicians about urinary incontinence. J Gerontol A Biol Sci Med Sci 1999; 54:M34-7. [PMID: 10026660 DOI: 10.1093/gerona/54.1.m34] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Urinary incontinence (UI) is a common but undertreated condition in older adults. The study objective was to determine older patients' characteristics related to communication patterns with their physicians about UI. METHODS Telephone surveys of a sample of patients age 60 and older who visited a primary care provider (PCP) for any reason within the past 2 months were conducted. Participating physicians included general internists and family physicians from 41 primary care practices located in the 17 counties of northwest North Carolina whose 435 incontinent and 711 continent patients completed the surveys. The main outcome measures were patients' frequency and amount of urinary leakage, being asked about incontinence, and initiating a discussion of incontinence if not asked by their PCP. RESULTS Age and gender were significant independent predictors of incontinence. PCPs were significantly more likely to assess incontinent women than incontinent men (21% vs 10%, p = .053). The older cohorts of older adults were significantly more likely to be symptomatic for UI than their younger counterparts. However, the younger cohorts were more likely to be screened for incontinence by their physicians. CONCLUSIONS Despite the publication of guidelines on improving the screening and management of UI, the problem remains common and underdetected in older adults. Physicians don't ask and patients don't tell. Interventions are needed to remind physicians to screen high risk patients and to encourage patients with UI to communicate with their physicians.
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Affiliation(s)
- S J Cohen
- Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
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Sevick MA, Levine DW, Burkart JM, Rocco MV, Keith J, Cohen SJ. Measurement of continuous ambulatory peritoneal dialysis prescription adherence using a novel approach. ARCH ESP UROL 1999; 19:23-30. [PMID: 10201337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
OBJECTIVE The purpose of the study was to test a novel approach to monitoring the adherence of continuous ambulatory peritoneal dialysis (CAPD) patients to their dialysis prescription. DESIGN A descriptive observational study was done in which exchange behaviors were monitored over a 2-week period of time. SETTING Patients were recruited from an outpatient dialysis center. PARTICIPANTS A convenience sample of patients undergoing CAPD at Piedmont Dialysis Center in Winston-Salem, North Carolina was recruited for the study. Of 31 CAPD patients, 20 (64.5%) agreed to participate. MEASURES Adherence of CAPD patients to their dialysis prescription was monitored using daily logs and an electronic monitoring device (the Medication Event Monitoring System, or MEMS; APREX, Menlo Park, California, U.S.A.). Patients recorded in their logs their exchange activities during the 2-week observation period. Concurrently, patients were instructed to deposit the pull tab from their dialysate bag into a MEMS bottle immediately after performing each exchange. The MEMS bottle was closed with a cap containing a computer chip that recorded the date and time each time the bottle was opened. RESULTS One individual's MEMS device malfunctioned and thus the data presented in this report are based upon the remaining 19 patients. A significant discrepancy was found between log data and MEMS data, with MEMS data indicating a greater number and percentage of missed exchanges. MEMS data indicated that some patients concentrated their exchange activities during the day, with shortened dwell times between exchanges. Three indices were developed for this study: a measure of the average time spent in noncompliance, and indices of consistency in the timing of exchanges within and between days. Patients who were defined as consistent had lower scores on the noncompliance index compared to patients defined as inconsistent (p = 0.015). CONCLUSIONS This study describes a methodology that may be useful in assessing adherence to the peritoneal dialysis regimen. Of particular significance is the ability to assess the timing of exchanges over the course of a day. Clinical implications are limited due to issues of data reliability and validity, the short-term nature of the study, the small sample, and the fact that clinical outcomes were not considered in this methodology study. Additional research is needed to further develop this data-collection approach.
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Affiliation(s)
- M A Sevick
- Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1063, USA
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Goldstein LB, Cohen SJ, Matchar DB, Bonito AJ, Samsa GP. Physician-reported readiness to change stroke prevention practices. J Stroke Cerebrovasc Dis 1998; 7:358-63. [PMID: 17895113 DOI: 10.1016/s1052-3057(98)80055-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/1998] [Accepted: 03/12/1998] [Indexed: 11/17/2022] Open
Abstract
There are a series of possible impediments to the incorporation of new treatment modalities into clinical practice, and any intervention intended to alter practice must consider physicians' motivation and readiness to change. As part of a national survey in the United States, physicians from a variety of specialties were asked whether they were comfortable with, considering changing or expecting to make changes in their screening and treatment practices for a series of eight hypothetical patients at elevated risk of stroke. Readiness to change varied with the type of patient under consideration and with physician specialty, but not with a series of other physician and practice characteristics. Knowledge of physicians' states of readiness to change in combination with data relating to current practices and potential barriers to implementation should aid in targeting educational efforts and in the development of specific interventions to improve stroke prevention.
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Affiliation(s)
- L B Goldstein
- Center for Clinical Health Policy Research, Duke University, Durham, NC, USA
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Preisser JS, Cohen SJ, Wofford JL, Moran WP, Shelton BJ, McClatchey MW, Wolfe P. Physician and patient predictors of health maintenance visits. Arch Fam Med 1998; 7:346-51. [PMID: 9682688 DOI: 10.1001/archfami.7.4.346] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Because of a strong association between health maintenance visits (HMVs) and cancer screening, knowledge of the predictors of an HMV have implications for screening. OBJECTIVE To examine the association of an HMV with patient, physician, and practice characteristics in the primary care setting. DESIGN A statewide study of cancer screening was conducted in Colorado to determine concordance with the National Cancer Institute's guidelines for screening for breast, cervical, prostate, and skin cancer. Medical records form patients were randomly chosen from primary care practices. Predictors of an HMV were determined by fitting a logistic model to baseline data, adjusting for the cluster sampling of patients within practices. SETTING Nonacademic primary care practices in Colorado. PARTICIPANTS A total of 5746 patients aged 42 to 74 years from 132 primary care practices. MAIN OUTCOME MEASURE Whether a patient had an HMV in the previous year. RESULTS Of all patients, 31% had an HMV in the previous year. Patient characteristics associated with having HMVs included nonsmoking status, odds ratio (OR) (95% confidence interval [CI]) of 1.27 (1.11-1.46), age, and sex. Women aged 50 to 69 years were significantly more likely to have an HMV than men aged 50 to 69 years (OR, 1.30; 95% CI, 1.10-1.54). Among adults aged 70 years and older, there were no significant sex differences in receiving HMVs. Physician and practice characteristics associated with providing HMVs included practice size (> or = 3 full-time physicians) (OR, 1.34; 95% CI, 1.01-1.77), physician contemplation of changing approaches to cancer screening (OR, 1.33; 95% CI, 1.04-1.70), and physician female sex (OR, 1.33; 95% CI, 1.04-1.70). Physician age and specialty (general internist or family physician) were not associated with the level of health maintenance delivery. CONCLUSION Certain subgroups, such as smokers, patients in smaller practices, and physicians not yet considering changing their approach to cancer screening, could be targeted in future intervention studies designed to provide preventive services in primary care settings.
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Affiliation(s)
- J S Preisser
- Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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Dugan E, Cohen SJ, Robinson D, Anderson R, Preisser J, Suggs P, Pearce K, Poehling U, McGann P. The quality of life of older adults with urinary incontinence: determining generic and condition-specific predictors. Qual Life Res 1998; 7:337-44. [PMID: 9610217 DOI: 10.1023/a:1024938014606] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Urinary incontinence (UI) is an unpleasant problem for many adults. This study determined the importance of demographic, health and incontinence variables for the generic and incontinence-specific quality of life (QoL) of older adults (age > or = 60 years). Telephone surveys of adults reporting at least weekly episodes of UI (n = 435) were conducted as part of a randomized, controlled trial. Logistic regression analyses showed that the predictors of generic and incontinence-specific QoL differed. Life satisfaction, a generic outcome, was predicted by education, the number of days in bed due to health problems, the number of days not feeling well and the amount of urine lost. Generic health was related to education, the number of days sick in the previous 30 days and the number of days health issues restricted activities. The incontinence-specific QoL outcomes were predicted by age, mobility difficulties, the amount of urine lost, the frequency of UI, and the number of daytime and night-time voids. The specific QoL measures provide a different profile of those most affected in this sample than that obtained by the generic measures. The most affected are younger persons with severe urine loss. Older persons may have other conditions impinging on QoL and may have adapted behaviourally and psychologically to urine loss.
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Affiliation(s)
- E Dugan
- Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1063, USA.
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Robinson D, Pearce KF, Preisser JS, Dugan E, Suggs PK, Cohen SJ. Relationship between patient reports of urinary incontinence symptoms and quality of life measures. Obstet Gynecol 1998; 91:224-8. [PMID: 9469280 DOI: 10.1016/s0029-7844(97)00627-3] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine if patient reports of urinary incontinence symptoms can predict quality of life as measured by the short forms of the Incontinence Impact Questionnaire and the Urogenital Distress Inventory, two standardized, disease-specific instruments. METHODS Telephone surveys were conducted of 384 community dwelling incontinent women, aged 60 years and older, who admitted to at least one episode of incontinence per week during the previous 3 months. Subjects were asked if they considered the incontinence a problem, as well as questions regarding volume and frequency of voids and urine loss. Each subject completed both standardized quality of life questionnaires. Responses to incontinence symptom questions were correlated with the standardized measures. RESULTS The question, "Do you consider this accidental loss of urine a problem that interferes with your day-to-day activities or bothers you in other ways?" was the best predictor of the subject's responses to both quality-of-life measures, with a correlation coefficient of 0.69 for the Incontinence Impact Questionnaire and 0.67 for the Urogenital Distress Inventory. The patients' symptoms that best correlated with both quality of life measures and the report of bothersome incontinence were frequent episodes of incontinence (0.40-0.58), greater amounts of urine loss (0.26-0.54), and more frequent voids (0.24-0.41). CONCLUSION Primary care practitioners may screen for problematic incontinence by asking if patients' incontinence is bothersome to them and by obtaining simple historic information on voiding and leaking patterns. These questions may provide an efficient tool to detect bothersome incontinence in older women.
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Affiliation(s)
- D Robinson
- Department of Obstetrics and Gynecology, The Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina, USA.
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van Cuyck-Gandré H, Zhang HY, Tsarev SA, Clements NJ, Cohen SJ, Caudill JD, Buisson Y, Coursaget P, Warren RL, Longer CF. Characterization of hepatitis E virus (HEV) from Algeria and Chad by partial genome sequence. J Med Virol 1998. [PMID: 9407381 DOI: 10.1002/(sici)1096-9071(199712)53:4<340::aid-jmv5>3.0.co;2-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The purpose of this study was to analyze partial nucleotide sequences and derived peptide sequences of hepatitis E virus (HEV) from two outbreaks of hepatitis E in Africa (Chad 1983-1984; Algeria 1978-1980). A portion of ORF3 and the major portion of ORF2 were amplified by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR). The PCR products were sequenced directly or after cloning into the pCRII vector. Sequences were then compared to the corresponding regions of reported full length HEV sequences. In the ORF2 and ORF3 regions, the homology between the Algerian and the Chad isolates at the nucleic acid level was 92 and 95%, respectively. At the peptide level the homology was 98% in both regions. In these regions, both strains are more related to Asian strains at the nucleic acid level (89 to 95%) and at the amino acid level (95 to 100%) than to the Mexico strain. At the peptide level the differences are less apparent. Both African isolates have amino acid changes in common with some reference strains although the Chad isolate has three unique changes. These African strains of HEV, based on the ORF2 and ORF3 phylogenetic trees, appear to be a distinct phylogenetic group, separate from the Mexican and Asian strains.
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Affiliation(s)
- H van Cuyck-Gandré
- Department of Virus Diseases, Walter Reed Army Institute of Research, Washington DC, USA
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Cohen SJ. Implementing smoking cessation protocols in medical and dental practices. Tob Control 1997; 6 Suppl 1:S24-6. [PMID: 9396116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- S J Cohen
- Department of Public Health Sciences, Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina 27157-1063, USA
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Gouvea V, Cohen SJ, Santos N, Myint KS, Hoke C, Innis BL. Identification of hepatitis E virus in clinical specimens: amplification of hydroxyapatite-purified virus RNA and restriction endonuclease analysis. J Virol Methods 1997; 69:53-61. [PMID: 9504751 DOI: 10.1016/s0166-0934(97)00146-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A multi-site nested reverse transcription and polymerase chain reaction (RT-PCR) followed by restriction endonuclease analysis (REA) was developed to identify hepatitis E virus (HEV) in clinical specimens. Four sets of primers were selected to amplify regions in the HEV genome supposed to encode the helicase, polymerase, and parts of the viral capsid protein. Digestion of the nested PCR products with HinfI, HaeII, AvaII, BglI, KpnI, SmaI, or EcoRI generated readily recognizable profiles that confirm the HEV sequences and/or distinguish the unique Mexico genotype (our positive control) from all other isolates (Asian genotype). In addition, the hydroxyapatite (HA) adsorption method was compared to other adsorption and extraction methods widely used to purify viral RNA from clinical specimens for RT-PCR. All methods presented the same sensitivity of recovery of HEV RNA, but only the adsorption methods efficiently removed fecal enzymatic inhibitors. The HA method gave the best results and was the most economic in terms of time, cost, manipulations and reagents. The method was validated by screening a small number of serum and fecal specimens available from patients with acute non-A,B,C hepatitis in Nepal. HEV RNA was identified in half (5/11) of the fecal specimens obtained from patients with evidence of recent HEV infection, but in none of the 14 patients without a serological marker for hepatitis E.
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Affiliation(s)
- V Gouvea
- Department of Virus Diseases, Walter Reed Army Institute of Research, Washington, DC 20307-5100, USA.
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40
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Wofford JL, Moran WP, Cohen SJ, Simon RC. Physicians in training as quality managers: survival strategy for academic health centers. Am J Manag Care 1997; 3:1851-6. [PMID: 10178474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Being responsible for medical education places academic health centers at a disadvantage in competing for managed care contracts. Although many suggestions have been made for changing medical education to produce physicians who are better prepared for the managed care environment, few studies have shown how physicians in training can actually contribute to the competitiveness of an academic health center. We present three examples of engaging trainees in projects with a population-based perspective that demonstrate how quality improvement for the academic health center can be operationalized and even led by physicians in training. In addition to gaining experience in a managed care skill that is increasingly important for future employment, physicians in training can simultaneously improve the quality of care delivered through the academic health center.
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Affiliation(s)
- J L Wofford
- Department of Internal Medicine, Bowman Gray School of Medicine, Winston-Salem, NC 27157, USA
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41
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van Cuyck-Gandré H, Zhang HY, Tsarev SA, Clements NJ, Cohen SJ, Caudill JD, Buisson Y, Coursaget P, Warren RL, Longer CF. Characterization of hepatitis E virus (HEV) from Algeria and Chad by partial genome sequence. J Med Virol 1997; 53:340-7. [PMID: 9407381 DOI: 10.1002/(sici)1096-9071(199712)53:4<340::aid-jmv5>3.0.co;2-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The purpose of this study was to analyze partial nucleotide sequences and derived peptide sequences of hepatitis E virus (HEV) from two outbreaks of hepatitis E in Africa (Chad 1983-1984; Algeria 1978-1980). A portion of ORF3 and the major portion of ORF2 were amplified by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR). The PCR products were sequenced directly or after cloning into the pCRII vector. Sequences were then compared to the corresponding regions of reported full length HEV sequences. In the ORF2 and ORF3 regions, the homology between the Algerian and the Chad isolates at the nucleic acid level was 92 and 95%, respectively. At the peptide level the homology was 98% in both regions. In these regions, both strains are more related to Asian strains at the nucleic acid level (89 to 95%) and at the amino acid level (95 to 100%) than to the Mexico strain. At the peptide level the differences are less apparent. Both African isolates have amino acid changes in common with some reference strains although the Chad isolate has three unique changes. These African strains of HEV, based on the ORF2 and ORF3 phylogenetic trees, appear to be a distinct phylogenetic group, separate from the Mexican and Asian strains.
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Affiliation(s)
- H van Cuyck-Gandré
- Department of Virus Diseases, Walter Reed Army Institute of Research, Washington DC, USA
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42
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Gouvea V, Snellings N, Cohen SJ, Warren RL, Myint KS, Shrestha MP, Vaughn DW, Hoke CH, Innis BL. Hepatitis E virus in Nepal: similarities with the Burmese and Indian variants. Virus Res 1997; 52:87-96. [PMID: 9453147 DOI: 10.1016/s0168-1702(97)00112-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatitis E has been the predominant type of acute hepatitis in Nepal both in adults and children, in sporadic and epidemic forms. We examined six hepatitis E virus (HEV) isolates obtained during an 8-year period, from 1987 to 1995, in the Kathmandu valley of Nepal. Analysis of portions of the putative helicase, polymerase and capsid genes demonstrated close genetic relatedness among themselves (> 96.4% identity) and with the Burmese (> 95.5%) and Indian (> 95.3%) isolates, and less so with the African (> 94.4%) and the Chinese (> 91%) isolates within the Asian genotype. Phylogenetic analysis placed the Nepali isolates in the Burma-India evolutionary branch and showed that the oldest isolate, TK78/87 was more similar to the Burmese isolates whereas the most recent isolates were closer to the Indian ones. Assuming no frameshifts, the Nepali isolates showed high amino acid conservation, but also unique changes when compared to other HEV isolates. Amino acid residue 614 of the capsid protein was identified as a possible marker to distinguish the Burma-Nepal-India from the China-Central Asian Republics subgenotype, and the Mexico genotype.
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Affiliation(s)
- V Gouvea
- Division of Communicable Diseases and Immunology, Walter Reed Army Institute of Research, Washington, DC 20307-5100, USA.
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Samsa GP, Cohen SJ, Goldstein LB, Bonito AJ, Duncan PW, Enarson C, DeFriese GH, Horner RD, Matchar DB. Knowledge of risk among patients at increased risk for stroke. Stroke 1997; 28:916-21. [PMID: 9158625 DOI: 10.1161/01.str.28.5.916] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE Patients who recognize their increased risk for stroke are more likely to engage in (and comply with) stroke prevention practices than those who do not. We describe perceived risk of stroke among a nationally diverse sample of patients at increased risk for stroke and determine whether patients' knowledge of their stroke risk varied according to patients' demographic and clinical characteristics. METHODS Respondents were recruited from the Academic Medical Center Consortium (n = 621, five academic medical centers, inpatients of varying age); the Cardiovascular Health Study (n = 321, population-based sample of persons aged 65+ years); and United HealthCare (n = 319, five health plans, inpatients and outpatients typically younger than 65 years). The primary outcome was awareness of being at risk for stroke. RESULTS Only 41% of respondents were aware of their increased risk for stroke (including less than one half of patients with previous minor stroke). Approximately 74% of patients who recalled being told of their increased stroke risk by a physician acknowledged this risk in comparison with 28% of patients who did not recall being informed by a physician. Younger patients, depressed patients, those in poor current health, and those with a history of TIA were most likely to be aware of their stroke risk. CONCLUSIONS Over one half of patients at increased risk of stroke are unaware of their risk. Healthcare providers play a crucial role in communicating information about risk, and successful communication encourages adoption of stroke prevention practices. Educational messages should be targeted toward patients least likely to be aware of their risk.
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Affiliation(s)
- G P Samsa
- Center for Health Policy Research and Education, Duke University, Durham, NC 27705, USA
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Matchar DB, Samsa GP, Cohen SJ. Should we just let the anticoagulation service do it? The conundrum of anticoagulation for atrial fibrillation. J Gen Intern Med 1996; 11:768-70. [PMID: 9016428 DOI: 10.1007/bf02598998] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Klotz FW, Cohen SJ, Szarfman A, Aikawa M, Howard RJ. Cross-reactive epitope among proteins in Plasmodium falciparum Maurer's clefts and primate leukocytes and platelets. Am J Trop Med Hyg 1996; 54:655-9. [PMID: 8686788 DOI: 10.4269/ajtmh.1996.54.655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Erythrocytes infected with malaria parasites often contain membranous vesicles that are presumed to facilitate macromolecule traffic between the parasite and erythrocyte membranes. One such vesicle network, called Maurer's clefts, is expressed in Plasmodium falciparum-infected erythrocytes and contains a 50-kD polypeptide. Using a monoclonal antibody reactive with this polypeptide, we show that hepatic stages of P. falciparum express an epitope common to this blood-stage antigen. In addition, this epitope is cross-reactive with antigens expressed by primate leukocytes and platelets. Such epitopes may induce autoantibodies commonly seen in patients with malaria.
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Affiliation(s)
- F W Klotz
- Department of Immunology, Walter Reed Army Institute of Research, Washington, District of Columbia, USA
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Ritter GD, Yamshchikov G, Cohen SJ, Mulligan MJ. Human immunodeficiency virus type 2 glycoprotein enhancement of particle budding: role of the cytoplasmic domain. J Virol 1996; 70:2669-73. [PMID: 8642705 PMCID: PMC190121 DOI: 10.1128/jvi.70.4.2669-2673.1996] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Previous studies have shown that the glycoprotein cytoplasmic domains of human immunodeficiency virus type 2 (HIV-2) or simian immunodeficiency virus of macaques modulate biological activities of the viral glycoprotein complex, including syncytium formation, exterior glycoprotein conformation, and glycoprotein incorporation into budding virus particles. We have now utilized a recombinant expression system to study interactions of full-length or truncated HIV-2 glycoproteins with coexpressed HIV-2 Gag proteins which self-assemble and bud as virus-like particles. Interestingly, budding of HIV-2 virus-like particles from cells was enhanced 5- to 24-fold when Gag was coexpressed with the full-length HIV-2 glycoprotein, compared with Gag expressed either alone or with a truncated HIV-2 glycoprotein. The results obtained in this model system indicate that an additional effect of the lengthy cytoplasmic domain of the glycoprotein of HIV-2 is enhancement of particle budding. We speculate that the cytoplasmic domain of the viral glycoprotein of HIV-2 enhances budding by (i) potentiation of Gag structure or function or (ii) membrane modulation.
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Affiliation(s)
- G D Ritter
- Department of Medicine, University of Alabama at Birmingham, USA
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Cohen SJ. Maxillary molar surgery: a buccal approach to the palatal root. A review of 96 clinical cases. Ont Dent 1996; 73:34-9. [PMID: 9470619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Cohen SJ. Maxillary molar surgery: a buccal approach to the palatal root. A review of 96 clinical cases. Ont Dent 1995; 72:19-24. [PMID: 9468920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Main DS, Cohen SJ, DiClemente CC. Measuring physician readiness to change cancer screening: preliminary results. Am J Prev Med 1995; 11:54-8. [PMID: 7748587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Our objective was to describe the development and validation of an instrument for measuring physician readiness to change cancer screening and counseling. We designed a cross-sectional survey of primary care physicians. Participants were 745 enrollees in the Copic Insurance Company, a physician liability insurer of more than 80% of Colorado's physicians. A large percentage of physicians do not perceive a need to change their screening patterns for eligible patients in both mammography and Pap tests. Approximately one third of the physicians are contemplating screening more of their patients within the next six months for sigmoidoscopy, clinical skin, and oral cavity exams and counseling more of their patients on skin protection and dietary fat. Few physicians are planning significant changes in cancer screening and counseling within the next month. Scales of readiness to change screening and counseling, as well as an overall readiness-to-change scale, had high internal consistency: .81, .65, .84, for screening, counseling, and overall, respectively. We conclude that readiness to change may be a useful construct for determining if and when physicians may be willing to make behavior changes. Moreover, the assessment of physician readiness to change may facilitate the tailoring of interventions designed to foster physician behavior change and improve patient care.
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Affiliation(s)
- D S Main
- Center for Studies in Family Medicine, University of Colorado Health Sciences Center, Denver 80220, USA
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Abstract
Physicians often fail to provide nationally recommended preventive services for their patients. Addressing this, we have reviewed selected literature on changing physician behavior using the organizational construct of the "readiness for change" transtheoretical model. This model suggests that behavior evolves through stages from precontemplation, to contemplation, to preparation, to initiation, and to maintenance of change. Traditional continuing medical education may affect knowledge and beliefs, but rarely results in behavior change. However, motivational strategies such as practice feedback reports and influential peers can foster stage change. Successful interventions aimed at physicians preparing for change frequently use an office-system approach that targets not only physicians, but office staff and patients as well. Illustrating how the readiness to change model can guide the design and implementation of interventions, we describe strategies being used in a statewide randomized controlled trial to improve cancer prevention counseling and early detection by primary care physicians. The multistage interventions of Partners for Prevention include support from a medical liability carrier, a motivational videotape, a task-delineated office manual, chart flowsheets, patient activation forms, practice feedback reports, a designated prevention coordinator within each practice and regular telephone calls and office visits by project staff.
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Affiliation(s)
- S J Cohen
- Department of Public Health Sciences, Bowman Gray School of Medicine, Winston-Salem, NC 27157
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