Intersectoral coordination and diabetes prevention: building capacity through professional agency

Background

Intersectoral coordination of disease prevention is highly complex. The case of women who develop diabetes during pregnancy (GDM) is a case in point: intersectoral coordination mainly concerns diabetes prevention and thus stretches over the life course of women and their families. Our study aims to analyse how health professions through their day-to-day practice contribute to the creation, maintenance and transformation of intersectoral coordination of diabetes prevention over the life course; and how contexts at systems/organisational influences such processes.

Methods

The study draws on organisational studies of professions and focuses on the mechanisms underlying the making of intersectoral coordination. As part of a pilot study, we conducted a review of the international literature on intersectoral coordination of public health, a review of national policy documents, and a secondary analysis of interviews conducted as part of the development of the Face-it intervention.

Results

The organisation of GDM diabetes prevention in Denmark emerges as fragmented. Care pathways are divided between different phases, types of services, sectors and health professions. There are additional variations among municipalities. Formal (intersectoral) coordination is also limited to vulnerable women and their families. GDM diabetes prevention involves a broad range of professions; professional agency in GDM diabetes prevention is dispersed. Clinical specialists in hospitals show the strongest interest, rooted in healthcare knowledge on prevention. General practitioners have a similar knowledge base, but consider prevention less central. The same applies to health visitors and midwives, whose knowledge base also includes social care.

Conclusions

Individual professions have a strong capacity for intersectoral agency. Strengthening this capacity requires alignment across professions and adaptation to specific contexts.

Total plasma proANP increases with atrial dilatation in horses

Equine atrial natriuretic peptide (ANP) plasma concentrations are correlated with left atrial size. However, species-specific assays are lacking and the results from human assays are poorly reproducible. A new methodology called processing independent analysis (PIA) that measures the total proANP product in plasma has proven to be successful in human medicine, but has never been used in horses. The aims were to establish an equine proANP reference interval by measurement of the total proANP product using PIA and to examine the proANP concentrations in horses with atrial dilatation. Sample stability was studied by comparison of storage at -80°C and -20°C. Plasma samples were obtained from 23 healthy horses, 12 horses with moderate or severe valvular regurgitation without atrial dilatation and 42 horses with valvular regurgitation and atrial dilatation. The proANP concentration was significantly (P<0.001) higher in horses with atrial dilatation (761.4 (442.1-1859.1) pmol/l) than in healthy horses (491.6 (429.5-765.9) pmol/l; P<0.001) or horses with cardiac disease but without atrial dilatation (544.4 (457.0-677.6) pmol/l). A cut-off value (573.8 pmol/l) for detection of atrial dilatation was calculated. Sample storage at -80°C did not differ from sample storage at -20°C. The measurement of total proANP in plasma detects atrial dilatation in horses and may be useful for clinical evaluation in equine medicine.

Explanatory factors of sexual function in sexual minority women breast cancer survivors

BACKGROUND

The sexual function of sexual minority women (women with female partners) who are breast cancer survivors is mostly unknown. Our objective is to identify explanatory factors of sexual function among sexual minority women with breast cancer and compare them with a control sample of sexual minority women without cancer.

PATIENTS AND METHODS

Using a conceptual framework that has previously been applied to heterosexual breast cancer survivors, we assessed the relationship of each explanatory factor to sexual function in sexual minority women. Using generalized estimating equations, we identified explanatory factors of sexual function and identified differences by case and control status.

RESULTS

Self-perception of greater sexual attractiveness and worse urogenital menopausal symptoms explain 44% of sexual function, after controlling for case and control status. Focusing only on partnered women, 45% of sexual function was explained by greater sexual attractiveness, postmenopausal status, and greater dyadic cohesion.

CONCLUSIONS

All of the relevant explanatory factors for sexual function among sexual minority survivors are modifiable as has been suggested for heterosexual survivors. Sexual minority survivors differ from heterosexual survivors in that health-related quality of life is less important as an explanatory factor. These findings can guide adaptation of interventions for sexual minority survivors.

Berufsstatus und Morbiditätsentwicklung von Krankenversicherten im Zeitraum 1990 bis 2003

In Germany there are only insufficient data both with regard to general morbidity events as well as with regard to the effects of specific professions on the morbidity process. For this reason the data of the Gmuender Ersatzkasse (GEK) have been analysed with a longitudinal design for the period 1990 to 2003. Our sample includes all employed members of the GEK who had been insured as of January 1, 1990 and were between 30 and 59 years old at this baseline. The total sample comprises 129,173 men and 13,567 women. The statistical analysis was performed with the statistical package "Transitional Data Analysis" (TDA) which was developed especially for longitudinal data. The analysis includes both cumulated morbidity rates as well as transition rates (Cox regression). The analysis shows that the cumulated morbidity rates of the seven diseases are higher for women than for men in the age category 30-39 years. In the age categories 40-49 and 50-59 years the cumulated morbidity rates are higher for men than for women. With regard to the occupations, the highest morbidity rates are found for manual occupations and services without special skills. The lowest rates are found for professions with high skills, engineers and managers. The results of the longitudinal analysis show distinctive social gradients. For occupations with lower skills the morbidity rates are about 100 percent higher than those of occupations with higher skills. Longitudinal analyses on the basis of health insurance fund data can make an important contribution to the monitoring of health and morbidity and should therefore be conducted also by other health insurance funds.

Wnt signaling in lymphopoiesis

Wnt signaling elicits changes in gene expression and cell physiology through beta-catenin and LEF1/TCF proteins. The signal transduction pathway regulates many cellular and developmental processes, including cell proliferation, cell fate decisions and differentiation. In cells that have been stimulated by a Wnt protein, cytoplasmic beta-catenin is stabilized and transferred to the nucleus, where it interacts with the nuclear mediators of Wnt signaling, the LEF1/TCF proteins, to elicit a transcriptional response. Loss-of-function and gain-of-function experiments in the mouse have provided insight into the role of this signaling pathway in lymphopoiesis. The self-renewal and maintenance of hematopoietic stem cells is regulated by Wnt signals. Differentiation of T cells and natural killer cells is blocked in the absence of LEF1/TCF proteins, and pro-B cell proliferation is regulated by Wnt signaling.

[Association of malignant tumors of the conjunctiva and HIV infection in Kinshasa (D. R. Congo). First results]

BACKGROUND

Conjunctival carcinomas are tumors especially of the 6th/7th decades. They occur in Germany with a frequency of 1/20,000. For years it has been well known that in Africa the number of malignant tumors of the conjunctiva has been increasing. The reasons for that are not well known. HIV is a possible pathogenetic cofactor.

METHOD

A histological examination of 34 specimens was performed in Rostock on conjunctival tumors removed at the Ophthalmologic Department of the University of Kinshasa in 2001. The study included 23 female and 11 male patients aged 20-75 years (mean 42). All patients underwent serological investigation for HIV infection.

RESULTS

Of 34 patients 18 were HIV positive. Of the HIV-positive patients, six had a squamous cell carcinoma, seven a CIN (conjunctival intraepithelial neoplasia) I-III, and five a pinguecula. Of the HIV-negative patients, five showed a squamous cell carcinoma, eight a CIN I-III, one a pinguecula, one a sebaceous gland carcinoma, and one a papilloma. The average age of the HIV-positive patients with a squamous cell carcinoma was 41 years compared to the HIV-negative patients with 58 years.

CONCLUSIONS

There was no difference in frequency of conjunctival intraepithelial neoplasia between HIV-positive or HIV-negative patients. HIV-positive patients with a squamous cell carcinoma were on average 17 years younger. UV radiation is the main risk factor and HIV infection is a possible carcinogenic cofactor. Investigations on additional viral infections as possible pathogenetic factors and on changed tumor suppressor genes are needed.

Wirtschaftlichkeit ambulanter Rehabilitation - Abschließende Ergebnisse eines Projektes in Mecklenburg-Vorpommern

This article presents the final results of a project comparing the economic effects of outpatient and inpatient rehabilitation in Mecklenburg-Vorpommern. The data analysed have been derived from the total population of applicants for orthopaedic-traumatologic rehabilitation who are suitable for outpatient rehabilitation in all criteria. The randomized and controlled study at first verified whether the outcome parameters of the two variants of rehabilitation are approximately equal. If this condition is fulfilled the differences between amounts and periods of payments and costs incumbent on the pension insurance agency are analyzed. And in fact, the final results confirm that, in suitable patients, outpatient rehabilitation can achieve approximately the same outcomes as inpatient rehabilitation -- but at distinctly lower cost.

Herpes zoster guideline of the German Dermatology Society (DDG)

Varicella zoster virus (VZV) causes varicella (chickenpox), remains dormant in dorsal root and cranial nerve ganglia and can be reactivated as a consequence of declining VZV-specific cellular immunity leading to herpes zoster (shingles). Patients older than 50 years of age affected by herpes zoster may suffer a significant decrease of quality of life. These patients and immunocompromised individuals are at increased risks for severe complications, involving the eye, the peripheral and the central nervous system (prolonged pain, postherpetic neuralgia). Such complications occur with and without cutaneous symptoms. The German Dermatology Society (DDG) has released guidelines in order to guarantee updated management to anyone affected by herpes zoster. Diagnosis is primarily clinical. The gold standard of laboratory diagnosis comprises PCR and direct identification of VZV in cell cultures. Detection of IgM- and IgA-anti VZV antibodies may be helpful in immunocompromised patients. Therapy has become very effective in the last years. Systemic antiviral therapy is able to shorten the healing process of acute herpes zoster, to prevent or to alleviate pain and other acute and chronic complications, particularly, when given within 48 h to a maximum of 72 h after onset of the rash. Systemic antiviral therapy is urgently indicated in patients beyond the age of 50 years and in patients at any age with herpes zoster in the head and neck area, especially in patients with zoster ophthalmicus. Further urgent indications are severe herpes zoster on the trunk and on the extremities, herpes zoster in immunosuppressed patients and in patients with severe atopic dermatitis and severe ekzema. Only relative indications for antiviral therapy exist in patients younger than 50 years with zoster on the trunk and on the extremities. In Germany acyclovir, valacyclovir, famciclovir and brivudin are approved for the systemic antiviral treatment of herpes zoster. These compounds are all well tolerated by the patients and do not differ with regard to efficacy and safety. Brivudin has a markedly higher anti-VZV potency than oral acyclovir, valacyclovir and famciclovir and thus offers a simpler dosing regimen. It must be given only once daily during 7 days in comparison to three and five times dosing per day of valacyclovir, famciclovir and acyclovir, respectively. Brivudin is an antiviral agent with no nephrotoxic properties, which is an advantage when compared to acyclovir. The most important aim of therapy of herpes zoster is to achieve painlessness. Appropriately dosed analgesics in combination with a neuroactive agent (i.e. amitriptylin) are very helpful when given together with antiviral therapy. The additive therapy with corticosteroids may shorten the degree and duration of acute zoster pain, but has no essential effect on the development of postherpetic neuralgia, which is a very difficult condition to treat. Thus early presentation to a pain therapist is recommended in specific cases.

Weekly oxaliplatin, high-dose infusional 5-fluorouracil and folinic acid as palliative third-line therapy of advanced colorectal carcinoma

The efficacy of oxaliplatin combined with high-dose 5-fluorouracil (5-FU) and folinic acid (FA) as an outpatient salvage treatment for patients with metastasized colorectal cancer was retrospectively analyzed in one center. Tumor progression had occurred for the majority of patients during two regimens (n = 11) otherwise during one (n = 1) regimen of prior 5-FU-based chemotherapy, which had been applied in a standardized sequential fashion. As third-line therapy oxaliplatin was infused intravenously over 2 h at a dose of 60 mg/m2 prior to a 2-h infusion of FA (500 mg/m2). 5-FU (2,600 mg/m2) was subsequently given over 24 h. A favorable response was observed in 9/12 (75%) of the heavily pretreated patients, including partial remissions in 3/12, minor responses in 2/12 and stable disease in 4/12 patients. The median progression free time was 23 weeks (interquartile range i. r. 0-28) for all patients, the median survival time from start of third-line therapy 55 weeks (i. r. 40-86). The median survival time from the beginning of first-line palliative chemotherapy was 34 months (i. r. 25-45 months). The highest toxicity was WHO grade III and was observed in six patients: Nausea (2), diarrhea (3), vomiting (2) and peripheral neuropathy (1). The quality of life was not adversely affected by the oxaliplatin/5-FU/FA-regimen as assessed by the EORTC QLQ-C30 questionnaire. Thus, the results show the efficiency and low toxicity of oxaliplatin/high-dose 5-FU/FA as palliative third-line therapy of patients with metastasized colorectal cancer and emphasize that sequential palliative chemotherapy may lead to extended survival of these patients.

A general method for identification of polyhydroxyalkanoic acid synthase genes from pseudomonads belonging to the rRNA homology group I

Using a 30-mer oligonucleotide probe highly specific for polyhydroxyalkanoic acid (PHA) synthase genes, the respective genes of Pseudomonas citronellolis, P. mendocina, Pseudomonas sp. DSM 1650 and Pseudomonas sp. GP4BH1 were cloned from genomic libraries in the cosmid pHC79. A 19.5-kbp and a 22.0-kbp EcoRI restriction fragment of P. citronellolis or Pseudomonas sp. DSM 1650, respectively, conferred the ability to accumulate PHA of medium-chain-length 3-hydoxyalkanoic acids (HAMCL) from octanoate as well as from gluconate to the PHA-negative mutant P. putida GPp104. An 11.0-kbp EcoRI fragment was cloned from P. mendocina, which restored in GPp104 the ability to synthesize PHA from octanoate but not from gluconate. From Pseudomonas sp. GP4BH1 three different genomic fragments encoding PHA synthases were cloned. This indicated that strain GP4BH1 possesses three different functionally active PHA synthases. Two of these fragments (6.4 kbp and 3.8 kbp) encoded for a PHA synthase, preferentially incorporating hydroxyalkanoic acids of short chain length (HASCL), and the synthases were expressed in either GPp104 and Alcaligenes eutrophus H16-PHB-4, respectively. The PHA synthase encoded by the third fragment (6.5 kbp) led to the incorporation of HAMCL and was expressed in GPp104 but not in PHB-4.

Molecular basis for biosynthesis and accumulation of polyhydroxyalkanoic acids in bacteria

The current knowledge on the structure and on the organization of polyhydroxyalkanoic acid (PHA)-biosynthetic genes from a wide range of different bacteria, which rely on different pathways for biosynthesis of this storage polyesters, is provided. Molecular data will be shown for genes of Alcaligenes eutrophus, purple non-sulfur bacteria, such as Rhodospirillum rubrum, purple sulfur bacteria, such as Chromatium vinosum, pseudomonads belonging to rRNA homology group I, such as Pseudomonas aeruginosa, Methylobacterium extorquens, and for the Gram-positive bacterium Rhodococcus ruber. Three different types of PHA synthases can be distinguished with respect to their substrate specificity and structure. Strategies for the cloning of PHA synthase structural genes will be outlined which are based on the knowledge of conserved regions of PHA synthase structural genes and of the PHA-biosynthetic routes in bacteria as well as on the heterologous expression of these genes and on the availability of mutants impaired in the accumulation of PHA. In addition, a terminology for the designation of PHAs and of proteins and genes relevant for the metabolism of PHA is suggested.

Cloning and molecular analysis of the poly(3-hydroxyalkanoic acid) gene locus of Pseudomonas aeruginosa PAO1

From genomic libraries, the polyhydroxyalkanoate gene locus of Pseudomonas aeruginosa PAO1 was cloned and characterised at the molecular level. Two genes coding for polyhydroxyalkanoate synthases, phaC1Pa and phaC2Pa, a polyhydroxyalkanoate depolymerase gene, phaDPa, and four adjacent open reading frames (ORF1, ORF2, ORF3 and ORF4) were identified from the nucleotide sequence. Two transcriptional start sites, which were preceded by sequences resembling the Escherichia coli consensus sequences for sigma 54 and sigma 70 promoters, were identified experimentally upstream of phaC1Pa, which was shown by Northern blot analysis to constitute an operon together with phaDPa. A third putative promoter resembling the E. coli consensus sequence for sigma 70-dependent promoters was proposed upstream of phaC2Pa, which is in a bicistronic operon with ORF3. Investigations of rpoN-negative mutants of related strains revealed that polyhydroxyalkanoate accumulation from gluconate required an intact rpoN locus in P. aeruginosa. Complementation experiments revealed multiple evidence that either polyhydroxyalkanoate synthase is involved in polyhydroylkanoate accumulation from gluconate as well as from octanoate. The P. aeruginosa PAO1 polyhydroxyalkanoate gene locus was expressed in the polyhydroxyalkanoate-negative mutant Alcaligenes eutrophus PHB-4 and in the poly(3-hydroxybutyrate)-accumulating strain P. oleovorans DSM1045. It conferred on the latter the ability to synthesize and accumulate polyhydroxyalkanoates consisting of medium-chain-length 3-hydroxyalkanoic acids from unrelated substrates in addition to poly(3-hydroxybutyrate). The sequence of the putative translational product of ORF1 was similar to those of the leukotoxin repressor of Pasteurella haemolytica and to the ORF9 product of Azotobacter vinelandii, and that of ORF4 was similar to the algP product of P. aeruginosa and to eukaryotic histone H1 proteins. The proteins of ORF2 and ORF3 appear to be previously unidentified.

Formation of polyesters consisting of medium-chain-length 3-hydroxyalkanoic acids from gluconate by Pseudomonas aeruginosa and other fluorescent pseudomonads

Pseudomonas aeruginosa PAO and 15 other strains of this species synthesized a polyester with 3-hydroxydecanoate as the main constituent (55 to 76 mol%) if the cells were cultivated in the presence of gluconate and if the nitrogen source was exhausted; 3-hydroxyhexanoate, 3-hydroxyoctanoate, and 3-hydroxydodecanoate were minor constituents of the polymer. The polymer was deposited in granules within the cell and amounted to 70% of the cell dry matter in some strains. Among 55 different strains of 41 Pseudomonas species tested, P. aureofaciens (21.6% of cellular dry matter), P. citronellolis (78.0%), P. chlororaphis (8.5%), P. marginalis (11.4%), P. mendocina (50.7%), P. putida (33.5%), and Pseudomonas sp. strain DSM 1650 (54.6%) accumulated this type of polymer at significant levels (greater than 5%) during cultivation on gluconate. In two strains of P. facilis and P. fluorescens, as well as in one strain of P. syringae, this polymer was detected as a minor constituent (much less than 5%). All other strains accumulated either poly(3-hydroxybutyrate) or a polymer consisting mainly of 3-hydroxyoctanoate with octanoate but no polyester with gluconate as the carbon source. Only a few species (e.g., P. stutzeri) were unable to accumulate poly(hydroxyalkanoic acids) (PHA) at all. These results indicated that the formation of PHA depends on a pathway which is distinct from all other known PHA-biosynthetic pathways. The polyesters accumulated by gluconate- or octanoate-grown cells of recombinant strains of P. aeruginosa and P. putida, which harbored the Alcaligenes eutrophus poly(3-hydroxybutyrate)biosynthetic genes, contained 3-hydroxybutyrate as an additional constituent.