Evidence-Based Communication to Increase Melanoma Knowledge and Skin Checks

Rates of melanoma-the deadliest form of skin cancer-have increased. Early detection can save lives, and patients have a critical role to play in checking their skin. We aim to identify health communication messages that best educate the public and increase intentions toward skin checks. After viewing messages intended to increase melanoma knowledge, participants correctly identified a greater proportion (74.6 vs 70.4%) of moles (mean number = 17.9, 95% confidence interval [CI] = 17.5-18.3 vs 16.9, 95% CI = 16.6-17.3; P < .001, partial eta-squared = 0.03) and had knowledge of more melanoma warning signs (mean number = 5.8, 95% CI = 5.7-5.8 vs 5.6, 95% CI = 5.5-5.7, P = .01, partial eta-squared = 0.02). After viewing messages intended to increase self-confidence in checking their skin accurately, they were also more likely to report greater intentions to do a skin check on a scale of 1-5 (mean number = 3.8, 95% CI = 3.7-3.9 vs 3.6, 95% CI = 3.4-3.7, P = .005, partial eta-squared = 0.02). Online melanoma messages aimed at increasing both melanoma knowledge and skin-check confidence may be most effective in improving the accuracy of skin self-examinations and intentions to do them.

Novel recruitment approaches and operational results for a statewide population Cohort for cancer research: The Healthy Oregon Project

Background

Cancer health research relies on large-scale cohorts to derive generalizable results for different populations. While traditional epidemiological cohorts often use costly random sampling or self-motivated, preselected groups, a shift toward health system-based cohorts has emerged. However, such cohorts depend on participants remaining within a single system. Recent consumer engagement models using smartphone-based communication, driving projects, and social media have begun to upend these paradigms.

Methods

We initiated the Healthy Oregon Project (HOP) to support basic and clinical cancer research. HOP study employs a novel, cost-effective remote recruitment approach to effectively establish a large-scale cohort for population-based studies. The recruitment leverages the unique email account, the HOP website, and social media platforms to direct smartphone users to the study app, which facilitates saliva sample collection and survey administration. Monthly newsletters further facilitate engagement and outreach to broader communities.

Results

By the end of 2022, the HOP has enrolled approximately 35,000 participants aged 18-100 years (median = 44.2 years), comprising more than 1% of the Oregon adult population. Among those who have app access, ∼87% provided consent to genetic screening. The HOP monthly email newsletters have an average open rate of 38%. Efforts continue to be made to improve survey response rates.

Conclusion

This study underscores the efficacy of remote recruitment approaches in establishing large-scale cohorts for population-based cancer studies. The implementation of the study facilitates the collection of extensive survey and biological data into a repository that can be broadly shared and supports collaborative clinical and translational research.

Population screening shows risk of inherited cancer and familial hypercholesterolemia in Oregon

The Healthy Oregon Project (HOP) is a statewide effort that aims to build a large research repository and influence the health of Oregonians through providing no-cost genetic screening to participants for a next-generation sequencing 32-gene panel comprising genes related to inherited cancers and familial hypercholesterolemia. This type of unbiased population screening can detect at-risk individuals who may otherwise be missed by conventional medical approaches. However, challenges exist for this type of high-throughput testing in an academic setting, including developing a low-cost high-efficiency test and scaling up the clinical laboratory for processing large numbers of samples. Modifications to our academic clinical laboratory including efficient test design, robotics, and a streamlined analysis approach increased our ability to test more than 1,000 samples per month for HOP using only one dedicated HOP laboratory technologist. Additionally, enrollment using a HIPAA-compliant smartphone app and sample collection using mouthwash increased efficiency and reduced cost. Here, we present our experience three years into HOP and discuss the lessons learned, including our successes, challenges, opportunities, and future directions, as well as the genetic screening results for the first 13,670 participants tested. Overall, we have identified 730 pathogenic/likely pathogenic variants in 710 participants in 24 of the 32 genes on the panel. The carrier rate for pathogenic/likely pathogenic variants in the inherited cancer genes on the panel for an unselected population was 5.0% and for familial hypercholesterolemia was 0.3%. Our laboratory experience described here may provide a useful model for population screening projects in other states.

Public perception of predictive cancer genetic testing and research in Oregon

The potential for using widespread genetic testing to inform health care has become a viable option, particularly for heritable cancers. Yet, little is known about how to effectively communicate the benefits and risks of both personal genetic testing and participation in biorepositories that aid scientific advancements. Nationwide efforts are engaging communities in large genetic studies to better estimate the population-wide prevalence of heritable cancers but have been met with hesitance or declination to participate in some communities. To successfully engage an Oregon population in longitudinal research that includes predictive genetic testing for pathogenic or likely pathogenic variants associated with an increased risk for cancer, researchers conducted 35 focus groups (two of which were held in Spanish) in 24 of Oregon's 36 counties to better understand knowledge and attitudes related to genetic testing and willingness to participate in longitudinal genetic research. A total of 203 adults (mean = 45.6 years; range 18-88), representing a range of education levels and prior knowledge of genetic research, participated in the focus groups. The majority (85%) of participants reported personal or family diagnoses of cancer (e.g., self, family, friends). A majority (87%) also reported a strong interest in cancer genetic testing and receiving genetic information about themselves. Nearly all focus groups (94%, 33 of 35 sites) included participant discussion citing their families (e.g., children, close relatives, and extended family members) as key motivators for participation in genetic research. For example, participants reported interest in increasing personal knowledge about their own and their families' cancer risks in order to respond proactively, if a pathogenic variant was found. While most focus groups (94%, 33 of 35 sites) included participant discussion describing barriers to predictive genetic, testing such as concerns about outcomes, the desire to learn about health risks in oneself mitigated or outweighed those fears for many participants. Other commonly reported concerns were related to potential mistrust of insurance companies, researchers, or institutions, or lack of knowledge about genetics, genetic testing, or genetic research. Participants, particularly in rural areas, highlighted critical factors for research recruitment, such as trust, personal interaction, public education about genetic research, and clear communication about study goals and processes. Our statewide findings reflect that public interest in predictive cancer genetic testing and cancer genetic research can surpass lack of knowledge of the complex topics, particularly when benefits for self and family are emphasized and when study considerations are well articulated.

Unblurring the lines of sexual consent with a college student-driven sexual consent education campaign

OBJECTIVE

To test the effectiveness of a college student-driven sexual consent education campaign to improve college students' sexual consent understanding.

PARTICIPANTS

Undergraduate students (N = 992) at a large, public Midwestern university between March and December 2015.

METHODS

Three online survey questionnaires assessing relevant outcome measures were distributed to the university's undergraduate student population before, during, and after the campaign's implementation over two consecutive academic semesters.

RESULTS

Exposure to the campaign and the sexual consent understanding of the student population improved over time. College men and members of university-affiliated social sororities or fraternities resulted in greater improvement than their respective counterparts (i.e., college women, nonmembers).

CONCLUSIONS

Sexual consent education campaigns for college students that are student-driven and address relevant sociocultural factors while authentically interacting with students can improve students' sexual consent understanding. These type of campaigns also have the opportunity to reach historically hard-to-reach audiences, such as college men.

Applying the Health Belief Model and an Integrated Behavioral Model to Promote Breast Tissue Donation Among Asian Americans

An important part in the effort to prevent, treat, and cure breast cancer is research done with healthy breast tissue. The Susan G. Komen for the Cure Tissue Bank at Indiana University Simon Cancer Center (KTB) encourages women to donate a small amount of healthy breast tissue and then provides that tissue to researchers studying breast cancer. Although KTB has a large donor base, the volume of tissue samples from Asian women is low despite prior marketing efforts to encourage donation among this population. This study builds on prior work promoting breast cancer screenings among Asian women by applying constructs from the Health Belief Model (HBM) and the Integrated Behavioral Model (IBM) to investigate why Asian-American women are less inclined to donate their healthy breast tissue than non-Asian women and how this population may be motivated to donate in the future. A national online survey (N = 1,317) found Asian women had significantly lower perceived severity, some lower perceived benefits, and higher perceived barriers to tissue donation than non-Asian women under HBM and significantly lower injunctive norms supporting breast tissue donation, lower perceived behavioral control, and lower intentions to donate under IBM. This study also compares and discusses similarities and differences among East, Southeast, and South Asian women on these same constructs.

Development and Evaluation of a Social Media Health Intervention to Improve Adolescents' Knowledge About and Vaccination Against the Human Papillomavirus

This study describes the formative research, execution, and evaluation of a social media health intervention to improve adolescents’ knowledge about and vaccination against human papillomavirus (HPV). Based on the results from formative focus groups with adolescents (N = 38) to determine intervention feasibility, parameters, and message preferences, we developed and conducted a pretest/posttest evaluation of a 3-month social media health intervention for adolescents who had not completed the HPV vaccine series (N = 108). Results revealed that adolescents who fully engaged with the intervention improved in their knowledge compared with a control group, and many were also likely to have interpersonal discussions with others about what they learned. Adolescents are generally interested in receiving information about HPV and the vaccine, along with other relevant health information, through social media channels if messages are considered interesting, their privacy is protected, and the source is credible.

The Role of Hypermasculinity, Token Resistance, Rape Myth, and Assertive Sexual Consent Communication Among College Men

PURPOSE

A greater understanding of how college men's gendered beliefs and communication styles relate to their sexual consent attitudes and intentions is essential within the shifting context of negative to affirmative consent policies on college campuses. The results of this study can be used to help design more effective sexual consent interventions.

METHODS

Three hundred seventy undergraduate college men completed cross-sectional online surveys. Hierarchical multiple regression examined how hypermasculinity, token resistance, rape myth acceptance, and sexual communication assertiveness were associated with consent-related attitudes, intentions, and interpretations.

RESULTS

Bivariate correlations among all variables were significant. In multivariate analyses, sexual communication assertiveness was positively associated with all consent outcomes, and token resistance and rape myth acceptance were negatively associated with some. Hypermasculinity was not a significant factor.

CONCLUSIONS

Programs seeking to improve sexual consent communication among college men should reduce destructive beliefs and encourage sexually assertive communication.

Evaluating the Ability of the PBS Children's Show Daniel Tiger's Neighborhood to Teach Skills to Two Young Children with Autism Spectrum Disorder

Daniel Tiger's Neighborhood is a children's television show incorporating many elements of video modeling, an intervention that can teach skills to children with autism spectrum disorders (ASD). This study evaluated the impact of watching Daniel Tiger's Neighborhood episodes on the accurate performance of trying new foods and stopping play politely with two five-year-old children with ASD. Both children showed improved performance of skills only following exposure to episodes of Daniel Tiger's Neighborhood, suggesting that watching episodes can help children with ASD learn specific skills.

Narrative Exemplars and the Celebrity Spokesperson in Lebanese Anti-Domestic Violence Public Service Announcements

Domestic violence is a worldwide epidemic. This study examines the effects of narrative exemplars and a celebrity spokesperson in anti-domestic violence ads on Lebanese college students' attitudes and beliefs towards domestic violence and whether these effects are impacted by personal experience. The practical significance is derived from the high prevalence of domestic violence internationally, making it important to find ways to effectively use media to address this health-related issue that has huge consequences for the individual and society. This study adds to the theoretical understanding of narrative persuasion and media effects. Results indicated that narrative exemplars in anti-domestic violence ads promoting bystander awareness and intervention were more beneficial for people without relevant experience compared to people who know someone affected by domestic violence. Anti-domestic violence ads without narrative exemplars, but that also featured an emotional self-efficacy appeal targeting bystanders, were more effective for participants who know someone who had experienced domestic violence compared to participants without relevant experience. The presence of a celebrity spokesperson elicited more positive attitudes about the ad than a noncelebrity, but failed to directly affect relevant anti-domestic violence attitudes or beliefs. These results highlight the significance of formative audience research in health communication message design.

Parents of children with eating disorders: developing theory-based health communication messages to promote caregiver well-being

Parents of children with eating disorders experience extreme emotional burden because of the intensity and duration of the recovery process. While parental involvement in a child's eating disorder treatment improves outcomes, parents often neglect their own well-being, which can impede their child's recovery. This study extends the research on caregivers and on health theory in practice by conducting formative research to develop a theory-based communication intervention encouraging parents to engage in adaptive coping and self-care behaviors. The Transactional Model of Stress and Coping and the Transtheoretical Model guided qualitative assessments of the determinants of parents' coping behaviors. Three focus groups with 19 parents of children with eating disorders and 19 semi-structured interviews with experts specializing in eating disorders were conducted. Findings indicate that parents and experts see parents' need for permission to take time for themselves as the main barrier to self-care. The main motivator for parents to engage in coping behaviors is awareness of a connection between self-care and their child's health outcomes. Participant evaluation of six potential messages for main themes and effectiveness revealed that theory-based elements, such as certain processes of change within the Transtheoretical Model, were important to changing health behavior.

Designing messages to motivate parents to get their preteenage sons vaccinated against human papillomavirus

CONTEXT

Human papillomavirus (HPV) vaccine, licensed for use in 9--26-year-olds, is most effective when given before sexual activity begins. HPV causes genital warts, is associated with several cancers and disproportionately affects racial and ethnic minorities. Parents are typically unaware of male HPV vaccine; messages that might motivate them to get their preteenage sons vaccinated are unexplored.

METHODS

Messages promoting vaccination of preteenage boys were designed and tested in 2009 and 2010. Five focus groups were conducted with 29 black parents of 11-12-year-old boys, recruited through three churches and a middle school in North Carolina, and a racially diverse sample of 100 parents of 9-13-year-old boys in a university-based adolescent health clinic was interviewed. A constant comparison method was used to code transcripts and interpret themes. Chi-square and t tests or analyses of variance were used to assess differences in quantitative data.

RESULTS

Focus group parents knew little about HPV in males. Although concerned about safety and cost, parents supported vaccination for their sons. They wanted to see racial diversity and both parents in motivational materials. In interviews, 89% of parents reported never having heard of male HPV vaccine. The largest proportion said that a message stressing the prevalence and possible consequences of HPV infection was the most motivating (32%); the design favored by the largest proportion (43%) showed two parents.

CONCLUSIONS

Messages that may most motivate parents to get preteenage boys vaccinated against HPV focus on infection risk and include images of parents with their sons.

Asking mom: formative research for an HPV vaccine campaign targeting mothers of adolescent girls

Vaccination against the types of human papillomavirus (HPV) that cause about 70% of cervical cancers is approved for use in girls and women between 9 and 26 years of age and recommended routinely in 11-12-year-old girls. This article reports on the systematic theory-based formative research conducted to develop HPV vaccine messages for a campaign targeting racially diverse mothers of nonvaccinated 11-12-year-old girls in rural Southeastern United States. A consortium of 13 county health departments concerned about high rates of cervical cancer in their region relative to state and national averages initiated the campaign. The research examined behavioral determinants for vaccination decisions as well as mothers' reactions to message frames and emotional appeals. On the basis of focus groups and intercept interviews (n = 79), the authors demonstrated how preproduction message research and production message testing were used to develop messages that would motivate mothers of preteen girls. Core emotional truths that emerged were a mother's instinct to protect her daughter from harm and to embrace aspirations for her daughter's future. Mothers also reacted more positively to text about preventing cervical cancer than about preventing HPV, a sexually transmitted disease. Mothers preferred message concepts with photos of minorities and Caucasian mothers and daughters.

Evaluating a County-Sponsored Social Marketing Campaign to Increase Mothers' Initiation of HPV Vaccine for their Pre-teen Daughters in a Primarily Rural Area

Routine vaccination against human papillomavirus (HPV), the main cause of cervical cancer, is recommended for 11-12 year old girls, yet vaccine uptake is low. This study evaluates a social marketing campaign initiated by 13 North Carolina counties to raise awareness among parents and reduce barriers to accessing the vaccine in a primarily rural area. The 3-month campaign targeted mothers of girls ages 11-12 and healthcare practices serving pre-teen girls in four counties. Principles of social marketing were: product (recommended vaccine against HPV), price (cost, perception of safety and efficacy, and access), promotion (posters, brochures, website, news releases, doctor's recommendation), and place (doctors' offices, retail outlets). We analyzed (1) website traffic, hotline calls, and media placement; (2) cross-sectional surveys of mothers and providers; and (3) HPV immunization rates in intervention versus non-intervention counties. Of respondent mothers (n=225), 82% heard or saw campaign messages or materials. Of respondent providers (n=35), 94% used campaign brochures regularly or occasionally in conversations with parents. HPV vaccination rates within six months of campaign launch were 2% higher for 9-13 year old girls in two of the four intervention counties compared to 96 non-intervention counties. This evaluation supports campaign use in other primarily rural and underserved areas.

How parents hear about human papillomavirus vaccine: implications for uptake

PURPOSE

To examine correlates of human papillomavirus (HPV) vaccine awareness and information sources in a state requiring schools to inform parents about HPV vaccine.

METHODS

Telephone survey of a North Carolina population-based sample of 696 parents of females aged 10-17 years about HPV vaccine awareness and information sources (daughters' schools, healthcare provider, drug company advertisements, news stories) was conducted.

RESULTS

Overall, 91% of parents had heard of HPV vaccine. Parents were more likely to be aware if they had household incomes of $50,000 or higher, were women, had non-Hispanic white daughters, or had daughters vaccinated against meningitis. Information sources included drug company advertisements (64%), healthcare providers (50%), news stories (50%), and schools (9%). Only parents who heard from their children's healthcare providers were more likely to initiate HPV vaccine for their daughters.

CONCLUSIONS

Parents had rarely heard of the vaccine through schools. The only source associated with vaccine initiation was hearing from a healthcare provider.

Capping the dose of paclitaxel in endometrial cancer patients: Does this affect clinical outcome?

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Background: Various protocols recommend capping chemotherapy dosing of paclitaxel at 2m2 while other protocols dose paclitaxel according to actual body weight (ABW). In endometrial cancer where a significant portion of patients are obese this dosing difference may affect clinical outcome. We performed a retrospective review of patients with endometrial cancer who received paclitaxel and carboplatin after surgical staging. We compared patients who received paclitaxel dosed according to ABW with patients whose dose was capped at 2m2 to determine if differences in dosing affected progression free survival (PFS). Methods: Patients with endometrial cancer undergoing adjuvant treatment with paclitaxel and carboplatin from January 2000 to January 2008 were identified. Patient age, endometrial histology, stage, BSA, and paclitaxel treatment dose were collected and progression free survival was determined. Differences in outcome were compared and evaluated using student's t test. Results: 109 women were identified of whom 70 were treated according to their ABW (<2m2) and 39 obese patients received paclitaxel dose capped at 2m2. 95% of all the patients received the complete course of chemotherapy. PFS for both groups were 21.4±2.2 and 23.2±2.2 months with no significant difference in PFS (p = 0.62). When evaluating patients with endometrioid histology alone, no difference between patients receiving dosages according to ABW compared to those whose dosages were capped at 2m2 (25 patients vs. 19 patients, PFS 19.3±3.7 and 27.0±3.7 respectively, p = 0.16). However for patients with serous histology, PFS was significantly greater in those patients treated per their ABW when compared to patients capped at 2m2 (45 patients vs. 20 patients, PFS 30.2±3.2 and 19.6±3.5 months respectively, p = 0.05). Conclusions: There was no difference in PFS for patients with endometrioid cancer who were treated with ABW vs. capped doses of paclitaxel. However patients with serous histology experienced longer PFS when receiving paclitaxel dosed per ABW as compared to patients whose dose was capped at 2m2. This difference may reflect increased sensitivity of serous cancers to chemotherapy or other unknown biologic variables. Capping paclitaxel dosing in patients with serous endometrial cancers may affect their PFS.

No significant financial relationships to disclose.

Hematologic toxicities before and during bevacizumab chemotherapy in women with gynecologic malignancy

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Background: Many women undergoing chemotherapy for gynecologic malignancy experience hematologic toxicity that delays therapy or requires supportive intervention. In animal models anti-VEGF antibodies increase erythropoietin levels. We examined the hematologic toxicities experienced by patients prior to (PR) and during bevacizumab (BR) treatment. Methods: Retrospective, single-institution study of women with gynecologic malignancy treated at the University of North Carolina with bevacizumab as part of their therapy from January 2005 to June 2007. Data collected included prior therapies, blood product and growth factor use, and interruptions in therapy. Comparisons were made between individual patients’ hematologic parameters during the PR and BR. Median differences between hematologic nadirs were compared using Wilcoxon Signed Rank Tests. Differences in proportions were compared by Chi-Square or Fisher's Exact tests. Results: 43 patients ware identified, 40 with complete data. Most women were Caucasian (88%) and had ovarian or primary peritoneal carcinoma (77%); median (range) age was 53 (23–73). 32 (74%) received three or more different chemotherapy drugs before starting bevacizumab. The median difference in HCT nadir (31.2 vs. 33, p = 0.01) and ANC nadir (1.2 vs. 1.4, p = 0.04) during the PR and BR were significant in favor of the bevacizumab regimens. The median nadir differences for WBC (2.7 vs. 3.1, p = 0.1) and PLT (129 vs. 150, p = 0.07) were non-significant favoring BR. For HCT toxicity grades, 22 (55%) had the same grade during their PR and BR, 15 (38%) had a lower grade during BR, and 3 (7%) had a higher grade during BR (p = 0.001). Similar trends were seen for WBC (p = 0.27), ANC (p = 0.1), and PLT (p = 0.15). During BR there was a trend toward fewer patients receiving darbepoetin (66% vs. 44%, p = 0.07) and filgastrim (29% vs. 14%, p = 0.1). Conclusions: Patients receiving bevacizumab had no worse hematologic toxicity compared to their prior regimens and may have had less severe anemia. While not statistically significant, there were trends toward less growth factor use with bevacizumab. Patients who have had prior hematologic toxicity should be considered for bevacizumab. The effect of bevacizumab on hematologic toxicity should be evaluated with prospective data.

No significant financial relationships to disclose.

Researching medicine in context: the Arts and Humanities Medical Scholars Program

In 2000, the Arts and Humanities Medical Scholars Program at Stanford University School of Medicine issued its first grants to medical students interested in researching an area of the medical arts or humanities in depth. To date, 34 projects have been funded, including renewals. The projects encompass a range of genres and topics, from a website on Asian American health and culture to an ethnographic study of women physicians in training in Spain. Two projects are highlighted here: an online history of medicine course and a poetry project. Students are mentored by faculty from a wide array of university departments and centres and submit completion documents to the committee overseeing the programme. Students are encouraged to present their work at conferences, such as the programme's annual symposium, as well as in publication or other appropriate formats. Future directions include integration with the scholarly concentrations initiative at the medical school.

Patient threats present an ethical dilemma for the anesthesiologist

IMPLICATIONS

Patients who receive sedation occasionally divulge thoughts that they would not usually express. This report describes a sedated patient who threatened to murder two family members. Immediate consultation with an attorney and psychiatrist is recommended when the anesthesiologist may be required to breach patient confidentiality to warn potential victims.

Tetracycline-regulatable expression vectors tightly regulate in vitro gene expression of secreted proteins

The regulation of gene expression by the tetracycline system has attracted a high level of interest in the recent past. However, expression of secreted proteins has not been evaluated precisely. In this study, we constructed two versions of a one-plasmid system containing the elements necessary for the regulation of gene expression. The regulatable elements and the selectable marker (Neor) were set up in two different configurations, pTRIN31 and pTRIN76. With these two regulatable versions, the levels of protein expression after transfection into the NIH/3T3 cell line were measured by insertion of three different genes encoding the secreted proteins (hGH, ApoE3, hGM-CSF). The maximum levels of gene expression obtained with the pTRIN76-derived plasmids were 100ng/24h/106 cells for hGH, 427ng/24h/106 cells for ApoE3 and 108ng/24h/106 cells for hGM-CSF. For the pTRIN31-derived plasmids the maximum levels were 2.7ng/24h/106 cells for hGH and 47ng/24h/106 for ApoE3. Both plasmids give rise to an expression of the transfected gene that can be tightly regulated by three different molecules: tetracycline, minocycline and doxycycline. The levels of the secreted proteins are below the detectable level when the reporter genes are repressed. This repression is reversible within 48h after the regulator has been removed from the medium.

Complications of sedation with midazolam in the intensive care unit and a comparison with other sedative regimens

OBJECTIVE

To describe the various complications that have been reported with use of midazolam for sedation in the intensive care unit (ICU).

DATA SOURCES

Publications in scientific literature.

DATA EXTRACTION

Computer search of the literature.

SYNTHESIS

Sedation is required in the ICU in order for patients to tolerate noxious stimuli, particularly mechanical ventilation. Under- and oversedation can lead to complications. To sedate patients in the ICU, midazolam is commonly administered via titrated, continuous infusions. Cardiorespiratory effects tend to be minimal; however, hypotension can occur in hypovolemic patients. Prolonged sedation after cessation of the midazolam infusion may be caused by altered kinetics of the drug in critically ill patients or by accumulation of active metabolites. In addition, paradoxical and psychotic reactions have been rarely reported. Tolerance and tachyphylaxis may occur, particularly with longer-term infusions (> or = 3 days). Benzodiazepine withdrawal syndrome has also been associated with high dose/long-term midazolam infusions. Compared with propofol infusions, midazolam infusions have been associated with a decreased occurrence of hypotension but a more variable time course for recovery of function after the cessation of the infusion. Lorazepam is a more cost-effective choice for long-term (> 24 hrs) sedation.

CONCLUSION

Continuous infusion midazolam provides effective sedation in the ICU with few complications overall, especially when the dose is titrated.

Vancomycin control measures at a tertiary-care hospital: impact of interventions on volume and patterns of use

OBJECTIVE

Evaluate vancomycin prescribing patterns in a tertiary-care hospital before and after interventions to decrease vancomycin utilization.

DESIGN

Before/after analysis of interventions to limit vancomycin use.

SETTING

420-bed academic tertiary-care center.

INTERVENTIONS

Educational efforts began August 10, 1994, and involved lectures to medical house staff followed by mailings to all physicians and posting of guidelines for vancomycin use on hospital information systems. Active interventions began November 15, 1994, and included automatic stop orders for vancomycin at 72 hours, alerts attached to the medical record, and, for 2 weeks only, computer alerts to physicians following each vancomycin order. Parenteral vancomycin use was estimated from the hospital pharmacy database of all medication orders. Records of a random sample of 344 patients receiving vancomycin between May 1, 1994, and April 30, 1995, were reviewed for an indication meeting published guidelines.

RESULTS

Vancomycin prescribing decreased by 22% following interventions, from 8.5 to 6.8 courses per 100 discharges (P<.05). The estimated proportion of vancomycin ordered for an indication meeting published guidelines was 36.6% overall, with no significant change following interventions. However, during the 2 weeks that computer alerts were in place, 60% of vancomycin use was for an approved indication.

CONCLUSIONS

Parenteral vancomycin prescribing decreased significantly following interventions, but the majority of orders still were not for an indication meeting published guidelines. Further improvement in the appropriateness of vancomycin prescribing potentially could be accomplished by more aggressive interventions, such as computer alerts, or by targeting specific aspects of prescribing patterns.

Cue reactivity in cocaine-dependent subjects: effects of cue type and cue modality

Thirty cocaine-dependent subjects were enrolled into a cue-laboratory study to determine the specificity and sensitivity of this paradigm as a craving measure. Subjects experienced three cue types (i.e., cocaine, arousing, and neutral stimuli) in three cue modalities (i.e., audio, visual, and manual). Cue types were administered in different experimental sessions with a period of 2 to 3 days between sessions. Our results showed that subjective and physiological craving for cocaine was relatively specific for the cocaine cue as compared with either the arousing or the neutral cue. The relative sensitivities of the cue modalities in decreasing order was manual, audio, and visual. We suggest that a modified conditioned-cue paradigm could be a useful tool in the repeated assessment of craving during a clinical study.

The expression of leptin and its receptors in pre-ovulatory human follicles

The expression of leptin and its receptors was examined by reverse transcriptase-polymerase chain reaction and immunofluorescence in granulosa and cumulus cells of pre-ovulatory follicles and in meiotically mature oocytes obtained from women undergoing in-vitro fertilization. Leptin concentrations were measured in newly aspirated follicular fluids and in maternal serum before and after the administration of an ovulatory dose of human chorionic gonadotrophin. The findings demonstrate leptin expression at the mRNA and protein levels by granulosa and cumulus cells, and the presence of leptin in mature human oocytes. While an association between follicular leptin concentration and embryo development was not observed, a post-ovulatory increase in serum leptin concentration was associated with implantation potential. The results are discussed with respect to possible roles of leptin in early human development.

Leptin stimulates fetal and adult erythroid and myeloid development

The ob gene product, leptin, has been shown in several studies to be involved in weight control and recombinant leptin recently has entered clinical trials to treat obesity. The leptin receptor (OB-R/B219) is expressed in a variety of protein isoforms not only in the central nervous system, but also in reproductive, and hematopoietic tissues. We reported recently that the OB-R/B219 was associated with a variety of hematopoietic lineages as well as the small fraction of cells containing the long-term reconstituting hematopoietic stem cells. Herein we report that leptin significantly stimulates the proliferation and differentiation of yolk sac cells and fetal liver cells and stimulates directly hematopoietic precursors. Leptin alone can increase the number of macrophage and granulocyte colonies, and leptin plus erythropoietin act synergistically to increase erythroid development. These data show that leptin has a significant, direct effect on early hematopoietic development and can stimulate the differentiation of lineage-restricted precursors of the erythrocytic and myelopoietic lineages. These observations along with a recent report strongly support our previous hypothesis that leptin has an unanticipated important role in hematopoietic and immune system development.

Preoperative anxiety and fear: a comparison of assessments by patients and anesthesia and surgery residents

We sought to compare self-assessment of preoperative anxiety levels and selection of worst fears by surgical patients with the assessments made by the anesthesia and surgery residents providing intraoperative care for those patients. One hundred inpatients at a Veterans Affairs hospital (Group 1) and 45 patients at a University hospital (Group 2) were asked to complete a brief questionnaire; the residents were asked to complete the same questionnaire. Group 1 results showed that median patient visual analog scale (VAS) scores were lower for anxiety about anesthesia compared to surgery (16 vs 22, P < or = 0.05). Anesthesia resident VAS scores were higher than patient or surgery resident scores. Neither type of resident was able to predict their individual patient's VAS score (Kendall's tau). The fear chosen with the greatest incidence by Group 1 patients and residents was "whether surgery would work". A significant number of residents (34%, anesthesia or surgery, P < or = 0.05) matched their patient's fear choice. Residents commonly chose fears related to their specialty (e.g., anesthesia residents chose anesthesia-related fears more often than surgery residents, 50% vs 28%, P < or = 0.001). In Group 2, residents demonstrated an improved ability to predict patient scores. For instance, both surgery and anesthesia residents were able to predict individual University patient VAS scores (P < or = 0.01). The fear chosen with the greatest frequency by Group 2 patients was "pain after the operation". Sixty percent of anesthesia residents matched their patients' fear choice (P < or = 0.001). This study indicates a variable ability of anesthesia and surgery residents to predict patient anxiety and fear which may be due, in part, to difficulty in understanding a Veterans Affairs hospital patient population.

A call for narrative: the patient's story and anesthesia training

Narrative plays a key role in medical education and knowledge, via the case history, the case presentation, or even the patient's chart. Hospitalization for elective surgery provides the structure for a discrete story in a person's life. The details make the story unique for each patient. By analyzing themes and content of narratives obtained from patients and medical trainees, the reader gains insight into the realms of patients' and residents' lives. We believe that even anesthesiologists, who work at the procedure-oriented end of the spectrum of patient care, can benefit from a narrative approach to understanding the patient's perspective. An unanticipated reward of the study is the therapeutic benefit that some of the patients express in their narratives. Patients write that they hope future patients will benefit ("Use this information to the betterment of anyone in need & etc" [patient 15]) or physicians and nurses will improve their interactive skills (patient 09). Perhaps physicians may share the rewards of narrative creation that patient 10 expresses when he triumphantly exclaims, "EUREKA!!! ... I hope you learn something from it (as I have from remembering it)." Patients can provide medical personnel not only with signs and symptoms, but also with insight into the human aspects of the medical process. Reading or writing narratives about such processes may enhance physicians' understanding of their patients' experiences.

Outpatient premedication: use of midazolam and opioid analgesics

The perioperative effects of administering sedative and analgesic drugs prior to outpatient surgery were evaluated. One hundred fifty adult outpatients were randomly assigned to one of six study groups according to a double-blind protocol design. Patients were given placebo (saline) or midazolam (5 mg im) 30-60 min prior to surgery, and then either placebo, oxymorphone (1 mg iv), or fentanyl (100 micrograms iv) 3-5 min prior to a standardized anesthetic technique. Preoperatively, midazolam premedication was associated with a significantly lower anxiety level (37 +/- 29 mm vs. 50 +/- 32 mm, P less than 0.05), higher sedation level (254 +/- 136 mm vs. 145 +/- 109 mm, P less than 0.01), worsening of psychomotor skill (5 +/- 5 vs. 2 +/- 2 dots missed, P less than 0.01; midazolam vs. placebo), and impaired recall abilities. In addition, use of midazolam did not prolong the discharge time. Compared to control patients, those who received fentanyl had a decreased incidence of intraoperative airway difficulties such as coughing (28% vs. 0%, P less than 0.01). Although use of opioids increased the incidence of postoperative nausea (42% vs. 18%, P less than 0.01) and vomiting (23% vs. 2%, P less than 0.01; opioid vs. no opioid), average recovery times were not affected by opioid administration. Oxymorphone use was associated with a lower incidence of pain at home compared with that following fentanyl (46% vs. 74%, P less than 0.05). Finally, preoperative administration of both midazolam and fentanyl or oxymorphone prior to a standardized methohexital-nitrous oxide anesthetic technique did not adversely affect recovery after outpatient surgery.

Benzodiazepine antagonism does not provoke a stress response

Acute anxiety reactions have been reported following antagonism of benzodiazepine-induced sedation. In this study, the level of sedation and anxiety was assessed in 30 patients randomly assigned to receive either saline or flumazenil (a benzodiazepine antagonist) after midazolam sedation according to a double-blind protocol. Carefully titrated doses of flumazenil, 0.8 +/- 0.2 mg (mean +/- SD), effectively reversed residual midazolam-induced sedation without producing significant changes in the patients' level of anxiety. In addition, plasma epinephrine, norepinephrine, vasopressin, and beta-endorphin concentrations were measured in a subset of patients (n = 5) from each group. The levels of these stress hormones did not acutely change following flumazenil (or saline). These results indicate that flumazenil, 0.6-1.0 mg iv, can antagonize midazolam sedation without producing acute anxiety or evidence of a stress response.

Pharmacokinetics and pharmacodynamics of propofol infusions during general anesthesia

The pharmacokinetic and pharmacodynamic properties of propofol were studied in 50 surgical patients. Propofol was administered as a bolus dose, 2 mg/kg iv, followed by a variable-rate infusion, 0-20 mg/min, and intermittent supplemental boluses, 10-20 mg iv, as part of a general anesthetic technique that included nitrous oxide, meperidine, and muscle relaxants. For a majority of the patients (n = 30), the pharmacokinetics of propofol were best described by a two-compartment model. The propofol mean total body clearance rate was 2.09 +/- 0.65 1/min (mean +/- SD), the volume of distribution at steady state was 159 +/- 57 l, and the elimination half-life was 116 +/- 34 min. Elderly patients (patients older than 60 yr vs. those younger than 60 yr) had significantly decreased clearance rates (1.58 +/- 0.42 vs. 2.19 +/- 0.64 l/min), whereas women (vs. men) had greater clearance rates (33 +/- 8 vs. 26 +/- 7 l.kg-1.min-1) and volumes of distribution (2.50 +/- 0.81 vs. 2.05 +/- 0.65 l/kg). Patients undergoing major (intraabdominal) surgery had longer elimination half-life values (136 +/- 40 vs. 108 +/- 29 min). Patients required an average blood propofol concentration of 4.05 +/- 1.01 micrograms/ml for major surgery and 2.97 +/- 1.07 micrograms/ml for nonmajor surgery. Blood propofol concentrations at which 50% of patients (EC50) were awake and oriented after surgery were 1.07 and 0.95 microgram/ml, respectively. Psychomotor performance returned to baseline at blood propofol concentrations of 0.38-0.43 microgram/ml (EC50). This clinical study demonstrates the feasibility of performing pharmacokinetic and pharmacodynamic analyses when complex infusion and bolus regimens are used for administering iv anesthetics.

Propofol-nitrous oxide versus thiopental-isoflurane-nitrous oxide for general anesthesia

One hundred and twenty patients undergoing elective operations were randomly assigned to receive anesthesia with either thiopental, 4 mg/kg-isoflurane, 0.2-3%-nitrous oxide, 60-70% (control) or propofol, 2 mg/kg-propofol infusion, 1-20 mg/min-nitrous oxide, 60-70% (propofol). Although anesthetic conditions were similar during the operation, differences were noted in the recovery characteristics. For non-major (superficial) surgical procedures, the times to awakening, responsiveness, orientation, and ambulation were significantly shorter in the propofol group (4 +/- 3, 5 +/- 4, 6 +/- 4, and 104 +/- 36 min) than in the control group (8 +/- 7, 9 +/- 7, 11 +/- 9, and 142 +/- 61 min, respectively). In addition, less nausea and vomiting (20 vs. 45%) and significantly less psychomotor impairment was noted in the non-major propofol (vs. control) group. Following major abdominal operations, recovery characteristics did not differ between propofol and control groups. Delayed emergence (greater than 20 min), significant psychometric impairment, and a high overall incidence of postoperative side effects (55-60%) were noted in both drug treatment groups. The authors conclude that propofol-nitrous oxide compares favorably to thiopental-isoflurane-nitrous oxide for maintenance of anesthesia during short outpatient procedures. However, for major abdominal operations, propofol anesthesia does not appear to offer any clinically significant advantages over a standard inhalational anesthetic technique.

Pharmacokinetics and pharmacodynamics of alfentanil infusions during general anesthesia

The pharmacokinetic and pharmacodynamic properties of alfentanil were studied in 64 surgical patients. Alfentanil was administered as a loading infusion (25-130 micrograms/kg) followed by a maintenance infusion (0.25-1.3 micrograms X kg-1 X min-1) as part of a nitrous oxide-narcotic-muscle relaxant technique. Although alfentanil doses of at least 50 micrograms/kg (in combination with thiopental, 2 mg/kg) were required to prevent hemodynamic changes during intubation, apnea or chest wall rigidity frequently occurred with alfentanil loading infusions exceeding 75 micrograms/kg. The alfentanil clearance rate was significantly lower in patients with liver dysfunction (2.3 +/- 1.3 vs 4.2 +/- 2.0 ml X kg-1 X min-1, mean +/- SD). In addition, the patients who required opioid antagonists to reverse postoperative respiratory depression had lower clearance rates (1.5 +/- 0.7 vs 4.1 +/- 1.9 ml X kg-1 X min-1) and longer elimination half-life values (406 +/- 304 vs 87 +/- 53 min). For maintenance of hemodynamic stability during superficial and intraabdominal operations, alfentanil serum concentration-response curves revealed ED95 values exceeding 300 ng/ml and 400 ng/ml, respectively. Our study also demonstrated a wide range of clinical responses to fixed doses of alfentanil. At equivalent doses, some patients required supplemental anesthetics, whereas others required an opioid antagonist. Careful titration of the alfentanil maintenance infusion is recommended to minimize the possibility of postoperative respiratory depression.

Comparative pharmacology of the ketamine isomers. Studies in volunteers

The clinical and electroencephalographic (EEG) effects of the individual ketamine isomers were compared with the racemic mixture in five volunteers who received each drug on a separate occasion. Racemic ketamine 275 +/- 25 mg, s(+) ketamine 140 +/- 21 mg or R(-) ketamine 429 +/- 37 mg produced an anaesthetic state lasting 6 +/- 2 min (mean +/- SD). However, the EEG evaluation of the R(-) isomer revealed less overall slowing, and an absence of the large slow wave complexes produced by the S(+) isomer and the racemic mixture. The pharmacokinetic profiles for the individual isomers of ketamine did not differ significantly from the racemic mixture. Even though the apparent anaesthetic state produced in these healthy volunteers did not differ qualitatively between the three drug groups, recovery times (assessed using a standardized battery of psychometric tests) were consistently shorter following the individual isomers compared with the racemic mixture. The serum ketamine concentrations associated with regaining consciousness and orientation were consistent with an S(+):R(-) isomer potency ratio of 4:1. In terms of their ability to impair psychomotor function, the S(+):R(-) potency ratio varied from 3:1 to 5:1. After comparable degrees of CNS depression, we conclude that the more potent S(+) isomer of ketamine was associated with a more rapid recovery of psychomotor skills than the currently used racemic mixture.