[Complications and emergencies in the recovery room]

The recovery room as a central monitoring unit plays a crucial role in the perioperative care of patients. Here, the patient is monitored until the subsequent transfer to a further care ward; however, due to the previous anesthesia and surgery the recovery room also provides a high risk for (the development of) complications. The present article provides an overview of the most frequent complications to be expected in the recovery room (in adults), the diagnostics and the acute treatment.

Nursing practice in mental health at family health strategy

The nurse practice model at the family health strategy is characterized by direct involvement in the patient's health-disease recovery process, deconstruction of social stigma involving mental health disorders, and the restoration of patient autonomy their social ties. This descriptive study follows a qualitative approach to document and analyse practices performed by mental health nurses at the family health strategy (FHS) in Rio das Ostras, Brazil. The study identifies practices implemented by Mental Health Nurses at FHS and the nurses’ own reflection and analysis on these mental health practices. Data was collected through semi-structured interviews. All interviewed nurses had worked in the primary mental health care for at least one year at the FHS units in Rio das Ostras. Data was analysed, grouped, and coded according to two categories: 1) The nurses’ professional practices in mental health at the FHS, and 2) The nurses’ view on mental health practices at the FHS. Results show that the main activities in mental health at FHS involve working with the matricial team, continuing education, reception, home visits, referrals, therapeutic workshops and community therapy. Nurse perspectives on professional practices involve prevention, establishment of bonds with patient, and nurses’ training to deliver care to patients who are suffering. The bond with and care for the patient, family and community, is one of the FHS differentiators. In that vein, the study looks at the link between health care delivery, territory and population attended. The health care based on territoriality, allows increased patient and family confidence.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

16alpha-Bromoepiandrosterone (HE2000) limits non-productive inflammation and stimulates immunity in lungs

16alpha-Bromoepiandrosterone (HE2000) is a synthetic steroid that limits non-productive inflammation, enhances protective immunity and improves survival in clinical studies of patients with human immunodeficiency virus (HIV), malaria and tuberculosis infections. We now show that HE2000 decreased nitric oxide production by lipopolysaccharide (LPS)-stimulated RAW264.7 cells. Treatment with HE2000 also reduced non-productive inflammation associated with carrageenan-induced pleurisy and LPS-induced lung injury in mice. In the hapten-carrier reporter antigen popliteal lymph node assay, HE2000 increased absolute numbers of lymphocytes, antigen-presenting cells, hapten-specific immunoglobulin (Ig)M antibody-forming cells and shifted the interferon (IFN)-gamma/interleukin (IL)-4 balance towards IFN-gamma production. In the cystic fibrosis transmembrane conductance regulator (CFTR(-/-)) mouse model of acute Pseudomonas aeruginosa infection, treatment with HE2000 consistently reduced bacterial burden in lungs. All HE2000 effects were dose-dependent. In H1N1 infection in mice, HE2000 was safe but not effective as a monotherapy, as treatment did not effect survival. HE2000 reduced mortality related to excessive inflammation and opportunistic lung infections in animals and patients, and this might extend to those with H1N1 influenza infection.

Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors

Part C of the guideline is preceded by Part B General Pharmacology IJCPT. 2008; 46: 600 - 617. Included in Part C are practical guidelines for improving the therapy of some age-specific diseases and problems commonly encountered in general practice. The article in this issue is dedicated to the therapy of Dementia and M. Parkinson. Further guidelines for the other age specific diseases and problems named above will be published in the following issues of IJCPT. An important feature of these guidelines are the inclusion of Levels of Evidence and of the Strength of Recommendations for the therapy which are shown when reliable studies are available. (For both see levels of evidence at the end of this article.).

Electron microscope characterization of CdSe/ZnSe quantum dots based on molecular dynamics structure relaxations

Molecular dynamics simulations using empirical potentials are applied to characterize the structure, the energy relaxation and the stability of pyramidal-shaped quantum dots in the CdSe/ZnSe system. The relaxed structure models are used for a reliable interpretation of electron microscope investigations to analyze the size, the shape and the strain fields of the quantum dots. Though the elastic strains modify the electron microsope image contrast by creating virtual truncations of the pyramids or additional black-white lobes, optimum imaging conditions chosen will reveal the shape and the size of the dots.

CD23 exhibits negative regulatory effects on allergic sensitization and airway hyperresponsiveness

The effects of an anti-CD23 monoclonal antibody (B3B4) in CD23-deficient and CD23-overexpressing mice were compared in a murine model of allergic sensitization. After sensitization and challenge with OA, mice developed increased serum levels of OA-specific IgE and IgG(1) with airway eosinophilia and AHR when compared with nonsensitized animals. Anti-CD23 treatment was studied under two protocols: 10-d OA aerosol exposure and intraperitoneal sensitization followed by aerosol challenge. In both protocols anti-CD23 significantly reduced IgE and IgG(1) levels, abolished eosinophilia, and normalized AHR in BALB/c and wild-type CD23+/+ mice but not in CD23-/- mice. These changes were associated with increases in IFN-gamma and decreases in IL-4 production, suggesting that CD23 binding may affect not only IgE production but also the Th1/Th2 imbalance during the development of allergic AHR. Absence of CD23 in gene-deficient mice significantly enhanced OA-specific IgE and IgG(1) levels, airway eosinophilia, and AHR when compared with CD23+/+ wild-type littermates after sensitization and airway challenge. Sensitized and challenged CD23 transgenic mice also developed eosinophilic airway inflammation and methacholine hyperresponsiveness. However, the extent of AHR, BAL, and tissue eosinophilia in these animals showed a significant negative correlation with levels of CD23 expression on splenic T and B cells, demonstrating a limiting role of CD23 in the development of allergic AHR.

Interleukin-4-dependent production of PPAR-gamma ligands in macrophages by 12/15-lipoxygenase

The peroxisome proliferator-activated receptor-gamma (PPAR-gamma) is a ligand-dependent nuclear receptor that has been implicated in the modulation of critical aspects of development and homeostasis, including adipocyte differentiation, glucose metabolism and macrophage development and function. PPAR-gamma is activated by a range of synthetic and naturally occurring substances, including antidiabetic thiazolidinediones, polyunsaturated fatty acids, 15-deoxy-delta prostaglandin J2 and components of oxidized low-density lipoprotein, such as 13-hydroxyoctadecadienoic acid (13-HODE) and 15-hydroxyeicosatetraenoic acid (15-HETE). However, the identities of endogenous ligands for PPAR-gamma and their means of production in vivo have not been established. In monocytes and macrophages, 13-HODE and 15-HETE can be generated from linoleic and arachidonic acids, respectively, by a 12/15-lipoxygenase that is upregulated by the TH2-derived cytokine interleukin-4. Here we show that interleukin-4 also induces the expression of PPAR-gamma and provide evidence that the coordinate induction of PPAR-gamma and 12/15-lipoxygenase mediates interleukin-4-dependent transcription of the CD36 gene in macrophages. These findings reveal a physiological role of 12/15-lipoxygenase in the generation of endogenous ligands for PPAR-gamma, and suggest a paradigm for the regulation of nuclear receptor function by cytokines.

TEM characterization of self-organized CdSe/ZnSe quantum dots

CdSe quantum dots (QDs) grown on ZnSe were investigated by various transmission electron microscopy (TEM) techniques including diffraction contrast imaging, high-resolution and analytical transmission electron microscopy both of plan-view as well as cross-section specimens. The size of the QDs ranges from about 5-50 nm, where from the contrast features in plan-view imaging two classes can be differentiated. In the features of the smaller dots there is no inner fine structure resolvable. The larger ones exhibit contrast features of fourfold symmetry as expected for pyramid-like islands. Corresponding simulations of diffraction contrast images of truncated CdSe pyramids with the edges of the basal plane orientated parallel to <100> are in relatively good agreement with this assumption. In TEM diffraction contrast imaging of cross-section samples the locations of the quantum dots are visualized by additional dark contrast features. The QDs have a distinct larger extension in growth direction compared to the almost uniformly thick CdSe wetting layer. The presence of the CdSe QDs was also confirmed by energy-dispersive X-ray spectroscopy.

Dysregulation of the cyclin-dependent kinase inhibitor p21WAF1/CIP1/MDA6 increases the susceptibility of human leukemia cells (U937) to 1-beta-D-arabinofuranosylcytosine-mediated mitochondrial dysfunction and apoptosis

The effects of dysregulation of the cyclin-dependent kinase inhibitor p21WAF1/CIP1 on the apoptotic response of U937 monocytic leukemia cells to 1-beta-D-arabinofuranosylcytosine (ara-C) were examined. After a 6-h exposure to 1 microM ara-C, cells stably transfected with a p21WAF1/CIP1 antisense construct were significantly more sensitive to the induction of classic apoptotic morphology, DNA fragmentation, caspase-3 activation, poly(ADP-ribose) polymerase degradation, and underphosphorylation of the retinoblastoma protein (pRb) than their empty-vector counterparts. Enhanced susceptibility of antisense-expressing cells to ara-C was accompanied by a corresponding reduction in clonogenic and suspension culture growth. The increased sensitivity of these cells to ara-C-mediated lethality could not be attributed to cytokinetic perturbations, nor did ara-CTP formation or (ara-C)DNA incorporation differ significantly between the cell lines. Moreover, synchronization of p21 antisense-expressing cells in S-phase by aphidicolin block resulted in a further increase in ara-C-mediated apoptosis, suggesting enhanced drug sensitivity of the S-phase cell fraction. After exposure to ara-C, p21 antisense-expressing cells displayed a greater decline in mitochondrial membrane potential (deltapsi(m)) and generation of reactive oxygen species than their empty-vector counterparts, as well as early potentiation (e.g., within 2-4 h) of cytochrome c release into the cytosolic S-100 fraction. Lastly, ara-C-mediated increases in mitogen-activated protein kinase activity over basal levels were attenuated in p21 antisense-expressing cells. Collectively, these findings indicate that dysregulation of the cyclin-dependent kinase inhibitor p21WAF1/CIP1 increases the susceptibility of U937 human leukemia cells to ara-C-related lethality, and this phenomenon occurs as a relatively early event that is independent of cell cycle or pharmacodynamic factors and is associated with mitochondrial perturbations implicated in activation of the apoptotic protease cascade.

Instillation of calf lung surfactant extract (calfactant) is beneficial in pediatric acute hypoxemic respiratory failure. Members of the Mid-Atlantic Pediatric Critical Care Network

OBJECTIVE

Prospective study of the efficacy of calf lung surfactant extract in pediatric respiratory failure.

DESIGN

Multi-institutional, prospective, randomized, controlled, unblinded trial.

SETTING

Eight pediatric intensive care units (ICU) of tertiary medical centers.

PATIENTS

Forty-two children with acute hypoxemic respiratory failure characterized by diffuse, bilateral pulmonary infiltrates, need for ventilatory support, and an oxygenation index of >7.

INTERVENTION

Instillation of intratracheal surfactant (80 mL/m2).

MEASUREMENTS AND MAIN RESULTS

Ventilator parameters, arterial blood gases, and derived oxygenation and ventilation indices were recorded before and at intervals after surfactant administration. Complications and outcome measures, including mortality, duration of mechanical ventilation, and length of pediatric ICU and hospital stay, were also examined. Patients who received surfactant demonstrated rapid improvement in oxygenation and, on average, were extubated 4.2 days (32%) sooner and spent 5 fewer days (30%) in pediatric intensive care than control patients. There was no difference in mortality or overall hospital stay. Surfactant administration was associated with no serious adverse effects.

CONCLUSIONS

Administration of calf lung surfactant extract, calfactant, appears to be safe and is associated with rapid improvement in oxygenation, earlier extubation, and decreased requirement for intensive care in children with acute hypoxemic respiratory failure. Further study is needed, however, before widespread use in pediatric respiratory failure can be recommended.

Cytomegalovirus retinitis, human immunodeficiency virus antibody positivity and normal T helper cell numbers

We describe a 46-year-old man in whom retinitis was diagnosed as his initial HIV and AIDS defining illness. A diagnosis of CMV infection was made based on the clinical appearance of the fundus and confirmed by DNA polymerase chain reaction (PCR) on his vitreous biopsy. His CD4+ T lymphocyte count at the time was 580 x 10(6)/l (16%) with a CD4:CD8 ration of 0.28. He had a splenectomy following trauma more than 20 years earlier. He responded very well to intravenous and oral ganciclovir and remains recurrence-free almost 2 years later. This case and others highlight two issues: (i) CMV retinitis in HIV positive is not confined to those with very low CD4+ T lymphocyte counts; (ii) previous splenectomy may have an impact on CD4+ cell numbers and function.

Chronic varicella-zoster virus epithelial keratitis in patients with acquired immunodeficiency syndrome

OBJECTIVE

To characterize further a chronic epithelial keratitis caused by varicella-zoster virus infection in patients with acquired immunodeficiency syndrome (AIDS).

METHODS

Patients with AIDS and chronic epithelial keratitis associated with varicella-zoster virus from 3 institutions were identified. Patient records were reviewed retrospectively for the following data: medical and demographic characteristics, techniques of diagnosis, physical findings, course, response to treatment, and outcome.

RESULTS

Sixteen patients were studied. CD4+ T-lymphocyte cell counts were available in 11 patients, with a median of 0.034 x 10(9)/L (range, 0-0.094 x 10(9)/L). Two patients had no history of a zosteriform rash. In the remaining patients, the interval between rash and keratitis ranged from 0 days to 6 years. In all cases, the keratitis was chronic and characterized by gray, elevated, dendriform epithelial lesions that stained variably with fluorescein and rose bengal. The peripheral and midperipheral cornea was most commonly affected, and, in 13 of the 16 patients, the lesions crossed the limbus. Pain was a prominent feature, occurring in 12 of 16 patients. In 9 of 12 patients tested, varicella-zoster virus was identified by culture, direct fluorescent antibody testing, polymerase chain reaction testing, or a combination of these studies, with direct fluorescent antibody testing (6 of 8 positive results) and polymerase chain reaction testing (3 of 3 positive results) appearing to be the most sensitive. Response to antiviral medication was variable.

CONCLUSIONS

In patients with AIDS, varicella-zoster virus may cause a chronic infection of the corneal epithelium. The keratitis is characterized by dendriform lesions, prolonged course, and frequently by extreme pain. It can occur without an associated dermatitis.

Conscious experience and information

Conscious experience, our main source of information, has special properties. Primary among them is privacy, or privileged access by persons to their own conscious states. The consequent theoretical and practical problems for research on both consciousness and information are delineated.

Management of dialysis catheters

The goals of dialytic therapy are to provide safe, effective care and to emphasize the continuous improvement of quality. To provide such effective care requires the availability of a functional dialysis access. This is a critical (and sometimes the most difficult) component of dialysis. Care should focus not only on the maintenance of function but also on the prevention of complications. This article will familiarize the healthcare professional with the types, uses, and management of peritoneal and hemodialysis catheters.

The complications of trauma and their associated costs in a level I trauma center

OBJECTIVES

To estimate the expected costs for acute trauma care, to quantify the costs associated with the development of complications in injury victims, and to determine the deficit incurred by patients in whom complications develop.

DESIGN

A retrospective, cohort design.

SETTING

A referral trauma center.

PATIENTS

A total of 12,088 patients admitted to a single regional trauma center during a period of 5 years.

INTERVENTIONS

This is an observational study, and no interventions specific to this study are included in the design.

MAIN OUTCOME MEASURES

(1) The expected costs for injury victims based on readily available clinical data. (2) The costs associated with the most important complications of trauma. (3) The effect of complications on inadequate reimbursement for trauma care.

RESULTS

The expected costs were estimated using a linear model incorporating demographic variables and measures of injury severity. The expected costs averaged $14,567, and the observed costs averaged $15,032. Six complications were important predictors of cost. These included adult respiratory distress syndrome, acute kidney failure, sepsis, pneumonia, decubitus ulceration, and wound infections. For 1201 individuals with these complications, the predicted costs averaged $23,266 and the observed costs averaged $47,457. The mean excess costs for a single complication ranged from $6669 to $18,052. Multiple complications led to greater increases in excess cost, averaging $110,007 for the 62 patients with 3 or more complications. Costs exceeded reimbursement to a much greater degree in those in whom any of the 6 complications developed.

CONCLUSION

Expected hospital costs can be estimated using admission clinical data. Each of 6 complications was associated with enormous increases in costs, indicating their importance as a cause of avoidable expenditures in injury victims and identifying situations in which reimbursement may not be adequate.

Does fluoridation reduce the use of dental services among adults?

OBJECTIVES

The authors determine whether prevention influences the use of health services. Fluoridation's effect on restorative dental demand among 972 Washington state employees and spouses, aged 20 to 34 years, in two fluoridated communities and a nonfluoridated community was examined.

METHODS

At baseline, adults were interviewed by telephone, and oral assessments were conducted to measure personal characteristics, lifetime exposure to fluoridated water, oral disease, and the quality of restorations. Adults were followed for 2 years to measure dental demand from dental claims. Each adult's baseline and claims data were linked with provider and practice variables collected from the dentist who provided treatment.

RESULTS

Relative to adults with no lifetime exposure to fluoridated water, adults drinking fluoridated water for half or more of their lives had less disease at baseline and a lower but nonsignificant probability of receiving a restoration in the follow-up period. In the 2-year follow-up period, however, more than half of the restorations were performed to replace fillings of satisfactory or ideal quality at baseline. When only teeth with decay and unsatisfactory fillings at baseline were considered, adults with high fluoridation exposure had a lower probability of receiving a restoration than adults with no exposure. Market effects also were detected in demand equations; relative to adults in the nonfluoridated community, adults residing in the fluoridated community with a large dentist supply received a greater number of restorations, suggesting potential supplier-induced demand from less disease and fewer patients.

CONCLUSIONS

Among adults aged 20 to 34 years with private dental insurance, fluoridation reduces oral disease but may or may not reduce use of restorative services, depending on dentists' clinical decisions.

The relationship between price of services, quality of care, and patient time costs for general dental practice

OBJECTIVE

To examine the relationships between price of services, quality of care, and patient time costs in private practices of general dentists.

DATA SOURCE/STUDY SETTING

In October 1992, a 3.7 percent sample of eligible general dentists in part-time or full-time private practice in 1991 was randomly drawn from a sampling frame tailored from data gathered by the 1991-1992 American Dental Association Distribution of Dentists census of all United States dentists.

DATA COLLECTION

A mail survey was used to collect data on dentist demographic characteristics, dental practice characteristics practice finances, and insurance. The survey was completed and returned by 3,048 general dentists (77 percent response rate). Local area population characteristics were obtained from secondary sources.

STUDY DESIGN

Two-stage least squares regression was used to evaluate the structural relationships between price of services, quality of care, and time costs to patients. Structural equations were estimated for four different quality of care measures and two time costs.

PRINCIPAL FINDINGS

Price of services and quality of care were significantly related to each other. Higher quality of care was associated with higher price of services and, reciprocally, higher price of services was associated with higher quality of care. Shorter waits for a new patient appointment were associated with higher prices. Higher price of services, lower quality of care, and longer waits for a new patient appointment were related to shorter in-office waiting time.

CONCLUSIONS

The implication of these findings is that if price of services is constrained, then the quality of care provided by the dentist may also be reduced.

Cytomegalovirus-associated acute retinal necrosis syndrome

PURPOSE

To describe a case of acute retinal necrosis syndrome in which a polymerase chain reaction-based assay provided evidence for cytomegalovirus as the causative agent of the syndrome.

METHODS

Polymerase chain reaction-based assays were used to analyze a vitreous aspirate from a 70-year-old man with acute retinal necrosis syndrome. The specimen was tested for cytomegalovirus, varicella-zoster virus, and herpes simplex virus type 1 and type 2.

RESULTS

The polymerase chain reaction assay for cytomegalovirus was positive, and polymerase chain reaction assays for varicella-zoster virus and herpes simplex virus type 1 and type 2 were negative.

CONCLUSION

Cytomegalovirus may be a causative agent of acute retinal necrosis syndrome.

Calf's lung surfactant extract in acute hypoxemic respiratory failure in children

OBJECTIVE

Open-label trial of the safety and short-term efficacy of calf's lung surfactant in pediatric respiratory failure.

DESIGN

Multi-institutional, uncontrolled, observational trial.

SETTING

Six pediatric intensive care units of tertiary medical centers.

PATIENTS

Twenty-nine children with acute hypoxemic respiratory failure, characterized by diffuse, bilateral, pulmonary infiltrates, need for ventilator support, and an oxygenation index of > or = 7.

INTERVENTIONS

Up to four doses of intratracheal surfactant (80 mL/m2).

MEASUREMENTS AND MAIN RESULTS

Ventilator parameters, arterial blood gases, and derived oxygenation and ventilation indices were recorded before, and at intervals after, surfactant administration. Complications and outcome measures were also noted. There was immediate improvement in oxygenation and moderation of ventilator support associated with surfactant administration in 24 of 29 patients. A modest but statistically insignificant effect was seen with subsequent doses. The only complications occurred in three patients who developed airleaks, two of which were coincident with surfactant administration. The overall mortality rate was 14%, which compares favorably with other published series.

CONCLUSIONS

Administration of calf's lung surfactant appears to be safe and is associated with rapid improvement in oxygenation and moderation of ventilator support in children with acute hypoxemic respiratory failure. These results set the stage for a randomized, controlled study.

Managing care, incentives, and information: an exploratory look inside the "black box" of hospital efficiency

OBJECTIVE

We sought to estimate the impact of individual dimensions of hospitals' managed care strategies on the cost per hospital discharge.

STUDY SETTING/DATA SOURCES

Thirty-seven member hospitals of seven health systems in the Pacific, Rocky Mountain, and Southwest regions of the United States were studied.

STUDY DESIGN

Separate cross-sectional regression analyses of 21,135 inpatient discharges were performed in 1991 and 23,262 discharges in 1992. The multivariate model was estimated with hospital cost per discharge as the dependent variable. Model robustness was checked by comparing regression results at the individual discharge level with those at the level of the hospital/clinical condition pair.

DATA COLLECTION/EXTRACTION METHODS

Information on hospitals' managed care strategies was provided by mail and phone survey of key informants in 1991 and 1992. Other hospital characteristics were collected from AHA Annual Survey data, and discharge data from hospital abstracting systems.

PRINCIPAL FINDINGS

The pooled discharge analysis indicated three dimensions of hospital managed care strategy that consistently related to lower costs per hospital discharge: the proportion of hospital revenues derived from per case or capitation payment, the hospital's mechanisms for sharing information on resource consumption with clinicians, and the use of formalized, systematic care coordination mechanisms.

CONCLUSIONS

Three strategies appear to hold promise for enhancing the efficiency of inpatient resource use: (1) "fixed price" hospital payment incentives, (2) hospital approaches to sharing resource use information with clinicians, and (3) the application of formal care management mechanisms for specific clinical conditions.

Contributions to the GC-MS-analysis of polyfluorinated dibenzo-p-dioxins (PFDD)

Polyfluorinated dibenzodioxins (PFDD) obtained by synthesis are investigated for their gas chromatographic and mass spectrometric behaviour. Kovats-indices of the investigated PFDD range between 1400 and 1600 on the unpolar column DB5, between 1500 and 1900 on the moderately polar column DB17 and between 2300 and 2800 on the strongly polar SP 2331. Thus PFDD elute between PFB and PCB. As for PCDD the molecular ion peak is the base peak for PFDD, too. However, other than for PCDD the second highest peak is the M-C(2)O(2)-peak for the lower fluorinated PFDD and the M-COF-peak for the higher fluorinated PFDD (directly followed by the M-C(2)O(2)-peak). PFDD also show intensive M(2+)-peaks. The intensity of C(x)F(y)-fragments increases with increasing degree of fluorination.

Consciousness, privacy, and information

The challenges for a scientific study of conscious experience are discussed, as well as the importance of such research for the foundations of information science. A three pronged approach to the investigation of consciousness and its functions is suggested.

Frustrating patient visits

OBJECTIVES

This study, part of a national mail survey of dentist malpractice liability claims, reports the reliability and validity of a new 22-item instrument measuring frustrating patient visits.

METHODS

The items were subjected to factor analysis and subscales constructed. Reliability was assessed using Cronbach's alpha. Validity was assessed by comparing subscale scores to self-reports of satisfaction and liability claims.

RESULTS

Factor analysis revealed four subscales representing unpleasant feelings, lack of communication, compliance, and practice organization (alpha = 0.60-0.86). Compliance was the most important factor. Subscale scores were related to satisfaction with practice and the proportion of patient visits in the practice that were frustrating to the dentist. Dentists who reported frustrating patient visits as quite typical of their practices were more likely to have had a malpractice liability claim within the last five years.

CONCLUSION

This instrument may be of value in detecting patient-dentist communication difficulties that are the precursor to liability claims.

Community organization to promote breast cancer screening among women ages 50-75

BACKGROUND

To reduce breast cancer mortality, ways to promote the use of mammography screening among women age 50 and above are needed. Community organization may be a useful approach.

METHODS

The Washington State Community Breast Cancer Screening Project involved implementation of promotional activities initiated by physician and lay community boards in two communities. Two comparable communities served as controls for evaluation purposes. Random-digit-dial telephone interviews were used to assess recent use of mammography at baseline and follow-up in independent samples of women ages 50 to 75 from the four communities. The extent of exposure to intervention activities and the relationship between exposure to intervention activities and mammography use were estimated from data collected at follow-up.

RESULTS

Exposure to patient reminders from physicians, wallet reminder cards, and newspaper advertisements were consistently related to mammography use. Physician office staff encouragement and a display board were significantly related to mammography use only in Intervention Communities A and B, respectively. Neither exposure to promotional activities nor the change in prevalence of mammography use was significantly higher in the intervention communities than in the comparison communities at follow-up.

CONCLUSIONS

Although several activities were useful in promoting mammography use, organization of the community did not enhance efforts undertaken spontaneously by comparable communities.

Tort reform and malpractice liability insurance

Legal factors related to the malpractice liability insurance purchased by general dentists in the United States were investigated using a comprehensive multivariate model that assessed the contribution of legal provisions affecting the probability of a malpractice claim, the probability of a payment, and the average size of the payment. General practice dentists in the United States were selected randomly, and 3,048 dentists were studied by mail survey. A number of legal statutes (periodic payment allowed, percentage fault liability informed consent limits, limits on res ipsa loquitor, attorney fee control, some statute of limitations provisions) had the intended effect of reducing the malpractice insurance sought by dentists. Other provisions, such as binding arbitration, may have unintended cost-raising effects. Previous malpractice claims were associated with purchasing greater amounts of insurance. These findings have implications for future changes in the legal system as part of health care reform.

Analysis of automated administrative and survey databases to study patterns and outcomes of care

Large computerized databases often arise from national surveys, insurance claims, and statewide health care registries. These databases are increasingly used to examine patterns of medical care and certain outcomes of care and may be helpful in planning clinical trials. They are highly representative of defined populations, but have limited clinical information. Methods have been developed to identify episodes of low back pain and to quantify the severity of unrelated, comorbid medical conditions. Pitfalls in analysis are discussed, including limitations of diagnosis and procedure coding, cross-sectional nature of most data, limited clinical detail, and the necessarily observational (not experimental) nature of any group comparisons. There is growing interest in expanding the clinical information in such databases, for both quality improvement and research purposes.

Costing medical care: using Medicare administrative data

This paper describes how the PORTS are using data from the Medicare administrative records systems to study the medical care costs of specific conditions. The general strengths and weaknesses of the Medicare databases for studying cost related issues are discussed, and the relevant data elements are examined in detail. Changes in the nature of the data collected over time are noted. Information is provided on how the PORTS are using these data to estimate the cost to Medicare of treating Medicare beneficiaries with specific conditions and the social (opportunity) cost of treating these patients. Furthermore, information is provided on how data from the Medicare administrative records system can be used to determine the cost of services for patients who have been identified through other large databases (i.e., state hospital discharge tapes) or who have been enrolled in prospective cohort studies.

Malpractice claims during 1988-1992: a national survey of dentists

Between 1988 and 1992, almost a quarter of surveyed dentists reported at least one patient complaint to malpractice insurance carriers. The incidence of claims more than doubled in that time and payment size increased nearly five times between 1988 and 1991. These and other trends in professional liability are examined in this national survey of general dentists.

Subcellular localization of squalene synthase in rat hepatic cells. Biochemical and immunochemical evidence

In the present study we investigated the subcellular localization of squalene synthase (farnesyl-diphosphate:farnesyl-diphosphate farnesyltransferase, EC 2.5.1.21). Squalene synthase catalyzes the formation of squalene from trans-farnesyl diphosphate in two distinct steps and is the first committed enzyme for the biosynthesis of cholesterol. Recently, a truncated form of the enzyme from rat hepatocytes was purified, and monospecific antibodies for squalene synthase were produced. This enabled the subcellular localization of squalene synthase by three different methods: (i) analytical subcellular fractionation and measurements of enzyme activities; (ii) immunodeterminations of squalene synthase in the isolated subcellular fractions with a monospecific antibody; and (iii) immunoelectron microscopy. All three methods gave consistent results. The data clearly illustrate that squalene synthase enzymatic activity and squalene synthase are exclusively localized in the endoplasmic reticulum. In rat hepatic peroxisomes we were not able to detect any squalene synthase. In addition, we also demonstrated that squalene synthase in the microsomal fraction is dramatically regulated by a number of hypolipidemic drugs and dietary treatments.

The binding of Pneumococcal lipoteichoic acid to human erythrocytes

Previous studies have evaluated the binding characteristics of lipoteichoic acids (LTA) composed of polyglycerol phosphate to mammalian cell membranes. This present study was performed to evaluate the binding characteristics of Pneumococcal LTA, a polyribitol phosphate containing LTA, to human erythrocytes. Binding was found to be specific, reversible, and dependent on temperature and time. Maximum binding was achieved within 2 h at 37 degrees C. Scatchard plot analysis of the binding revealed a biphasic plot which suggests two receptor sites with different affinities. Competitive inhibition studies with LTA composed of polyglycerol phosphate and isolated from Streptococcus pyogenes and Lactobacillus fermentum revealed significant inhibition of Pneumococcal LTA-binding to the erythrocyte membrane by these heterologous LTAs. These results demonstrate that Pneumococcal LTA binds specifically to human erythrocytes and that the receptor site is similar for other structurally different LTAs.