What happens when peer support workers are introduced as members of community-based clinical mental health service delivery teams: a qualitative study.

The insights of people who have experienced mental health issues are at the core of recovery frameworks. The inclusion of peer support workers in clinical care teams is crucial to a recovery-supportive focus. Peer support workers facilitate egalitarian spaces for non-peer staff and consumers to frankly discuss the lived experience of mental illness. This study was part of a larger evaluation study which aimed to explore the implementation of a newly formed community-based mental health team in South-East Queensland, Australia. The paper reports the role of peer support workers and answers two research questions: "How is peer support work constructed in an interprofessional clinical care team?" and (2) "How do interprofessional mental health clinical care teams respond to the inclusion of peer support workers as team members?" Three themes were identified: peer support worker' ability to navigate a legitimate place within care teams, their value to the team once they established legitimacy and their ability to traverse the care landscape. Ultimately, successful integration in interprofessional teams was dependent upon the ability of clinical staff to focus on unique strengths that peer support workers bring, in addition to lived experience with mental illness as a carer or consumer.

The nutrition care needs of patients newly diagnosed with type 2 diabetes: informing dietetic practice.

BACKGROUND: Understanding patients' experiences and preferences for health care is important with respect to informing how to provide best-practice, patient-centred care. The present study aimed to explore the perceptions of patients who have been recently diagnosed with type 2 diabetes regarding nutrition care received from dietitians. METHODS: Ten individuals recently diagnosed with type 2 diabetes participated in three individual semi-structured qualitative telephone interviews: at baseline, then at 3 and 6 months after recruitment. Data were analysed using content analysis at each time point and meta-synthesis of findings over time. RESULTS: Participants' initial interactions with dietitians were challenging and overwhelming as a result of the instructional nature of consultations. Many participants questioned the use of dietary guidelines to inform nutrition care because this was not adapted to the individual. Some participants valued receiving education on topics such as label reading and serving sizes; however, others considered that the nutrition care was rushed and overly directive. Very few participants perceived that an ongoing relationship with a dietitian would be useful, and limited interaction was planned beyond 6 months after diagnosis. CONCLUSIONS: These findings suggest that there is considerable opportunity for dietitians to enhance the nutrition care provided to patients with type 2 diabetes. Tailoring of dietary guidelines to individuals, utilising supportive counselling styles, and focusing on open communication in consultations that facilitate ongoing, useful care for patients, may help patients with type 2 diabetes achieve and maintain healthy dietary behaviours.

Characterization of the replication origin (Ori(S)) and adjoining parts of the inverted repeat sequences of the pseudorabies virus genome.

The DNA sequence of a 2.4 kbp fragment located in the internal and terminal inverted repeat sequences of the pseudorabies virus genome determined in this study closes a gap between the previously described genes for the ICP4 and ICP22 homologues. The novel sequence contains no conserved herpesvirus open reading frames. Northern blot and cDNA analyses revealed a viral immediate-early transcript of 1.8 kb, which is spliced by the removal of two small introns close to its 5' end and which presumably represents the mRNA of the downstream open reading frame encoding the ICP22 homologue. Upstream of the transcribed region, an imperfect set of three directly repeated sequences was identified. Each of them contains a complementary pair of the alphaherpesvirus origin-binding protein recognition motif GTTCGCAC, spaced by AT-rich sequences. In vitro studies confirmed that the DNA fragment analysed includes a functional origin of viral DNA replication.

Satisfaction, gender, and communication in medical visits.

The authors conducted two studies of routine medical visits, investigating the relation of physician gender, patient gender, and physician age to patient satisfaction, and the correlations between communication behaviors and satisfaction separately for different combinations of patient and physician gender. Study 1 was based on videotaped visits to a hospital-based internal medicine practice (n = 97 visits). Study 2 was based on audiotaped visits to 11 different community and hospital-based practices in the United States and Canada (n = 524 visits). In both studies, patients examined by younger physicians, especially younger female physicians, reported lower ratings of satisfaction. These findings were true for male and female patients; however, in both studies, the lowest satisfaction in absolute terms was among male patients examined by younger female physicians. The effects were not explained by patient and physician background characteristics or by measured communication during the visit. Correlations between verbal and nonverbal communication and satisfaction for different combinations of physician and patient gender suggested that gender-related values and expectations influence patients' reactions to physicians' behavior. There also was evidence that patient satisfaction is reflected in the patient's affective behavior during the visit.

Gender in medical encounters: an analysis of physician and patient communication in a primary care setting.

The relation of physician and patient gender to verbal and nonverbal communication was examined in 100 routine medical visits. Female physicians conducted longer visits, made more positive statements, made more partnership statements, asked more questions, made more back-channel responses, and smiled and nodded more. Patients made more partnership statements and gave more medical information to female physicians. The combinations of female physician-female patient and female physician-male patient received special attention in planned contrasts. These combinations showed distinctive patterns of physician and patient behavior, especially in nonverbal communication. We discuss the relation of the results to gender differences in nonclinical settings, role strains in medical visits, and current trends in medical education.

Orientation of medical residents to the psychosocial aspects of primary care: influence of training program.

PURPOSE: To describe the attitudes of residents in general medicine to the psychosocial dimensions of primary care and to evaluate the influences of selected variables. METHOD: A cross-sectional analysis-of-variance design (two training programs involving residents in all three residency years) was used in the analysis of 21 psychosocial attitude items from a survey questionnaire completed by general medicine residents. In 1991-92, 77 general medicine residents in ambulatory care group practices associated with the Massachusetts General Hospital were surveyed. Eighteen of the residents were in a primary care program (PCP), and 59 were in a traditional medicine program (TMP). RESULTS: The overall response rate was 82% (63 of 77 residents), with slightly lower rates for four items. The residents' attitudes to the psychosocial role of the primary care physician were positive but with reservations: 55 (87%) endorsed asking psychosocial questions, while only 28 (44%) indicated that most internists felt competent to diagnose and treat. Most residents did not feel defensive about enacting the role (neither uncomfortable asking questions in ambulatory care settings, 58, 92%; nor nosey, 56, 89%; nor personally interfering, 47, 76%). Fifty-two residents (83%) perceived patients to be receptive to psychosocial questions, yet 31 (49%) indicated that patients were resistant to psychosocial attributions, and 48 (76%) indicated that patients need to be prompted to talk about life problems. The clearest and strongest influence on attitudes was setting: ambulatory care over inpatient (p < .0001). Overall, the responses of the residents from the PCP and TMP were more similar than different. CONCLUSION: The residents accepted the psychosocial role of the primary care physician, found it most appropriate in ambulatory care settings, felt ambivalent about their ability to carry it out, and assigned it a secondary priority in patient care. To interest residents in primary care, more training should be based in ambulatory care settings and more emphasis should be placed on improving residents' competency in psychosocial skills.

An Intercomparison Between NPL (India) and NIST (USA) Pressure Standards in the Hydraulic Pressure Region up to 26 MPa.

Results are presented of an intercomparison of pressure measurements between the National Physical Laboratory (NPL), India, and the National Institute of Standards and Technology (NIST), USA, using piston gauge pressure standards over the range 6 MPa to 26 MPa. The intercomparison, using the NPL piston gauge pressure standard, with a nominal effective area of 8.4×10-5 m2 and the NIST piston gauge pressure standard, with a nominal effective area of 2.0× 10-5 m2 was carried out at the NPL. The intercomparison data obtained show a relative difference of 1 × 10-6 in the zero-pressure effective area (A0) of the NPL standard as obtained by the NIST standard. At 6 MPa the relative difference in effective areas is 3.5×10-6; at the full scale pressure of 26 MPa, the relative difference is 12×10-6. These differences are in excellent agreement with the statements of uncertainty of the respective standards as obtained from the primary standards of these two laboratories.

Blood transfusion and the risk of recurrence in squamous carcinoma of the vulva.

OBJECTIVE: Our purpose was to determine if postoperative transfusion increases the risk of recurrence in patients who have undergone operation for squamous carcinoma of the vulva. STUDY DESIGN: Data from 154 patients with squamous carcinoma of the vulva treated at Indiana University Medical Center from 1974 through 1988 were retrospectively analyzed to determine the influence of postoperative transfusion on recurrence risk. Patients were evaluated for International Federation of Gynecology and Obstetrics stage, lesion size, lesion depth, grade, patient age, number of transfusions, and recurrence with chi 2 analysis, Fisher's exact test, and the Student t test where appropriate. RESULTS: Transfusions were given to 57 patients (37%) with a mean of 2.2 units delivered (range 1 to 5 units). Transfused patients differed significantly from those not transfused in that they had more advanced stage (p = 0.002), more positive nodes (p = 0.03), and higher grade lesions (p = 0.03), and they were older (p = 0.005). Recurrences developed in 25 patients (16.2%). Recurrences were more common in those with positive nodes (10-39, 25.6%) than in those with negative nodes (8/99, 8%), (p = 0.01). Only nodal status was predictive of recurrence in this series. Transfused patients had a 14% (8/57) rate of recurrence, whereas the recurrence risk was 17.5% (17/97) in those not transfused (p = 0.65). CONCLUSIONS: We have been unable to confirm that postoperative transfusions increase the risk of recurrence in patients with squamous carcinoma of the vulva.

Recurrent squamous carcinoma of the vulva.

OBJECTIVE: This study reviews experience at Indiana University with recurrent squamous carcinoma of the vulva over an 18-year period from 1971 to 1989. The pattern of recurrence, time interval to recurrence, and efficacy of salvage therapy are evaluated in the context of the primary tumor. STUDY DESIGN: This is a retrospective study of 40 patients, 21 of whom underwent primary therapy for invasive squamous carcinoma of the vulva at Indiana University. RESULTS: Vulvar recurrences were observed in 17 patients (43%), the groin was involved in 12 (30%), whereas pelvic and distant recurrences were observed in 2 (5%) and 9 (22.5%) patients, respectively. Salvage surgery and/or radiotherapy were successful in 25 patients (62.5%) alive from 1 to 144 months (median 8 months) from secondary therapy. Survival after retreatment varied significantly by site of recurrence (p = 0.002), tumor grade (p = 0.009), and interval to recurrence (p < 0.001). Best outcomes were in patients with initial stage I or II disease (International Federation of Gynecology and Obstetrics), grade 1 tumors, local failure, and interval to relapse of > 16 months' duration. Two of 12 patients with groin recurrences were salvaged with surgery and radiotherapy. CONCLUSION: Long-term follow-up of patients with vulvar cancer and careful restaging at the time of recurrence are mandatory. Although local and nodal recurrences may be controlled with surgery and/or radiotherapy, regional recurrences are usually fatal.

Inhibition by tiazofurin of inosine 5'-phosphate dehydrogenase (IMP DH) activity in extracts of ovarian carcinomas.

Cancer cells have an increased ability to synthesize GTP (guanosine triphosphate) because of increased activity of IMP DH (inosine 5'-phosphate dehydrogenase, EC 1.1.1.205). Because IMP DH activity is rate limiting for de novo biosynthesis of GTP, this enzyme was suggested as a sensitive target for chemotherapy. Tiazofurin (2-beta-D-ribofuranosylthiazole-4-carboxamide) is converted in the cells into the active metabolite, TAD, (thiazole-4-carboxamide adenine dinucleotide) which potently inhibits IMP DH activity. By adding TAD to tissue extracts one can determine the extent of inhibition of IMP DH. We applied the IMP DH assay method to extracts of normal ovaries (N = 11) and epithelial ovarian carcinomas (N = 10). The IMP DH activity (mean +/- SE) in ovarian carcinoma was 21.1 +/- 5.8 which was markedly higher than that observed in normal ovaries (2.9 +/- 0.7 nmol/hr/mg protein) (P < 0.05%). The inhibition by TAD of IMP DH activity in ovarian carcinomas (N = 4) was 81%. The results indicate that IMP DH activity is elevated sevenfold in ovarian carcinomas as compared to normal ovary and can be inhibited by exposure to tiazofurin (TAD). Similar high IMP DH activity and inhibition of the activity by TAD was observed in patients with chronic granulocytic leukemia in blast crisis among whom 70 to 80% remissions were reported. Since there is increased IMP DH activity in human ovarian carcinomas and in OVCAR-5 cells and tiazofurin and TAD inhibit IMP DH activity of these cells and the proliferation of human ovarian carcinoma xenografts in the mouse, tiazofurin may merit serious consideration for a Phase II trial for patients with recurrent/refractory epithelial ovarian carcinoma.

Trends in the operative management of invasive squamous carcinoma of the vulva at Indiana University, 1974 to 1988.

From January 1974 to March 1988, 150 patients with primary invasive squamous cell carcinoma of the vulva underwent surgery at Indiana University. There has been a trend toward more conservative surgical management of this disease. To determine the impact of this trend on clinical outcome, cases were divided into three groups according to date of operation: group I, 1974 to 1978; group II, 1979 to 1983; and group III, 1984 to 1988. Overall, 80 patients had en bloc radical vulvectomy and groin dissection, 20 had modified radical vulvectomy and bilateral groin dissection through three separate incisions, and 36 had modified radical vulvectomy and unilateral superficial groin dissection. Fourteen patients had other operations. Forty-two patients (27.3%) had radiotherapy in addition to surgery. Among the three groups, there were no differences when mean age, International Federation of Gynecology and Obstetrics stage distribution (1988 system), mean lesion size, mean depth of invasion, or grade distribution were compared. A significant trend toward more conservative surgical therapy was observed. En bloc radical vulvectomy was performed in 77.4% of group I patients, 71.1% of group II patients, and 35.8% of group III patients (p less than 0.001). Mean days of hospitalization were also reduced significantly. Group I had a mean stay of 30 days, group II had a mean stay of 23 days, and group III had a mean stay of 11 days (p less than 0.001). Mean operative blood loss (group I, 754.8 ml; group II, 620.0 ml; group III, 393.6 ml; p = 0.03), mean units of blood transfused (group I, 1.4 units; group II, 1.3 units; group III, 0.4 units; p less than 0.01), and mean hours of operating time (group I, 3.7 hours; group II, 3.7 hours; group III, 3.2 hours; p = 0.02) were also reduced.

DNA content as a prognostic index in gestational trophoblastic neoplasia.

Hydatidiform mole will progress to malignant gestational trophoblastic neoplasia (GTN) in some cases. Aneuploidy and high proliferative activity are associated with malignant tumors. Molar pregnancy tissue was considered a precursor to malignant GTN, and was studied retrospectively using paraffin-embedded tissue to determine whether aneuploidy or proliferative rates measured on molar tissue could predict a malignant course. Tissues from 51 complete hydatidiform moles were analyzed for nuclear DNA content by flow cytometric techniques. A chart review identified the clinical course after evacuation of the mole. A satisfactory DNA histogram was generated in 40 cases. Of the 40 patients, 22 (55%) had spontaneous resolution, and 18 patients (45%) required treatment for persistent GTN. The molar tissue was found to be euploid in 27 cases and aneuploid in 13 cases. Eight of the twenty-seven euploid cases (30%) required treatment after evacuation, whereas 10 of the 13 aneuploid cases (77%) required treatment after molar evacuation. Proliferative index (PI) was compared with treatment requirements. Average PI was 0.11 +/- 0.10 for the treatment group and 0.08 +/- 0.06 for the spontaneous resolution group. The correlation of clinical course with ploidy was significant (P less than 0.01). The association with proliferative index was not (P greater than 0.05). Aneuploidy, therefore, identifies a high-risk group of molar pregnancies, and may represent those that have undergone one stage of malignant transformation.

Aggressive angiomyxoma first diagnosed as levator hernia.

When a 32-year-old woman was first seen, physical findings suggested she had a large levator hernia, but at the time of surgical resection an aggressive angiomyxoma was found.

Features associated with survival and disease-free survival in early endometrial cancer.

Age, clinical stage, histologic grade, depth of myometrial penetration, adnexal status, peritoneal cytology, and progesterone and estrogen receptor status were available for 139 patients with clinical stage IA, IB, or II endometrial adenocarcinoma who had therapy at Indiana University Hospital or St. Vincent Hospital in Indianapolis. These features were analyzed for their association with survival and disease-free survival. Patients treated at Indiana University Hospital were similar to those from St. Vincent Hospital when comparisons were made by chi 2 test for age, clinical stage, grade, adnexal metastases, peritoneal cytologic results, progesterone receptor status, or estrogen receptor status. However, patients treated at Indiana University Hospital had lesions that were deeper (p = 0.03) than those treated at St. Vincent Hospital. Survival differences were observed for patients with progesterone receptor-rich versus progesterone receptor-poor tumors (p = 0.004), grades 1 and 2 versus grade 3 lesions (p = 0.013), and malignant versus benign peritoneal cytologic results (p = 0.01). Differences in disease-free survival were observed for those patients with adnexal metastases versus those with no adnexal disease (p = 0.002), those with estrogen receptor-rich versus estrogen receptor-poor tumors, outer third myometrial invasion (p = 0.002), and patients with clinical stage I versus clinical stage II disease (p = 0.03). A stepwise Cox proportional hazards model was constructed to determine correlates of disease-free survival. In the final model, grade (p = 0.0002), peritoneal cytologic results (p = 0.0002), progesterone receptor status (p = 0.004), and age as a continuous variable (p = 0.008) were most closely associated with disease-free survival.

Ten-year follow-up of patients receiving cisplatin, doxorubicin, and cyclophosphamide chemotherapy for advanced epithelial ovarian carcinoma.

Fifty-six patients were randomly assigned to receive either one-day cisplatin, doxorubicin, and cyclophosphamide (PAC) chemotherapy (PAC-I) or five-day PAC (PAC-V) for advanced epithelial ovarian carcinoma. Follow-up has been 120+ months or to death. Ninety-one percent had either suboptimal stage III or stage IV disease and 55% had grade 2 or 3 lesions. Two patients died of toxicity and were free of disease at autopsy. A third patient died of congestive heart failure with no disease at 103 months. Additionally, eight patients had a negative second-look laparotomy, and three (37.5%) are alive with no evidence of disease (NED) 133 to 144 months after diagnosis. Five patients (62.5%) died of disease 2 to 123 months after negative second-look. Patients with optimal stage III disease had a longer median progression-free interval (PFI) and survival (33.3 and 44.5 months, respectively) than those with suboptimal or stage IV disease (16.4 and 22.5 months, respectively), and the difference in median PFI is significant (P less than .02). Patients with ascites at diagnosis had a shorter median PFI and survival (14.7 and 18 months) than those without ascites (30.0 and 33.0 months). Both differences were significant (PFI, P less than .04; survival, P = .005). PAC produces response rates that are superior to those obtained historically with single-agent alkylating therapy. Late recurrences after negative second-look laparotomy suggest that 5-year survival data may be inadequate in ovarian carcinoma.

The Reduction of Uncertainties for Absolute Piston Gage Pressure Measurements in the Atmospheric Pressure Range.

NIST pressure calibration services with nitrogen are now based on two transfer standard piston gages for which the effective areas have been determined by calibration with the manometer developed at NIST for gas thermometry. Root-sum-squared three sigma uncertainties for the areas for the two gages are 3.05 ppm and 4.18 ppm.

Eaton-Lambert syndrome as a harbinger of recurrent small-cell carcinoma of the cervix with improvement after combination chemotherapy.

Eaton-Lambert or myasthenic syndrome was diagnosed in a young woman with recurrent small-cell carcinoma of the cervix. Therapy with vincristine, doxorubicin, and cyclophosphamide resulted in a partial response of the tumor and marked improvement in neurologic symptoms. Diagnosis and treatment of this paraneoplastic syndrome are discussed.