Active participation of patients with type 2 diabetes in consultations with their primary care practice nurses - what helps and what hinders: a qualitative study.

BACKGROUND: Patients with type 2 diabetes mellitus (T2DM) receiving primary care regularly visit their practice nurses (PNs). By actively participating during medical consultations, patients can better manage their disease, improving clinical outcomes and their quality of life. However, many patients with T2DM do not actively participate during medical consultations. To understand the factors affecting engagement of patients with T2DM, this study aimed to identify factors that help or hinder them from actively participating in consultations with their primary care PNs. METHODS: Two semi-structured focus groups and 12 semi-structured individual interviews were conducted with patients with T2DM (n = 20) who were undergoing treatment by primary care PNs. All interviews were transcribed verbatim and analyzed using a two-step approach derived from the context-mapping framework. RESULTS: Four factors were found to help encourage patients to actively participate in their consultation: developing trusting relationships with their PNs, having enough time in the appointment, deliberately preparing for consultations, and allowing for the presence of a spouse. Conversely, four factors were found to hinder patients from participating during consultations: lacking the need or motivation to participate, readjusting to a new PN, forgetting to ask questions, and ineffectively expressing their thoughts. CONCLUSION: Patients lacked the skills necessary to adequately prepare for a consultation and achieve an active role. In addition, patients' keen involvement appeared to benefit from a trusting relationship with their PNs. When active participation is impeded by barriers such as a lack of patient's skills, facilitators should be introduced at an early stage. TRIAL REGISTRATION: Current Controlled Trials NTR4693 (July 16, 2014).

Morbidity on Kauai before and after Hurricane Iniki.

BACKGROUND: On September 11, 1992, Hurricane Iniki, a Class III/IV storm, passed directly over Kauai. This study is the first attempt to measure increases in injuries and other health outcomes among an entire population in the impact zone of a hurricane. METHODS: Medical chart data were abstracted from all facilities providing primary and emergency care on Kauai. Incidence of injury, cardiovascular disease, and asthma for the 2-week period following Hurricane Iniki were compared to those for the 2-week period preceding Iniki. RESULTS: A total of 1,584 injuries were treated in the post-Iniki period compared with 231 injuries treated in the pre-Iniki period (relative risk = 6.86, 95% confidence interval 5.98-7.87). Open wounds constituted over half of these injuries. Physician visits for asthma and cardiovascular disease were also significantly increased in the post-Iniki period (relative risks, respectively: 2.81, 95% confidence interval 1.93-4.09; 2.73, 95% confidence interval 1.51-4.94). CONCLUSIONS: Significant increases in the incidence of injuries, asthma, and cardiovascular disease occurred following Hurricane Iniki. Although no changes occurred in the proportion of patients needing hospitalization, additional injuries and illnesses after a natural disaster can burden existing medical facilities in a rural community with limited resources. Disaster preparedness plans need to include methods to increase services and supplies at existing medical facilities.

A rapid public health response to a cryptic outbreak of cholera in Hawaii.

In November 1991, toxigenic Vibrio cholerae O1 infection was confirmed in two unrelated persons in Hawaii. Cholera had not been acquired in Hawaii since 1895. To determine the source and extent of V cholerae O1 infections in Hawaii, both patients were interviewed, suspect food sources were investigated, and surveillance of physicians, laboratories, hospitals, and sewage treatment plants was instituted. One patient's husband had serologic titers consistent with recent V cholerae O1 infection; no other cases were confirmed and V cholerae O1 was not recovered from active surveillance of laboratories or sewage treatment plants. The investigation demonstrated that the outbreak had affected few persons and had ended.

Characterization of a variant strain of Norwalk virus from a food-borne outbreak of gastroenteritis on a cruise ship in Hawaii.

A gastroenteritis outbreak affecting at least 217 (41%) of 527 passengers on a cruise ship was caused by a variant strain of Norwalk virus (NV) that is related to but distinct from the prototype NV strain. Consumption of fresh-cut fruit served at two buffets was significantly associated with illness (P < or = 0.01), and a significant dose-response relationship was evident between illness and the number of various fresh-cut fruit items eaten. Seven (58%) of 12 paired serum specimens from ill persons demonstrated at least fourfold rises in antibody response to recombinant NV capsid antigen. A 32-nm small round-structured virus was visualized by electron microscopy in 4 (29%) of 14 fecal specimens, but none of the 8 specimens that were examined by an enzyme immunoassay for NV antigen demonstrated antigen. Four (40%) of 10 fecal specimens were positive by reverse transcriptase-PCR by using primer pairs selected from the polymerase region of NV. In a 145-bp region, the PCR product shared only 72% nucleotide sequence identity with the reference NV strain and 77% nucleotide sequence identity with Southampton virus but shared 95% nucleotide sequence identity with UK2 virus, a United Kingdom reference virus strain. In addition, the outbreak virus was serotyped as UK2 virus by solid-phase immune electron microscopy. The genetic and antigenic divergence of the outbreak strain from the reference NV strain highlights the need for more broadly reactive diagnostic assays and for improved understanding of the relatedness of the NV group of agents.

The immunologic staging of chronic active hepatitis B patients in Hawaii.

The hepatitis B antigen/antibody levels and natural killer cell activity status of chronic hepatitis B patients identified by the Hawaii State Department of Health were evaluated to select chronically infected hepatitis B patients for interferon therapy and to determine possible immunodeficiencies. The presence of hepatitis Be antigen denotes active replication of the virus. Ninety-five patients were studied: 17/95 (18%) had chronic active hepatitis B, 71/95 (75%) were hepatitis B carriers and 7/95 (7%) had seroconverted. NK activity to the erythroleukemia K562 cell and virus-infected HSV-1 cell of the chronic active and carrier population (P < .05) were lower than that of the control population and those who had spontaneously seroconverted. Of this population 18% were identified with active viral infection and would be candidates for interferon therapy.

Norwalk virus-associated gastroenteritis traced to ice consumption aboard a cruise ship in Hawaii: comparison and application of molecular method-based assays.

Investigation of an outbreak of acute nonbacterial gastroenteritis on a cruise ship provided an opportunity to assess new molecular method-based diagnostic methods for Norwalk virus (NV) and the antibody response to NV infection. The outbreak began within 36 h of embarkation and affected 30% of 672 passengers and crew. No single meal, seating, or food item was implicated in the transmission of NV, but a passenger's risk of illness was associated with the amount of ice (but not water) consumed (chi-square for trend, P = 0.009). Of 19 fecal specimens examined, 7 were found to contain 27-nm NV-like particles by electron microscopy and 16 were positive by PCR with very sensitive NV-specific primers, but only 5 were positive by a new highly specific antigen enzyme immunoassay for NV. Ten of 12 serum specimen pairs demonstrated a fourfold or greater rise in antibody titer to recombinant baculovirus-expressed NV antigen. The amplified PCR band shared only 81% nucleotide sequence homology with the reference NV strain, which may explain the lack of utility of the fecal specimen enzyme immunoassay. This report, the first to document the use of these molecular method-based assays for investigation of an outbreak, demonstrates the importance of highly sensitive viral diagnostics such as PCR and serodiagnosis for the epidemiologic investigation of NV gastroenteritis.

Hepatitis B virus infection in Honolulu students.

OBJECTIVES: To determine hepatitis B virus (HBV) carrier and infection rates and HBV epidemiology in Honolulu students. DESIGN: Cross-sectional survey. SETTING: Honolulu public elementary, intermediate, and high schools. PATIENTS: A volunteer sample of 4936 students from 43 Honolulu schools. MAIN OUTCOME MEASURES: HBV carrier rate (presence of hepatitis B surface antigen) and infection rate (presence of either hepatitis B surface antigen, antibody to hepatitis B surface antigen, antibody to hepatitis B core antigen, or any combinations of these) by school grade, ethnicity, and place of birth. RESULTS: Eighty-three (1.68%) students were identified as HBV carriers, and a total of 353 (7.15%) students had serologic evidence of infection. Infection rates increased from elementary school age to high school age, more so in Asian/Pacific Island-born students. The prevalence of infection was higher in Asian/Pacific Island-born students than in those born in the United States. The majority of infected Hawaiian-born students were first-generation Asian/Pacific Island Americans. CONCLUSIONS: Horizontal transmission of HBV occurs in Honolulu school-age children. HBV immunization of all infants in Hawaii, not just those born to carrier mothers, is necessary to reduce HBV transmission in Hawaii.

Ciguatera: a review.

Hawaii State Department of Health epidemiological records were reviewed for cases of ciguatera poisoning for the entire state, from January 1984 through December 1988. During the 5 year interval, the numbers of ciguatera poisoning incidents, number of cases, and date of onset were recorded, as well as age and sex of individuals involved. The place of catch of each fish was noted as well as whether or not the fish was obtained commercially. The parts of the fish consumed were also recorded. A total of 150 ciguatera incidents occurred during this period, involving 462 individuals for an average annual incidence rate of 8.7/100,000 population. The 3 most frequently implicated species of fish were the Carangoides species (jack or papio or ulua), Ctenochaetus strigosus (surgeon fish or kole), and Aphareus furcatus (fork-tailed snapper or waha nui); however, more than 50 species of fish had caused one or more outbreaks. The most frequently implicated areas of the toxic fish were the Kona coast as well as the South Point of the island of Hawaii, and the Napali coast of the island of Kauai. Of the 150 outbreaks, 32 (21%) were related to commercial fish. The rest were related to sportfishing.

L-tryptophan-related eosinophilia-myalgia syndrome: a case report.

Eosinophilia-myalgia syndrome (EMS) is characterized by intense eosinophilia and, very often, debilitating generalized myalgia in the absence of infectious or neoplastic causation. The Centers for Disease Control have established that the latter two features, along with an eosinophil count greater than 1000 cells per cu mm, are criteria for the syndrome. EMS has been reported in epidemic proportions over the last several months. Early data strongly suggested that in at least a small percentage of patients the syndrome leads to death. Epidemiological work in New Mexico, Minnesota, and Oregon has linked EMS most impressively to L-tryptophan-containing products (LTCPS).

Outbreak of hemorrhagic fever with renal syndrome among U.S. Marines in Korea.

Fourteen of 3,754 U.S. Marines who participated in a joint United States-Republic of Korea training exercise during the autumn of 1986 developed hemorrhagic fever with renal syndrome (HFRS). Clinical and laboratory findings among cases included fever, headache, fatigue, gastrointestinal dysfunction, thrombocytopenia, and proteinuria. Ten individuals were hospitalized; 2 died. No subclinical infections were identified through a post-deployment screen of sera obtained from 2,053 exercise participants. Analysis of questionnaires identified no environmental, occupational, or temporal factors as risks for developing disease. However, 13 of the 14 cases occurred among individuals housed at 1 of the 2 base camps used during the exercise. This outbreak represents the largest cluster of HFRS cases among U.S. personnel in the Republic of Korea since the Korean conflict.

An unusual case of penicillinase-producing Neisseria gonorrhoeae resistant to spectinomycin in California.

We report a case of gonorrhea due to a penicillinase-producing strain of Neisseria gonorrhoeae resistant to spectinomycin in a 26-year-old man who had not been out of the United States for a year-and-a-half. His sexual contact also had no recent travel out of the United States. The genital and oropharyngeal infections were successfully treated with cefoxitin (1 g im) plus probenecid (1 g orally) and trimethoprim-sulfamethoxazole (80 mg of trimethoprim and 400 mg of sulfamethoxazole). The patient took nine of the latter tablets daily for five days. The organism was a serovar IB-3, proline-requiring auxotype. The patient's isolate contained both 2.6-megadalton and 4.4-megadalton plasmids. Measurement of minimal inhibitory concentrations (MICs) of antibiotics for the isolate confirmed the penicillin resistance and showed an MIC of spectinomycin of greater than 256 micrograms/ml. The epidemiologic investigation suggested that the source of the infection was a male contact with unusual clinical features, including bloody urethral discharge and a possible incubation period of 28 days.