Treatment of caudal cavoatrial junction obstruction in a dog with a balloon-expandable biliary stent.

A 2-year-old intact female mixed breed dog was presented for ascites. Echocardiography demonstrated severe obstruction at the level of the caudal right atrium. Initially, a variant of cor triatriatum dexter was diagnosed, and balloon catheter dilation was performed. However, ascites recurred within a week. Further imaging revealed an obstruction at the entrance of the caudal vena cava into the right atrium rather than a dividing membrane in the right atrium. The diagnosis was revised to suprahepatic obstruction of the caudal vena cava because of remnant Eustachian valve tissue. Deployment of a balloon-expandable biliary stent was performed relieving the obstruction. Fifteen months after stent deployment, the patient is doing well without reaccumulation of ascitic fluid.

Prognostic importance of marital quality for survival of congestive heart failure.

Mounting evidence indicates that social support is associated with better outcomes of cardiovascular disease and reduced all-cause mortality. Much less is known about the specific contribution of marital functioning to these outcomes, and the potential prognostic significance of marital quality for congestive heart failure (CHF) has not been explored. Interview and observational measures of marital quality obtained from 189 patients with CHF (139 men and 50 women) and their spouses were examined as predictors of patient survival up to 48 months after assessment and compared with prediction based on illness severity (New York Heart Association [NYHA] class). Four-year survival rates were 52.5% and 68% for male patients and female patients, respectively. In Cox regression analyses, a composite measure of marital quality predicted 4-year survival as well as the patient's concurrent NYHA class did (both p <0.001). Adjusting for CHF severity did not diminish the prognostic significance of marital functioning, and prediction of survival from marital quality appeared stronger for female than for male patients. Thus, when marital quality and NYHA class are considered jointly, they both make independent, statistically significant contributions to the prediction of patient mortality.

Couple dynamics of change-resistant smoking: toward a family consultation model.

Smoking is North America's leading cause of preventable morbidity and mortality. Although effective cessation treatments exist, their overall effect is modest, and they rarely reach the high-risk, health-compromised smokers who need them most. Surprisingly, despite evidence that marital relationship variables predict the success of cessation efforts, family systems ideas have had little impact on current intervention research. We review and critique the cessation literature from a systemic viewpoint, illustrate two couple-interaction patterns relevant to the maintenance of high-risk smoking, and outline a family-consultation (FAMCON) intervention for couples in which at least one partner continues to smoke despite having heart or lung disease. Taking into account ironic processes and symptom-system fit, FAMCON focuses on the immediate social context of smoking, aiming to interrupt well-intentioned "solutions" that ironically feed back to keep smoking going, and to help clients realign important relationships in ways not organized around tobacco usage. Currently in its pilot-testing phase, FAMCON is an adjunctive, complementary approach designed to include collaboration with primary-care physicians and to make smokers more amenable to other, evidence-based cessation strategies.

The Drosophila homolog of Onecut homeodomain proteins is a neural-specific transcriptional activator with a potential role in regulating neural differentiation.

We report here the characterization of the Drosophila homolog of the onecut homeobox gene, which encodes a protein product with one cut domain and one homeodomain. We present evidence that D-Onecut can bind to similar DNA sequences with high specificity and affinity as other Onecut proteins through the highly conserved cut domain and homeodomain. Interestingly, the cut domain alone can mediate DNA-binding, but the homeodomain cannot. However, depending upon the promoter context, we observed cooperative interactions between the two domains to confer high DNA-binding affinity and specificity. D-Onecut appears to be a moderate transcriptional activator and functions as a nuclear protein in neuronal tissues of both the CNS and PNS during development and in the adult. In the eye, D-Onecut expression is independent of glass, a transcriptional regulator of R cell differentiation. Taken together, our results suggest a role for D-Onecut in the regulation of some aspects of neural differentiation or maintenance. In support of this notion, overexpression of a putative dominant negative form of D-Onecut during eye development does not affect early cell fate specification, but severely affects photoreceptor differentiation.

What did the doctor do? When physicians and patients disagree.

OBJECTIVE: A serendipitous finding in a study of routine clinical encounters was that physicians and patients frequently gave discrepant reports of what had happened during a clinic visit. This report examines the conditions under which these discrepant perceptions occurred. DESIGN: Five experienced physicians and 189 patients completed postencounter questionnaires immediately following visits to an academic family practice clinic. After each encounter, the physician and patient estimated the duration of the visit and reported whether each of seven clinical events had occurred. RESULTS: The most common disagreements concerned whether the physician had provided counseling or performed a treatment procedure. Multiple regression analyses suggest that patient characteristics contributed to specific forms of physician-patient disagreement but that overall discrepancy was greatest in cases in which the physician minimized the importance of psychosocial issues and/or felt relatively confident about understanding the patient's problem. CONCLUSIONS: Although correlation need not imply causality, the results raise the possibility that physicians can promote shared physician-patient understanding by paying more attention to psychosocial factors and being more circumspect in drawing conclusions about patients' problems.

Can experts predict health risk from family genograms?

BACKGROUND: The family genogram is sometimes used to aid diagnostic, therapeutic, and preventive care decisions. This study evaluated the efficacy of genograms for predicting health risk in comparison to predictions made using demographic and chart review data. METHODS: Six physicians with expertise in using genograms were asked to evaluate 20 actual patient cases and use three methods to predict the patients' chances, over the next three months, of: a) experiencing illness causing at least one disability day, b) making an unexpected physician visit for a new problem, or c) requiring hospitalization. The three methods were genogram evaluation, review of patient demographics, and review of patients' charts. Predictions from demographic data were always made first; the other two methods were used in varied order. Three months later, actual patient outcomes were reviewed and compared to predictions. RESULTS: Over the next three months, 44% of subjects experienced a disability day, 35% made an unexpected clinic visit, and none required hospitalization. Predictions of these events with genograms were no more accurate than predictions generated from chart review. The six genogram experts did not predict outcomes at better than chance levels. CONCLUSIONS: Genograms may be no more accurate than standard clinical chart review for predicting short-term (three month) health outcomes.

The SAGE-PAGE trial: do family genograms make a difference?

BACKGROUND: Despite enthusiastic promotion of family genograms, the impact of routine use of this tool on clinical practice has not been systematically examined. The present study investigated whether doing a genogram, or having one available, makes physicians more sensitive to psychosocial issues or in other ways affects the physician-patient relationship or the process of clinical care. METHODS: In a randomized clinical trial, patients visiting 5 physicians at an academic family practice center (n = 189) received a physician-administered genogram (PAGE); a self-administered genogram (SAGE), which the patient completed before seeing the physician; or no genogram. A fourth (baseline) group was tested without genograms prior to the randomized trial. RESULTS: Analyses of patients' and physicians' postencounter questionnaires showed no impact of genograms on how physicians think about and deal with clinical problems or how patients view the encounter with their physicians. Compared with control groups, neither patient- nor physician-administered genograms increased the physician's (self-defined) understanding of the patient or the importance the physician attached to psychosocial issues in the case. A positive finding was that physicians considered genograms more relevant when they did them themselves. On the other hand, physician-administered genograms also increased the length of the encounter and were substantially less complete (conveying less information) than genograms completed by patients. CONCLUSIONS: THe results leave open the possibility that genograms do make a difference when used routinely by residents or experts or in difficult cases when family assessment is indicated. While enthusiasm about genogram applications in family medicine is understandable, the clinical utility of this tool remains to be demonstrated scientifically.

The time-line genogram: highlighting temporal aspects of family relationships.

The genogram, or family diagram, is an assessment tool widely used by clinicians to study family members and their relationships over several generations. The standard genogram format is limited, however, because it does not show temporal patterns directly. An alternative, the Time-Line Genogram (TLG), which plots time on the vertical axis to display life events and changes in relationships when they actually occurred, highlights temporal aspects of family history that the standard format sometimes obscures.

Researching ethnic family stereotypes.

Ethnic stereotypes in the family therapy literature make intuitive sense, but are based on surprisingly little empirical data. In a questionnaire survey of the family experiences of 220 mental health professionals representing eight American ethnic groups, most items differentiated the groups as predicted. A smaller, partial replication study comparing samples from Holland, Ireland, and North America found fewer discriminating items, but the differences that did appear were again as predicted. Implications for therapy and research with ethnic families are discussed.

DNA sequence analysis of a 5.27-kb direct repeat occurring adjacent to the regions of S-episome homology in maize mitochondria.

The DNA sequence of the 5270-bp repeated DNA element from the mitochondrial genome of the fertile cytoplasm of maize has been determined. The repeat is a major site of recombination within the mitochondrial genome and sequences related to the R1(S1) and R2(S2) linear episomes reside immediately adjacent to the repeat. The terminal inverted repeats of the R1 and R2 homologous sequences form one of the two boundaries of the repeat. Frame-shift mutations have introduced 11 translation termination codons into the transcribed S2/R2 URFI gene. The repeated sequence, though recombinantly active, appears to serve no biological function.

Transcription unit of the rabbit beta 1 globin gene.

We have hybridized pulse-labeled nuclear transcripts to cloned DNA fragments from the rabbit beta-like globin genes to determine the developmental timing, extent, and asymmetry of their transcription. The fetal-adult gene beta 1 was transcribed in fetal liver but not embryonic nuclei, whereas genes beta 3 and beta 4, which encode embryonic globin polypeptides, were transcribed only in embryonic nuclei. This shows that the switch from embryonic to fetal-adult globin production in rabbits is accomplished primarily by differential transcription of the beta-like globin genes. Gene beta 1 was subdivided into M13 subclones and tested for hybridization to nascent RNA. The nucleotide sequence of the 3' flanking region of gene beta 1 was also determined for 2,447 base pairs past the polyadenylation [poly(A)] site. No transcripts were found 5' to the cap site, but asymmetric transcription of gene beta 1 proceeded at a high level through the gene and past the poly(A) addition site for 603 nucleotides. The level of transcription declined after this, gradually dropping through the next 568 nucleotides. No polymerases were found on a fragment that begins 1,707 nucleotides past the poly(A) site; this fragment was part of a segment of repetitive DNA. These data show that the transcription unit of gene beta 1 begins at or near the cap nucleotide and extends at least 1,171 but no more than 1,706 nucleotides past the poly(A) addition site. The DNA segment that precedes the region of declining transcription contained an inverted repeat and encoded a short RNA transcribed by RNA polymerase II from the strand opposite the beta 1 transcript. These two features may function to attenuate the transcription of gene beta 1. An inverted repeat and a potential polymerase II transcription unit were also found in the homologous segment 3' to the human beta-globin gene. A short DNA segment close to the 3' end of the beta 1 transcription unit was transcribed more actively than the surrounding DNA, and it contained sequences that match the consensus internal control region for RNA polymerase III. This DNA segment may contain a separate polymerase III transcription unit. A member of the D repeat family located 3' to gene beta 1 was not transcribed in its entirety coordinately with beta 1.

Analysis of rabbit beta-like globin gene transcripts during development.

We have analyzed the differential expression of a family of beta-like globin genes during the development of rabbits, from four days post implantation to one week before birth. The family is composed of four genes, arranged 5'-beta 4-beta 3-psi beta 2-beta 1-3' on the chromosome; psi beta 2 is an inactive pseudogene. Using the technique of hybrid-arrested translation in vitro, we have identified the embryo-specific globin polypeptides encoded by genes beta 3 and beta 4. The beta 3 and beta 4 globins are replaced by the adult beta 1 globin halfway through gestation; this corresponds temporally with the switch in site of erythropoiesis from the embryonic yolk sac to the fetal liver. The decline in production of beta 3 globin polypeptide precedes the decline in beta 4 globin. Transcripts from genes beta 1, beta 3 and beta 4 were analyzed at progressive stages of gestation by a blot-hybridization assay and by an S1 nuclease protection assay. Mature messenger RNA and presumptive precursor RNAs from genes beta 3 and beta 4 are synthesized abundantly in embryonic erythroid cells but only at very low levels later in fetal development. Conversely, precursor and mature mRNA from gene beta 1 are found at very low levels in embryos but are abundant in fetal and adult erythroid cells. The co-ordinate appearance of precursor RNA, mRNA and polypeptide from all three active genes indicates that the primary developmental regulation of this gene family is exerted at the level of transcription. RNA species larger than the expected precursors were observed when the RNA was denatured with formaldehyde but not when methylmercury was the denaturant. These large RNAs are a formaldehyde-generated artifact, possibly a result of cross-linking globin transcripts to ribosomal RNA. We observe no extensive stable transcripts from the 5' or 3' flanking regions of these genes.

Attitudes toward cancer. II: A comparative analysis of cancer patients, medical students, medical residents, physicians and cancer educators.

The current investigation was designed to determine how cancer patients, medical students, medical residents, nononcologically oriented physicians, and cancer educators differ with respect to attitudes towards cancer. A total of 372 individuals completed the Cancer Attitude Survey. Cancer educators displayed more confidence in the patient's ability to cope with diagnostic and prognostic information than students, other physicians, and patients themselves. Patients and cancer educators favored aggressive therapy to greater extent than other physicians, students, and alumni. Among nononcologic physicians and students there were significant effects of respondent's sex and prior personal experience with cancer on the attitudes expressed. Cancer educators differed significantly by specialty with surgical oncologists most likely to favor aggressive therapy. When compared to physician groups studied in the 1960s, our overall physician group (residents, cancer educators, and other physicians) was more likely to exhibit: (1) confidence in the patient's coping ability; (2) skepticism about the efficacy of early diagnosis and the value of aggressive treatment; and (3) stronger beliefs in the patient's ability to prepare for and accept death. Comparisons of our medical student group with students studied by Haley and his colleagues revealed a similar picture. Implications of these findings for the education of medical students are discussed.

MMPI correlates of menstrual distress.

The MMPI and Moos' Menstrual Distress Questionnaire (MDQ) were administered to 60 undergraduate women. Partial correlations between MMPI clinical scales and menstrual and premenstrual MDQ symptom scales were computed with intermenstrual (baseline) symptom reports and response set (Gough's F-K index) statistically controlled MMPI variables tended to correlate with some symptom scales (premenstrual pain, negative affect; menstrual behavior change) but not with others (water retention, arousal). Where correlations did occur, common MMPI scales (Sc, Hs, Hy, Pt) were involved. Results suggest that psychological factors are more closely associated with some areas of menstrual symptomatoloty than with others.