The value of peer support for self-management of diabetes among veterans in the Empowering Patients In Chronic care intervention.

AIM: To examine the value of peer support in the self-management of diabetes among veterans in an integrated health care system. METHODS: We conducted semi-structured in-depth interviews with veterans and clinicians 6 months after their participation in Empowering Patients in Chronic Care (EPIC), a group-based diabetes intervention with a peer-support component. Interviews elicited clinicians' narratives of how peer support unfolded in the groups and veterans' experiences of giving and receiving support from their peers. Data analysis was guided by principles of framework analysis using Heisler's peer-support model. RESULTS: Findings support Heisler's peer-support model and provide evidence supporting professional-led group visits with peer exchange. Clinicians and veterans endorsed informational and emotional support received in EPIC groups. Clinicians often referred to EPIC as an open forum or a support group where veterans could both give and receive help. Veterans noted the benefits of shared problem-solving and the support they received. Clinicians and veterans perceived the peer-support component of EPIC as facilitating increased empowerment in terms of self-efficacy, increased perceived social support and increased understanding of self-care. Ultimately, many veterans acknowledged that their participation in EPIC facilitated improved health-related quality of life, improved health behaviours and improved chronic disease control. CONCLUSIONS: Findings emphasize the value of peer support in managing chronic illness. Peer-support programmes may address veterans' unique challenges and have the potential to improve physical and mental health.

Healthy People 2020: assessment of pharmacists' priorities.

OBJECTIVE: The purpose of this study was to assess perceptions of pharmacy educators on the priorities and roles of pharmacists in meeting the Healthy People 2020 objectives. STUDY DESIGN: Cross-sectional, qualitative online national survey. METHODS: A comprehensive literature review identified documented roles and responsibilities of pharmacists in addressing the 42 topic areas in Healthy People 2020. From this, a 14-item survey was developed to identify priorities of categories to improve the health of the nation and importance of the pharmacist role to achieve the objectives. The survey was sent electronically to the members of the Public Health Special Interest Group of the American Association of Colleges of Pharmacy in May and June 2014. RESULTS: Participants identified the following Healthy People 2020 categories as most important in improving the health of the nation: chronic diseases, health care services, lifestyle, prevention/well-being, and environmental factors. They identified the following Healthy People 2020 categories as possessing the most important roles for pharmacists in working to improve the health of the nation: chronic diseases, health care services, lifestyle, prevention/well-being, and infectious disease. CONCLUSIONS: There exists great congruence between top categories of importance and those that the pharmacist can impact to improve the health of the nation. The results of this study can guide efforts to educate and activate pharmacists as interprofessional team members improving health locally and globally.

Long-term phenotypic correction in factor IX knockout mice by using ΦC31 integrase-mediated gene therapy.

Hemophilia B, a hereditary bleeding disorder caused by a deficiency of coagulation factor IX (FIX), is an excellent candidate for gene therapy. However, to date, success in hemophilia gene therapy clinical trials has been limited due to failure to achieve or sustain therapeutic levels of factor expression. The ΦC31 integrase system efficiently integrates plasmid DNA carrying a transgene and an attB site into a limited number of endogenous pseudo attP sites in mammalian genomes, leading to robust, sustained transgene expression. A strategy utilizing plasmid DNA integrated with ΦC31 integrase may offer a facile and safe alternative for sustained human FIX (hFIX) expression. Hydrodynamic tail vein injection was used for delivery of plasmids encoding ΦC31 integrase and hFIX to the liver of FIX knockout mice. We demonstrated prolonged therapeutic levels of hFIX in this knockout mouse model of hemophilia B over a 6-month time course when ΦC31 integrase was used. Additionally, we observed sustained FIX activity in plasma and phenotypic correction of bleeding after tail clip in ΦC31-treated mice. In the livers that received integrase, we also demonstrated prolonged hFIX expression in hepatocytes by immunohistochemistry and documented sequence-specific genomic integration of the hFIX plasmid. These studies suggest the possibility that a similar approach in large animals and humans could lead to a simple and successful gene therapy for hemophilia.

Effect of nuclear localization and hydrodynamic delivery-induced cell division on phiC31 integrase activity.

Phage phiC31 integrase is a recombinase that can be expressed in mammalian cells to integrate plasmids carrying an attB sequence into the genome at specific pseudo attP locations. We show by immunofluoresence that wild-type phiC31 integrase is cytoplasmic and that addition of the SV40 nuclear localization signal (NLS) localized phiC31 integrase to the nucleus. Unexpectedly, the NLS depressed integration efficiency in HeLa cells and provided no benefit when used to integrate the human Factor IX (hFIX) gene into mouse liver. As breakdown of the nuclear membrane during mitosis could allow cytoplasmic integrase access to the chromosomes, we analyzed whether cell division was required for integration into liver cells in vivo. Hepatocytes were labeled with iododeoxyuridine to mark cells that underwent DNA replication during the week after hydrodynamic injection. Hydrodynamic delivery led to DNA replication in one-third of hepatocytes. Approximately three out of four cells having phiC31 integrase-mediated stable hFIX expression did not undergo replication, indicating that cell division was not required for integrase function in liver. Therefore, although the bulk of phiC31 integrase protein seems to be cytoplasmic in mammalian cells, integration can still occur in the nucleus, even without cell division.

Use of recombinant human erythropoietin in two-stage total knee arthroplasty for infection.

A multicenter prospective study was conducted to determine whether epoetin alfa could be used to lower transfusion requirements after two-stage exchange arthroplasty for infection. Forty-one consecutive patients undergoing successful two-stage exchange arthroplasty for an infected total knee arthroplasty were enrolled in a prospective study. Epoetin alfa (40,000 units) was administered subcutaneously after prosthesis resection and antibiotic spacer placement. Although there was no difference in the hemoglobin levels before resection arthroplasty or on postoperative Day 3 between the study group and the control group, hemoglobin levels before reimplantation were higher in the patients who received epoetin alfa (12.4 mg/dL; range, 9.3-15.1 mg/dL) compared with the control group (11.3 mg/dL; range, 8.1-14.4 mg/dL). Average increase in hemoglobin level in the interval between stages was higher in the treatment group (3.2 mg/dL; range, -0.7-6.8 mg/dL) than the control group (1.7 mg/dL; range, -1.9-6 mg/dL). The transfusion rate decreased from 83% of patients in the control group to 34% in the study group during reimplantation. In addition, overall incidence of transfusion for either stage improved from 89% in the control group to 44% in the patients treated with epoetin alfa. Perioperative epoetin alfa statistically increased the hemoglobin levels and decreased transfusion rates for patients undergoing two-stage revision for infected total knee arthroplasty.

Clinical and demographic predictors of late-stage cervical cancer.

BACKGROUND: Despite increasingly widespread use of the Papanicolaou smear, almost half of all women with invasive cervical cancer are diagnosed at a late stage (regional or distant). Little is known about factors associated with late-stage diagnosis of cervical cancer. OBJECTIVE: To examine the relationship of age, race, education level, income level, smoking, marital status, health insurance type, comorbidity, and residence in an urban or rural setting to late stage at diagnosis of cervical cancer. METHODS: Incident cases of invasive cervical cancer occurring in 1994 in Florida were identified from the state tumor registry (N = 852). Cases were linked with state discharge abstracts and the 1990 US census. Multiple logistic regression was used to determine the relationship between predictor variables (age, race or ethnicity, marital status, smoking status, education level, income level, insurance type, comorbidity, and urban vs rural residence) and the odds of late-stage diagnosis. RESULTS: Age, marital status, and insurance type were associated with late-stage diagnosis. Each additional year of age was associated with a 3% increased odds of late-stage diagnosis (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.05; P<.001). Being unmarried was associated with a 63% increased odds of late-stage diagnosis (OR, 1.63; 95% CI, 1.18-2.25; P=.003). Being uninsured was associated with a 60% increased odds of late-stage diagnosis (OR, 1.60; 95% CI, 1.07-2.38; P=.02). Having commercial health maintenance organization insurance was associated with a 46% decreased odds of late-stage disease (OR, 0.54; 95% CI, 0.30-0.96; P=.04). Race, education level, income level, smoking status, comorbidity, and urban residence were not associated with stage at diagnosis. CONCLUSIONS: Women with cervical cancer who are elderly, unmarried, and uninsured are more likely to be diagnosed at a late stage. These women should be targeted for cervical cancer education and screening programs.

Effects of supplemental protein type on productivity of primiparous beef cows.

Effects of supplemental degradable (DIP) and undegradable (UIP) intake protein on forage intake, BW change, body condition score (BCS), postpartum interval to first estrus, conception rate, milk production and composition, serum metabolites and metabolic hormones, and calf gain were determined using 36 primiparous Gelbvieh x Angus rotationally crossed beef cows. On d 3 postpartum, cows (average initial BW = 495 +/- 10 kg and BCS = 5.5 +/- 0.1) were randomly assigned to one of three dietary supplements (12 cows/treatment). Date of parturition was evenly distributed across treatment (average span of calving date among treatments = 2.4 +/- 2.5 d). Individually fed (d 3 through 120 postpartum) dietary supplements were 0.82 kg of corn and 0.23 kg of soybean meal per day (DIP), the DIP + 0.12 kg of blood meal and 0.13 kg of corn gluten meal per day (DIP + UIP), and 0.82 kg of corn, 0.07 kg of blood meal, and 0.08 kg of corn gluten meal per day in an isonitrogenous replacement of soybean meal (UIP IsoN). Cows had ad libitum access to native grass hay (8.5% CP) and trace-mineralized salt. Total OM intake was greater (P = 0.06) for DIP + UIP than UIP IsoN cows. At 30 d postpartum, DIP + UIP cows produced more milk than UIP IsoN, with DIP being intermediate; however, at 60 d postpartum, DIP + UIP and DIP cows were not different, but both had greater milk production than UIP IsoN (treatment x day interaction; P = 0.08). A treatment x day interaction (P = 0.06) for BCS resulted from DIP + UIP cows having the greatest BCS at 60, 90, and 120 d d postpartum and DIP having greater BCS than UIP IsoN cows only on d 60 postpartum. Serum insulin concentrations were highest (treatment x day interaction; P = 0.09) for DIP + UIP cows at 30 d postpartum but did not differ among treatment thereafter. Serum insulin-like growth factor-binding protein (IGFBP)-2 (34 kDa) and -3 (40 and 44 kDa) were greatest (P < 0.0003) for DIP cows. Serum urea-N concentrations were greater (P < 0.01) in DIP + UIP cows than in either DIP or UIP IsoN cows. However, postpartum interval to first estrus, conception rate, and calf weaning weights were unaffected (P = 0.35, 0.42, and 0.64, respectively) by treatment. Although UIP in addition to or in replacement of DIP affected milk production and blood metabolites, the productivity of these primiparous beef cows was not altered. Thus, the type of supplemental protein does not seem to influence productivity of primiparous beef cows in production systems with conditions similar to our experimental conditions.

Commun-I-Care: experience in the first four years.

The medically uninsured ("working poor") comprise roughly 10 percent of the citizens in South Carolina. These individuals are more likely than the insured to have chronic health conditions including hypertension, diabetes, and respiratory diseases. They appear to have poorer outcomes as as result of misallocation of health care resources from prevention to acute intervention. CIC is a novel program which represents an effort to coordinate the efficient utilization of existing resources to meet the non-emergent health care needs of the medically uninsured. The CIC program has enjoyed a successful beginning and, with the continued strong support of providers and sponsors, looks forward to exciting progress in the future.

Evidence of gender bias in patients undergoing flexible sigmoidoscopy.

Some studies have revealed gender bias against women in various aspects of medical care. There is no substantial evidence of gender bias in patients undergoing cancer evaluations, specifically colorectal cancer screening and diagnosis of colorectal complaints. This study was designed to examine the role of gender bias related to patients undergoing flexible sigmoidoscopy. At the University of South Florida, we conducted a retrospective study of 1910 patients at three distinct flexible sigmoidoscopy clinics over several years, through 1992. The proportions of male and female patients who underwent the procedure for indications of either screening for colorectal cancer or the diagnosis of colorectal complaints were determined. These proportions were compared with the respective male and female patient proportion from the total number of currently active patients at each site who were eligible to have the procedure for an appropriate indication. At all three sites, a significantly smaller proportion of women (p < 0.01) underwent the procedure than expected. This was true for both screening and diagnostic indications. Conversely, at all sites significantly more men (p < 0.01) underwent the procedure for both indications. The results of this study suggest gender bias against women for patients undergoing flexible sigmoidoscopy for both screening and diagnosis. This bias may adversely affect the lethality of colorectal cancer in women. It is important to determine if such biases are influenced by the physician's recommendation or mainly due to patient attitudes.

Prevalence and epidemiology of trichostrongylids in Wyoming cattle with consideration of the inhibited development of Ostertagia ostertagi.

During 1988, monthly collections of abomasa and the cranial portion of the small intestine of 208 native Wyoming cattle were examined for adult and larval helminth parasites. Egg counts were performed on colonic faecal specimens. The animals ranged from 7 months to 8 years of age and were sampled at slaughter houses or diagnostic laboratories from five different counties in the State. Most of the cattle had ranged for a long time on non-irrigated, high altitude grass plains from about 1250 to 2500 m above sea level. All animals examined were found infected. Nematode genera (and number of species) found included Ostertagia (4), Trichostrongylus (2), Haemonchus (1), Cooperia (4) and Nematodirus (2). One trematode, Fasciola hepatica, and a cestode, Moniezia benedeni, also were found. Trichostrongylus axei, Trichostrongylus longispicularis and Cooperia lyrata were found for the first time in Wyoming, Ostertagia circumcincta was found for the first time in cattle in Wyoming, and Haemonchus placei, tentatively identified in a previous survey, was definitively confirmed. Predominant species (and prevalence) were Ostertagia ostertagi (98%), Cooperia oncophora (60.6%), Ostertagia bisonis (41.8%), Cooperia bisonis (33.6%) and T. Axei (27.9%). One or more of the four species of Ostertagia were found in all animals. Inhibited O. ostertagi and O. bisonis larvae predominated from November to April and reached a peak in January to comprise 88% of the total nematode burden for that month. The adult population of abomasal nematodes peaked in April and predominated thereafter until October. Haemonchus placei also spent the autumn-winter period in an inhibited state of development. Faecal egg counts were lowest during winter months, when the highest number of worms were present as L4 larvae, as determined by luminal and mucosal counts. Nematode populations in the small intestine peaked in June and persisted until November. The results of this study showed the magnitude and species composition of nematode parasitism in cattle raised on high altitude grass plains, underscored the inaccuracy of faecal egg counts as an indicator of worm burden during fall and winter seasons, and provided information on which anthelmintic treatment timing would be most efficacious.

Does early clinical exposure enhance performance during third-year clerkship?

This study was undertaken to assess the effects of early clinical exposure in an indigent care free clinic on third-year clerkship mini-board scores (clinical knowledge), faculty evaluation (especially rapport with colleagues and patients), and final rotation grades. After completion of third-year clerkships, a sample of participants was compared with nonparticipants. Comparative statistics, repeated measure analysis, and analyses of variance were performed on the entire group as well as by sex and by individual rotation. No statistically significant differences were found in the mainframe, but subgroup findings indicate further study is warranted. Negative findings might be explained in part by small sample size and the fact that the clinic is exclusively outpatient, while the third-year clerkship experience is inpatient. Data collection is being continued, and studies are ongoing to look at the long-term effect of the program on participants.

Seasonality of Chlamydia trachomatis genital infections in university women.

Previous studies have shown seasonal fluctuations in the incidence of most sexually transmitted diseases, with a peak in the third quarter, but none have specifically evaluated Chlamydia trachomatis genital infections. From 1989 to 1991, 8,234 women presenting to the student health centers of Florida's two largest universities for routine gynecologic care and diagnosis of sexually transmitted diseases were tested for Chlamydia trachomatis genital infections. The bimonthly variation in incidence was statistically significant, with a significant peak in the months of August and September of 10.70%, compared with the yearly average of 8.74%. Because the pattern of incidence of chlamydia in university women is seasonal, those concerned with healthcare should increase their efforts during the third quarter to identify infected individuals and to provide preventive programs.

Influence of longitudinal primary care training on medical students' specialty choices.

BACKGROUND: At the University of South Florida College of Medicine, a program designed to give students four years of primary care training began in 1983. As of 1992, six classes that included program participants had graduated. The present study examined the effect of the program on the participants' choices of specialty by comparing their choices with those of other graduates. METHOD: Each year program volunteers were solicited from a class size of about 96 freshmen. Of the 201 volunteers from the classes of 1987-1992, 93 were randomly selected to participate in the program. The participants received primary care education one half-day per week in a community-based clinical setting. The specialty choices of the 543 graduates from 1987-1992 were determined from the National Resident Matching Program and were divided into primary care (family practice, internal medicine, pediatrics); surgery, obstetrics-gynecology, and psychiatry; and other (high-technology specialties). Comparisons were made (1) between volunteers and nonvolunteers and (2) between volunteers who were participants and those who were not. The Z-test was used, with alpha set at .01. RESULTS: Significantly more volunteers--with no difference between participants and nonparticipants--matched with primary care specialties, and more volunteers were women. Significantly more nonvolunteers matched with high-technology specialties--again, no difference between participants and nonparticipants. CONCLUSION: The program did not seem to influence the students' specialty choices, because students interested in participating--regardless of whether they actually participated--were more likely to match with primary care specialties and were more likely to be women.

Validity of immunization documentation presented to a student health program.

BACKGROUND: Unavoidable exposure to disease and to patients susceptible and vulnerable to disease warrants that students entering medical school be immunized against many of the illnesses for which vaccines are available. The validity of immunization records presented at the time of registration, however, is largely dependent on the provision of accurate and reliable documentation by the student. METHODS: We evaluated for authenticity the immunization and tuberculin testing records of 85 students entering medical school in 1990. Five levels of valid documentation were defined, and the information on each record was reviewed accordingly. RESULTS: Only 43% of the records were original documents or laboratory reports of antibody titers, and 7.5% were not date-specific. We found that 8% to 20% of the forms were missing physician and/or student signatures, and 12% to 19% of the forms did not have health care provider addresses. CONCLUSIONS: Even though medical student preventive health programs may have strict requirements, there may be substantial deficiencies in the quality of the documentation provided by the students. Such deficiencies undermine the purpose of these programs.

Barriers to screening among participants of a media-promoted breast cancer screening project.

Breast cancer detection and awareness projects have been implemented nationwide in an attempt to increase compliance with screening mammography. Previous studies, however, showed that the elderly, minorities, and women of lower socioeconomic status fail to respond in representative numbers. A cross-sectional analysis of 6640 participants of a Breast Cancer Detection and Awareness Project in Tampa, FL, was conducted to determine if barriers and motivations to screening differed among targeted (the elderly, minorities, women of lower socioeconomic status) and nontargeted groups. Targeted demographic groups reported far more barriers to screening and fewer motivating factors in their decision to participate in screening. This was true for the elderly, minorities, and women of lower socioeconomic status. Women in greater need of screening mammography report fewer motivations, and must overcome greater barriers to participate in media-promoted breast screening projects. Changes in the design and promotion of these screening projects must occur to prevent reverse targeting.

The disclosure of the diagnosis of cancer.

In summary, the consensus today is that full disclosure of the diagnosis of cancer to competent individuals (including children) is morally, ethically, legally, and therapeutically the appropriate policy. Unfortunately, this task is one that most physicians still find awkward, in part because of the continued de-emphasis of "soft" clinical skills in the medical education. Thus, doctors have little opportunity to address their own beliefs and emotions. By being cognizant of clinician unease and using well-described communication skills, however, disclosure can be satisfactorily accomplished. As American health care becomes increasingly ambulatory in nature, primary care physicians will have even more need to hone this skill.

Adenosine is a pulmonary vasodilator in newborn lambs.

We investigated the systemic and pulmonary vascular effects of adenosine and determined plasma adenosine levels in pulmonary circulation in 12 newborn lambs during normoxia and during alveolar hypoxia (10% O2, 5% CO2, and 85% N2). Lambs were instrumented at 7 days of age with catheters in the descending aorta, main pulmonary artery, and right and left atria, and a flow transducer around the main pulmonary artery, and were studied following a 3-day recovery. Adenosine or an equal volume of normal saline (control) was infused into the right atrial line in doses ranging from 0.01 to 2.5 mumol/kg/min. In normoxic lambs, adenosine caused a significant decrease in pulmonary vascular resistance and increase in heart rate in doses of 0.15 to 2.5 mumol/kg/min and a decrease in systemic vascular resistance, with increase in cardiac output in doses of 0.3 to 2.5 mumol/kg/min. Baseline plasma adenosine levels in pulmonary artery and left atrium decreased significantly during alveolar hypoxia. Adenosine infusion in hypoxic lambs caused decreases in pulmonary artery pressure and pulmonary vascular resistance at all the doses tested. Aortic pressure and systemic vascular resistance decreased, and heart rate and cardiac output increased at doses greater than or equal to 0.3 mumol/kg/min in hypoxic lambs during adenosine infusion. The pulmonary vascular effects of adenosine in hypoxic lambs were attenuated by prior treatment of animals with aminophylline. Thus, adenosine appears to be an important regulator of pulmonary vascular response to hypoxia in newborn lambs. Its vasodilator effects were specific for pulmonary circulation when it was infused in doses less than or equal to 0.15 mumol/kg/min into the right atrium and appear to be mediated by P1 purinergic receptors.