Implementing evidence-based patient self-management programs in the Veterans Health Administration: perspectives on delivery system design considerations.

While many patient self-management (PSM) programs have been developed and evaluated for effectiveness, less effort has been devoted to translating and systematically delivering PSM in primary and specialty care. Therefore, the purpose of this paper is to review delivery system design considerations for implementing self-management programs in practice. As lessons are learned about implementing PSM programs in Veterans Health Administration (VHA), resource allocation by healthcare organization for formatting PSM programs, providing patient access, facilitating PSM, and incorporating support tools to foster PSM among its consumers can be refined and tailored. Redesigning the system to deliver and support PSM will be important as implementation researchers translate evidence based PSM practices into routine care and evaluate its impact on the health-related quality of life of veterans living with chronic disease.

Particle size characterizations of copper and zinc oxide exposures of employees working in a nonferrous foundry using cascade impactors.

This study characterized exposures to copper and zinc oxide as respirable or nonrespirable using personal impactors and compared the results with previous findings obtained using cyclones. Twenty-five sets of air samples were taken over a 10-month period using single jet cascade impactors. Five to six stages were used to capture and classify aerosols according to their aerodynamic diameter (d(ae)). These ranged from < 0.5 microm to > 10 microm d(ae). Twenty-two air samples were taken on employees casting brass alloys, and three samples were taken in areas in the vicinity where employees routinely worked. Twenty-one air samples were taken during the casting of a single brass alloy (containing 70% copper and 30% zinc), and the remaining samples were obtained from employees casting two different brass alloys: a nearly pure copper alloy and a nickel-copper alloy. The results indicated that 55-96% (by mass) of all copper aerosols collected had a d(ae) > or = 10 microm. More than 85% (by mass) of all copper exposures were estimated as nonrespirable using the current ACGIH-CEN-ISO definition. Zinc oxide aerosols were collected at all stages of the impactors, with significant amounts found to have a d(ae) > or = 10 microm. More than 60% (by mass) of all zinc oxide exposures were estimated to be nonrespirable. A comparison of data collected using impactors and cyclones demonstrated that cyclones could be used to differentiate larger aerosol particles from fumes, rather than requiring the use of impactors. It is recommended that appropriate particle size selective sampling methods be used to classify exposures of metals to dusts and fumes.

Oral mesalamine (Asacol) for mildly to moderately active ulcerative colitis. A multicenter study.

OBJECTIVE: To evaluate the efficacy and safety of a pH-sensitive, polymer-coated oral preparation of mesalamine in patients with mildly to moderately active ulcerative colitis. DESIGN: A multicenter, double-blind, placebo-controlled randomized trial. SETTING: Five university-based medical centers, one inflammatory bowel disease center, and three private practice sites. PATIENTS: A total of 158 patients with newly or previously diagnosed active ulcerative colitis. INTERVENTION: A pH-sensitive, polymer-coated oral preparation of mesalamine (5-aminosalicylic acid) was used at 1.6 and 2.4 g/d for 6 weeks. MEASUREMENTS: Efficacy was measured by scores for stool frequency, rectal bleeding, patient's functional assessment, sigmoidoscopic findings, and physician's global assessment. Stringent criteria for disease activity were established prospectively. RESULTS: The analysis of protocol-compliant patients showed a significant improvement at 3 weeks in patients taking 2.4 g/d of mesalamine compared with patients taking placebo (32% versus 9%; P = 0.003). At 6 weeks, both the 1.6 g/d (43%) and 2.4 g/d (49%) doses were significantly superior to placebo (23%) (P = 0.03 and P = 0.003, respectively). In addition, more patients worsened in the placebo group compared with the 2.4 g/d group (50% versus 19%; P = 0.003); however, there was no statistically significant difference in worsening between the 1.6 g/d mesalamine group and the placebo group. The oral mesalamine tablet was well tolerated, and no clinically significant changes were observed in hematologic, hepatic, or renal laboratory profiles. CONCLUSION: Colon-targeted oral mesalamine at 2.4 g/d is effective therapy for mildly to moderately active ulcerative colitis. It is well tolerated and should provide a viable therapeutic alternative to sulfasalazine.

Chlorzoxazone hepatotoxic reactions. An analysis of 21 identified or presumed cases.

A drug rechallenge proved chlorzoxazone to be hepatotoxic in a patient who had been treated with a combination of it and acetaminophen (Parafon Forte) for several months. Failure to demonstrate a toxic response to acetaminophen coupled with a dramatic response to a single dose of chlorzoxazone implicated chlorzoxazone as the hepatotoxic agent. A review of US Food and Drug Administration records and cases reported in the medical literature disclosed 23 cases of chlorzoxazone-associated hepatotoxic reactions occurring since 1970. These cases were examined in terms of age, duration of therapy, other confounding etiologic factors, and ultimate outcome. There were two deaths involving hepatic failure. Reports of adverse reactions among six commonly used analgesic-muscle relaxants in Sweden have indicated a low, but comparatively greater, incidence of hepatotoxic reactions associated with a chlorzoxazone-containing compound.

A clinical research data base system for the Apple IIe/IIc.

A data base program for some types of patient visits, especially medical procedures, is described. It would be primarily useful as a tool for clinical research, but its implementation would depend on its contributing to the routine documentation of patient visits (i.e. generate typed reports appropriate for charting). To achieve this, and to standardize the information to be collected, several concepts have been developed: a data base template; a branched data structure; bit-mapped, multi-option data fields; and flexible, efficient search capabilities. The program is presently configured for the Apple IIe/IIc and it is not a substitute for keeping patient records (although it may be helpful). It is presented as an approach to the "computerization" of medical information developed through a combined appreciation of basic computer capabilities, and an awareness of how some clinical information may be categorized.