Cardiovascular Risk Screening among Women Veterans: Identifying Provider and Patient Barriers and Facilitators to Develop a Clinical Toolkit.

INTRODUCTION: Cardiovascular (CV) disease is the leading cause of death among women in the United States, making CV risk screening and management a women's health priority. Objectives were to elicit barriers and facilitators to CV risk identification and reduction among women veterans, and iteratively cocreate clinical tools to identify CV risk factors and promote goal-setting for lifestyle changes. METHODS: We conducted three exploratory focus groups with 21 Veterans Health Administration primary care team members and piloted patient CV screeners with brief interviews with 19 patients from two Veterans Health Administration women's clinics to inform toolkit development. We then conducted two focus groups and one interview for feedback from a total of 12 staff on the proposed toolkit components. Transcripts were summarized, and a matrix analysis was used to synthesize qualitative findings. RESULTS: Provider-identified barriers included difficulties disseminating CV information in clinic, limited patient knowledge, and lack of organized resources for provider communication and available referrals. Women's complex health needs were notable challenges to CV risk reduction. Facilitators included having a single place to track patient CV risks (e.g., an electronic template note), a patient screening worksheet, and aids to complete referrals. Patient-identified barriers included difficulties balancing health, finances, and physical and mental health concerns. Facilitators included resources for accountability and gender-specific information about CV risks and complications. Providers requested easy, accessible tools in the electronic record with gender-specific CV data and resources linked. Patients requested lifestyle change supports, including trustworthy sources vetted by providers. CONCLUSIONS: Iteratively eliciting end-users' perspectives is critical to developing user-friendly, clinically relevant tools. CV risk reduction among women veterans will require multilevel tools and resources that meet providers' and women's needs.

Direct preparation of particles from liquid suspension for ESEM or SEM analysis.

A simplified method for the preparation of particles from liquid suspensions has been developed. Particles are deposited directly on carbon planchets for rapid analysis by environmental scanning electron microscopy or by conventional scanning electron microscopy after an additional drying step. This is accomplished by filtering the liquid through thin carbon planchets. Three different grades of graphite were investigated for their suitability as the source material for these planchets. The high quality isomolded graphite is recommended for the filtration and direct observation of particles by electron microscopy. This technique is demonstrated for particles in hydraulic fluid and aquatic suspended particulate material from a natural water source.

Experimental data and model simulations of beam spread in the environmental scanning electron microscope.

This work describes the comparison of experimental measurements of electron beam spread in the environmental scanning electron microscope with model predictions. Beam spreading is the result of primary electrons being scattered out of the focused beam by interaction with gas molecules in the low-vacuum specimen chamber. The scattered electrons form a skirt of electrons around the central probe. The intensity of the skirt depends on gas pressure in the chamber, beam-gas path length, beam energy, and gas composition. A model has been independently developed that, under a given set of conditions, predicts the radial intensity distribution of the scattered electrons. Experimental measurements of the intensity of the beam skirt were made under controlled conditions for comparison with model predictions of beam skirting. The model predicts the trends observed in the experimentally determined scattering intensities; however, there does appear to be a systematic deviation from the experimental measurements.

Immunization levels and risk factors for low immunization coverage among private practices.

OBJECTIVES: Previous studies have indicated that provider characteristics are an important determinant of immunization coverage. The objectives of this study were to: 1) assess immunization coverage levels among 2-year-old children receiving care in private practices in 3 California counties; and 2) evaluate practice and patient risk factors for low immunization coverage. STUDY DESIGN: Cross-sectional chart review of immunization histories and provider survey of immunization policies. SETTING: Forty-five randomly selected, private medical practices in 3 counties in California. PATIENTS: Children 12 to 35 months old, followed by the participating practices. METHODS: Providers underwent a detailed assessment of their immunization coverage and completed a questionnaire describing their immunization policies and procedures. Immunization data were abstracted from randomly selected medical charts of children 12 to 35 months old. Only patients who met the criteria for active status (>/=2 visits and >/=1 visit during the preceding 18 months) were included in analyses. Immunization coverage levels were calculated and logistic regression was used to estimate the risk of underimmunization associated with different practice and child characteristics. RESULTS: Of the 72 eligible practices that were contacted, 45 participated in the study, yielding a participation rate of 62%. The median immunization coverage of participating offices was 54% (range: 0%-91%). Multivariate analysis revealed 5 independent risk factors for underimmunization. The strongest predictors were having fewer than 50% active children in the practice and children having fewer than 8 visits to the provider. Other significant predictors were the percentage of patients in the practice on Medicaid, administering diphtheria-tetanus-pertussis 4 at a separate visit from the Haemophilus influenzae type b booster, and practice location. CONCLUSIONS: These data provide new insights into immunization practices in an important clinical setting that has been poorly characterized previously. Immunization coverage levels were found to be low and significant risk factors for underimmunization were identified. Recommendations are made for immunization policy changes and targeting of immunization improvement interventions at practices that may be at risk for low immunization coverage. immunization, vaccination, immunization programs, primary prevention, private practice, child, preschool, pediatrics, family practice.

Incidence of ponticulus posterior of the atlas in migraine and cervicogenic headache.

BACKGROUND: The clinical significance of the ponticulus posticus is far from clear. It has been associated with headaches, Barré-Lieou syndrome, photophobia, and migraine. However, little epidemiologic evidence for this exists. OBJECTIVE: This study investigated the relationship of ponticulus posticus on x-ray studies and headache symptoms in a series of chiropractic patients. METHODS: Eight hundred ninety-five patients who visited a chiropractic clinic for the first time and whose conditions required cervical spine x-ray examinations were studied. Complaints were categorized as migraine with aura, migraine without aura, cervicogenic headache, neck pain only, and other conditions. The presence or absence of the ponticulus posticus (whether partial or complete) was determined by means of a lateral cervical film and noted as a positive or negative finding. The data were analyzed by frequency analysis and Pearson's chi 2 test. RESULTS: Forty-six percent of the sample were men and the predominant complaint was neck pain (33%). Most patients were in the fourth decade of life. The frequencies of the other complaints were migraine with aura (7%), migraine without aura (4%), cervicogenic headache (22%), other conditions (33%). An 18% prevalence of ponticulus posticus was found. This finding was significantly associated with migraine without aura (chi 2 = 4.97; P = .03) and not with any other conditions. CONCLUSION: In a chiropractic patient population that required cervical x-ray examinations, a significant association was found between ponticulus posticus and migraine without aura, with an odds ratio of 2.19:1 in favor of this complaint being present with the osseous anomaly. The mechanism for this remains obscure but may be related to ischemic compression of the vertebral artery or by dural tension at the craniocervical junction.

Characterization of biomimetic surfaces formed from cell membranes.

A method for fabricating biomimetic surfaces from intact cell membranes is described. A monolayer of alkanethiol on gold is covered by a second layer derived from the components of erythrocyte membranes either by self-assembly or by Langmuir-Blodgett methods. The resulting asymmetric hybrid layer was characterized by ellipsometry, surface plasmon resonance (SPR), contact angle, capacitance, voltammetry, and electron and atomic force microscopy. The erythrocyte membrane layer was measured to be approximately 30-40 A in thickness. Using SPR, the presence of erythrocyte components on the surface was demonstrated by their selective removal by enzymatic action. The uniform deposition of membranous material on the substrate was shown by electron and atomic force microscopy. Demonstration of acetylcholinesterase (AChase) activity, a membrane-anchored enzyme, on the surface for at least 8 days, suggests that the outer leaflet of the erythrocyte membrane is present in its native form. Cyclic voltammetry demonstrates that enhanced electron transport from a solution redox species accompanies formation of the erythrocyte layer at the surface. This enhanced electron transport is blocked by 4,4'-diisothiocyanate stilbene-2,2'-disulfonic acid, a well known blocker of anion transport, suggesting that an erythrocyte anion transporter protein is incorporated into the surface layer in an active conformation.

Maternal smoking during pregnancy and birth outcomes with weight gain adjustments via varying-coefficient models.

There is considerable interest in the impact of maternal exposures during pregnancy on birth outcomes. Clearly, exposures associated with poor birth outcomes need modification or avoidance. However, arriving at such estimates of association is made challenging by a number of features characteristic of the relevant data. First, exposures may be time varying (for example, cigarette and alcohol consumption) so that, to relate them to birth outcomes, one needs to model them and then extract derived parameters. Secondly, there are likely to be unequal numbers and spacings of exposure determinations during pregnancy. Thirdly, one needs to account for a variety of additional covariates. Finally, the variability and non-linearities inherent in birth outcomes mandate flexible modelling approaches. Here we use data from a cohort of East Boston mothers to assess the impact of smoking during pregnancy on birth weights. We emphasize modelling of, and then adjusting for, maternal weight gain during pregnancy and a proxy measure for pre-pregnancy weight, so as to obtain better estimates of the smoking effect. Throughout, our analysis is guided by appropriate graphics. The adjustment features an interesting application of varying-coefficient models. Results indicate that smoking related deficits in birth weights depend on the mode of adjustment, and that previously observed deficits of approximately 200 g are best recaptured with use of varying-coefficient models.

Prospective assessment of fecundability of female semiconductor workers.

To investigate a possible effect of reduced fecundability (probability of conception per menstrual cycle) among women who fabricate silicon wafers, 152 fabrication-room (fab) and 251 nonfab workers were followed for an average of five menstrual cycles. Daily urine samples were analyzed to confirm clinical spontaneous abortions (SABs) and early fetal losses (EFLs). Adjusted fecundability odds ratios (FRs) for fab workers ranged from 0.59 to 0.72 (p = 0.09-0.28 vs. nonfab). For clinical pregnancies only, the adjusted FR ranged from 0.43-0.50 (p = 0.04-0.09 vs. nonfab). This lower fecundability was most pronounced among dopants and thin-film workers [adjusted FR = 0.61, 95% confidence interval (CI) = 0.27-1.40 for all pregnancies; adjusted FR = 0.22, 95% CI = 0.05-0.96 for clinical pregnancies] and in workers exposed to ethylene-based glycol ethers (adjusted FR = 0.37, 95% CI = 0.11-1.19).

Prospective monitoring of early fetal loss and clinical spontaneous abortion among female semiconductor workers.

Women who work in silicon wafer fabrication rooms (fabs) have been reported to have an increased risk of spontaneous abortion (SAB). Although previous studies have included only clinically recognized SABs, more than two-thirds of SABs may be clinically unrecognized. To determine whether fab work is associated with SAB, we recruited 152 fab and 251 nonfab workers, who collected urine samples for a 6-month period. Samples were analyzed by immunoradiometric assay for the presence of human chorionic gonadotropin to detect early fetal losses. Approximately 63% of fab and 46% of nonfab pregnancies ended in SAB [adjusted relative risk (RR) = 1.25; 95% confidence interval (CI) = 0.63-1.76]. Similar RR were seen for women who worked in dopant and thin-film processes (adjusted RR = 1.30; 95% CI = 0.51-1.96) or in masking (adjusted RR = 1.30; 95% CI = 0.59-1.84). The four pregnancies among women who worked with ethylene-based glycol ethers ended in SAB.

Physical exertion as a risk factor for spontaneous abortion.

This study examined the association of physical exertion and spontaneous abortion in a case-control study of 607 women whose pregnancies ended in spontaneous abortion and 1,287 women who delivered livebirths in Santa Clara County, CA, in 1986 and 1987. We interviewed women about the number of hours they spent doing heavy housework and caring for young children. We also interviewed women employed during their pregnancies (71% in each group) about their work schedule; the number of hours they worked, stood, commuted, and stooped or bent; and the number of times per day they lifted weights of > 15 pounds. Standing > 8 hours per day at work was the only variable associated with increased risk [adjusted odds ratio (OR) = 1.6; 95% confidence limits (CL) = 1.1, 2.3]. This association was present only for women with a history of spontaneous abortion (adjusted OR = 2.8; 95% CL = 1.4, 5.9). Among women with this history, the OR for a second trimester abortion was 4.9 (95% CL = 1.9, 12.2). Cleaning house for > 7 hours per week or caring for young children for > 50 hours per week was associated with decreased risk (adjusted OR = 0.6, 95% CL = 0.5, 0.9; adjusted OR = 0.8, 95% CL = 0.6, 1.0, respectively). Again, these associations were specific to women with a history of spontaneous abortion (adjusted OR = 0.4, 95% CL = 0.2, 0.7; adjusted OR = 0.5, 95% CL = 0.3, 0.8). These results indicate that the specific type of physical exertion, the amount of exertion, and the context of the exertion may be important.

Environmental scanning electron microscope imaging examples related to particle analysis.

This work provides examples of some of the imaging capabilities of environmental scanning electron microscopy applied to easily charged samples relevant to particle analysis. Environmental SEM (also referred to as high pressure or low vacuum SEM) can address uncoated samples that are known to be difficult to image. Most of these specimens are difficult to image by conventional SEM even when coated with a conductive layer. Another area where environmental SEM is particularly applicable is for specimens not compatible with high vacuum, such as volatile specimens. Samples from which images were obtained that otherwise may not have been possible by conventional methods included fly ash particles on an oiled plastic membrane impactor substrate, a one micrometer diameter fiber mounted on the end of a wire, uranium oxide particles embedded in oil-bearing cellulose nitrate, teflon and polycarbonate filter materials with collected air particulate matter, polystyrene latex spheres on cellulosic filter paper, polystyrene latex spheres "loosely" sitting on a glass slide, and subsurface tracks in an etched nuclear track-etch detector. Surface charging problems experienced in high vacuum SEMs are virtually eliminated in the low vacuum SEM, extending imaging capabilities to samples previously difficult to use or incompatible with conventional methods.

Continuous intravenous morphine infusions for terminal pain control: a retrospective review.

The continuous intravenous infusion of morphine may control terminal cancer pain unrelieved by conventional narcotic therapy. A retrospective review was conducted of the medical records of 79 terminal cancer patients who received a total of 84 intravenous morphine infusions. Data were recorded on morphine dosage, pain control, adverse effects, duration of infusion, and concomitant medication requirements. Infusion duration varied from less than 24 hours to 162 days (median: 7 days). Morphine dosage ranged from 0.5 to 300 mg/h. All patients experienced an improvement in baseline pain control; however, 54 percent required additional medication to enhance analgesia. Serious adverse effects, including marked sedation, hallucinations, diaphoresis, and respiratory depression, were recorded in 14 patients. These effects may be a reason for reducing the dose. Guidelines for the use of continuous intravenous morphine infusions are presented. Accurate pain assessment, morphine dosage calculation, and monitoring of adverse effects are essential to insure the safe and effective use of these infusions.