Perspectives on cervical cancer screening and prevention: challenges faced by providers and patients along the Texas-Mexico border.

BACKGROUND: The Rio Grande Valley (RGV) and Laredo regions located along the Texas-Mexico border consist of seven counties with a population of approximately 1.5 million people and a high uninsured rate (33.5%). Cervical cancer mortality in these border counties is approximately 30% higher than the rest of Texas. The RGV and Laredo areas were studied to better understand the state of access to cervical cancer prevention services along the Texas-Mexico border. METHODS: Data on the population served and the services provided were analyzed to determine the gap between cervical cancer screenings recommended versus those received. Through interviews, we gathered the perspectives of 16 local stakeholders regarding cervical cancer screening for underserved individuals in the region. FINDINGS: It is estimated that 69,139 uninsured women aged 21-64 years in the RGV/Laredo per year are recommended to undergo cervical cancer screening with Papanicolaou (Pap) and/or human papillomavirus (HPV) testing, but only 8941 (12.9%) Pap tests are being performed by the Federally Qualified Health Center (FQHC) serving uninsured women in these regions. Systemic barriers identified include insufficient provider clinical capacity, the high cost of healthcare, and uncertainty about government funding sources. Patient barriers identified include inadequate knowledge on navigating the local healthcare system, low health literacy, lack of money and childcare, an inability to miss work, limited transportation, and fear of deportation. CONCLUSION: Decreasing the disparity between cervical cancer screening services provided and those recommended requires addressing the barriers, identified by local experts, which prevent uninsured women from accessing care. These challenges are being addressed through ongoing programs and collaborations.

Understanding how axial loads on the spine influence segmental biomechanics for idiopathic scoliosis patients: A magnetic resonance imaging study.

BACKGROUND: Segmental biomechanics of the scoliotic spine are important since the overall spinal deformity is comprised of the cumulative coronal and axial rotations of individual joints. This study investigates the coronal plane segmental biomechanics for adolescent idiopathic scoliosis patients in response to physiologically relevant axial compression. METHODS: Individual spinal joint compliance in the coronal plane was measured for a series of 15 idiopathic scoliosis patients using axially loaded magnetic resonance imaging. Each patient was first imaged in the supine position with no axial load, and then again following application of an axial compressive load. Coronal plane disc wedge angles in the unloaded and loaded configurations were measured. Joint moments exerted by the axial compressive load were used to derive estimates of individual joint compliance. FINDINGS: The mean standing major Cobb angle for this patient series was 46°. Mean intra-observer measurement error for endplate inclination was 1.6°. Following loading, initially highly wedged discs demonstrated a smaller change in wedge angle, than less wedged discs for certain spinal levels (+2,+1,-2 relative to the apex, (p<0.05)). Highly wedged discs were observed near the apex of the curve, which corresponded to lower joint compliance in the apical region. INTERPRETATION: While individual patients exhibit substantial variability in disc wedge angles and joint compliance, overall there is a pattern of increased disc wedging near the curve apex, and reduced joint compliance in this region. Approaches such as this can provide valuable biomechanical data on in vivo spinal biomechanics of the scoliotic spine, for analysis of deformity progression and surgical planning.

[Psychiatric comorbidity in patients in tertiary care suffering from severe somatoform disorders]. / Psychiatrische comorbiditeit bij ernstige somatoforme stoornissen in de derde lijn.

BACKGROUND: Although it is generally the severity of a patient's symptoms and impairments which determines the amount of care allocated to patients with somatoform disorders, comorbidity appears to be an additional relevant factor. A number of studies in different populations with somatoform disorders have shown that these disorders overlap with mood disorders, anxiety disorders, and personality disorders. So far, however, little is known about comorbidity in patients in tertiary care who are suffering from severe somatoform disorders. AIM: To determine comorbidity of mood, anxiety and personality disorders in patients in tertiary care suffering from severe somatoform disorders. METHOD: The study was based on a sample of 340 patients with dsm-iv-tr somatoform disorder who were awaiting treatment in a specialised care centre. The sample was examined by means of structured clinical assessment of dsm-iv-tr axis I and axis II disorders. RESULTS: 49.4% of the 340 participants was diagnosed with a mood disorder, 62.1% with an anxiety disorder and 50.6% with a personality disorder. CONCLUSION: Patients in tertiary care suffering from (severe) somatic disorders show higher comorbidity of mood, anxiety and personality disorder than previously reported for somatoform disorder patients in primary and secondary care.

Pharmacist review prevents evolving metformin-associated lactic acidosis.

WHAT IS KNOWN: There is controversy surrounding the risk of metformin and the development of lactic acidosis. There have been no reports of a pharmacist preventing a patient developing metformin-associated lactic acidosis. OBJECTIVES: Our objective was to report on a pharmacist potentially preventing an evolving case of metformin-associated lactic acidosis (MALA). CASE DESCRIPTION: A patient who had been having episodes of nausea and vomiting for a year was referred for a home medicines review (HMR) by his general practitioner. The pharmacist who conducted the HMR suspected that the patient's symptoms could have been due to metformin. It was recommended to measure the serum lactate level and suspend metformin. Our patient was found to have a high lactate level and was referred to the emergency department by his general practitioner. Recovery was prompt with symptomatic support and cessation of metformin. WHAT IS NEW: This appears to be the first case reported in the literature of a pharmacist recognizing an evolving case of MALA. CONCLUSION: Although the incidence of MALA is rare, health professionals should be aware of the initial symptoms of lactic acidosis, especially in elderly patients with risk factors, to prevent a fatal lactic acidosis event.

Cardiovascular risk factors in outpatients with bipolar disorder.

BACKGROUND: The mortality due to cardiovascular diseases in bipolar patients is much higher than in the general population. It is unclear whether lithium treatment contributes to this cardiovascular morbidity. METHODS: The cardiovascular risk factors in outpatients with bipolar disorder on monotherapy lithium were explored. Cardiac (family) history, important habits and recent stressful events were assessed. Quetelet Index (QI) was calculated and blood samples were taken. Blood pressure (BP) was measured in supine position and during orthostatic challenge. RESULTS: 40 out of 81 patients on monotherapy lithium were studied in detail. In this group, one patient was hypothyroid; six patients suffered from hypertension. QI was > 25 in 57.5% of the patients; mean cholesterol level was 5.7 mmol/L. Renal functioning, electrolytes and glucose concentrations were normal. There were no significant relationships between the duration of lithium treatment, the duration of bipolar disorder, recent stressful events and hypertension. Out of the group of 81 patients on lithium monotherapy, 13 patients in total used antihypertensive medication, indicating a high prevalence of hypertension in this group as compared to the general population. CONCLUSIONS: Cardiovascular risk factors, including hypertension, were increased in a large proportion of this population on monotherapy lithium. However, no significant relationships were observed between duration of lithium treatment or bipolar disorder and presence of hypertension.

Development of an optimal sampling strategy for clinical pharmacokinetic studies of the novel anthracycline disaccharide analogue MEN-10755.

AIM: MEN-10755 is a novel anthracycline analogue that has shown an improved therapeutic efficacy over doxorubicin in animal models, especially in gynaecological and lung cancers and is currently under clinical development for the treatment of solid tumours. The aim of the project was to develop an optimal sampling strategy for MEN-10755 to provide an efficient basis for future pharmacokinetic/pharmacodynamic investigations. METHODS: Data from 24 patients who participated in a phase I clinical pharmacokinetic study of MEN-10755 administered as a short i.v. infusion were included. Individual pharmacokinetic values were calculated by fitting the plasma concentration data to a two-compartment model using nonlinear least-squared regression (KINFIT, Ed 3.5). Population pharmacokinetic analysis was carried out using (a) the traditional standard two-stage method (STS) based on all data (KINFIT-ALL), (b) the iterative two-stage Bayesian (IT(2)B) population modelling algorithm (KINPOP), and (c) the STS method using KINFIT and using four optimally timed plasma concentrations (KINFIT-OSS4). Determinant (D) optimal sampling strategy (OSS) was used to evaluate the four most information-rich sampling times. The pharmacokinetic parameters V(c) (l), k(el) (h(-1)), k(12) (h(-1)) and k(21) (h(-1)) calculated using KINPOP served as a model for calculation of four D-optimal sampling times. D-optimal sampling data sets were analysed using KINFIT-OSS4 and compared with the population model obtained by the traditional standard two-stage approach for all data sets (KINFIT-ALL). RESULTS: The optimal sampling times were: the end of the infusion, and 1.5 h, 3.8 h and 24 h after the start of the infusion. The four-point D-optimal sampling design determined in this study gave individual parameter estimates close to the basic standard estimates using the full data set. CONCLUSION: Because accurate estimates of pharmacokinetic parameters were achieved, the four-point D-optimal sampling design may be very useful in future studies with MEN-10755.

Doctors' beliefs on the use of antithrombotic therapy in atrial fibrillation: identifying barriers to stroke prevention.

AIMS: To assess the attitudes of Australian doctors towards the use of antithrombotic drug therapy for stroke prevention in patients with non-valvular atrial fibrillation (AF), and investigate the barriers to prescribing warfarin. METHODS: A postal survey was undertaken among approximately 10% of all registered general practitioners (GPs), cardiologists and physicians in Australia. The anonymous questionnaire used case scenarios to assess doctors' knowledge of current guidelines for the therapeutic management of AF and sought opinions on potential barriers to the use of anticoagulation. RESULTS: Completed questionnaires were received from 711 doctors (30% response rate). The GPs performed better than the cardiologists and other specialists in estimating the risk of stroke in case scenarios. However, the cardiologists were more likely to select the recommended treatment, with GPs being more hesitant to use anticoagulation and tending to underestimate its reported benefit for stroke prevention in non-valvular AF. The GPs were also more likely to overestimate the reported risk of major bleeds with warfarin. In contrast, over one-third of the cardiologists went as far as to give warfarin to a low-risk patient and they were more likely to overestimate the reported benefit of aspirin and warfarin in AF. Only half the doctors correctly classified a patient without a previous stroke (but with other risk factors) as being at high risk. Increased experience as a registered medical practitioner was generally related to a poorer performance on classifying patients according to the risk of stroke. The principal barriers to the use of anticoagulation were nominated as: (i) active gastrointestinal bleeding, (ii) previous intracranial haemorrhage, (iii) alcoholism, (iv) a history of daily falls, (v) liver disease, (vi) severe anaemia and (vii) concurrent use of non-steroidal anti-inflammatory drugs. CONCLUSION: There is scope for improvement in doctors' knowledge about the appropriate use of antithrombotic drug therapy in non-valvular AF and awareness of the results of recent clinical trials. Compilation and dissemination of clear guidelines and focused education on some of the other risk factors (apart from previous stroke or transient ischaemic attacks) in patients with non-valvular

Therapeutic drug monitoring of clozapine: an unexpected outcome.

A patient is described who died with the diagnosis of septicemia. After her death the delayed results of a clozapine determination for TDM were sent to the clinician. The clozapine serum level was 4034 microg/L, which was considered to be the primary cause of death. However, a forensic autopsy revealed unexpected metastases of unknown origin with gross liver involvement. Thus the high clozapine levels were judged to be secondary to liver failure. This case is an example of an unexpected outcome of TDM.